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Title
Cost-effectiveness of dolutegravir compared with efavirenz for prevention of perinatal transmission in women presenting with HIV in late pregnancy in Uganda
Presenter
Elly Nuwamanya
Authors
E. Nuwamanya1, M. Lamorde1, A. Kuznik2, S. Cornelia Nassiwa1, H. Reynolds3, C. Waitt3, S. Khoo4, L. Myer5, T. Malaba5, I. Nakatudde1, A. Colbers6, D. Wang7, J. Read7, DolPHIN-2 Study Group
Institutions
1Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda, 2Regeneron Pharmaceuticals, Health Economics and Outcomes Research, New York, United States, 3Liverpool School of Tropical Medicine, Department of Pharmacology and Therapeutics, Liverpool, United Kingdom, 4London School of Tropical Medicine, Department of Pharmacology and Therapeutics, Liverpool, United Kingdom, 5University of Cape Town, School of Public Health and Family Medicine, Cape Town, South Africa, 6Radboud University Medical Center, Department of Pharmacy, Radboud Institute for Health Sciences, Nijmegen, Netherlands, 7Liverpool School of Tropical Medicine, Global Health Trials Unit, Liverpool, United Kingdom

BACKGROUND: Dolutegravir (DTG) has proved to be more efficacious, tolerable, and safer than efavirenz (EFV) among mothers living with HIV and their infants in Uganda. However, no study has evaluated the cost-effectiveness of a DTG-based antiretroviral therapy (ART) for preventing perinatal transmission (PT) in women who present with HIV in late pregnancy. Therefore, this study assessed the cost-effectiveness of DTG-based ART compared to the existing standard of care (EFV-based ART) for preventing PT among pregnant women initiating ART in late pregnancy in Uganda.
METHODS: We used data from a randomized open-label trial (DolPHIN-2) and a two-part cost-effectiveness model composed of a short-term decision tree to estimate the PT rate and costs and an individual-based 3-state Markov model (HIV, AIDs, Dead) to estimate the long-term costs and health outcomes from the Ugandan payer perspective using a lifetime horizon and a 1-year Markov cycle. The main outcomes were the mean annual costs in US dollars ($), disability-adjusted life years (DALYs), and incremental cost-effectiveness ratio (ICER). Both the deterministic and probabilistic sensitivity analyses were conducted to assess parameter uncertainty. All costs were reported in 2022 US dollars, and costs and DALYs were discounted at an annual rate of 3%.
RESULTS: Compared to the EFV-based ART, the DTG-based ART was associated with fewer mean annual costs ($279 vs. $471) and DALYs (0.33 vs. 0.56), leading to an ICER of $851 per DALY averted. In the incremental analysis, the DTG-based ART dominated the EFV-based ART, i.e., it was less costly and more effective. These results were robust to deterministic and probabilistic sensitivity analyses.
CONCLUSIONS: The DTG-based ART is a highly cost-effective strategy compared with the EFV-based ART among women initiating treatment in the third trimester of pregnancy in a low-income setting. Given the favorable health benefits and cost savings associated with the DTG-based ART, this study supports the recommendations to use DTG as first-line therapy for pregnant and breastfeeding mothers and their children.