Drug-resistance tests urged for treatment-naïve HIV
A new study argues that genotypic drug-resistance testing in treatment-naïve human immunodeficiency virus (HIV) patients at the time of initial HIV diagnosis is cost-effective.
Data from the United States and Europe show an average baseline drug resistance of 8-10% in treatment-naïve HIV patients, the researchers say. Genotype resistance testing is not standard procedure when a patient is diagnosed with HIV. It is used more commonly before a new antiretroviral regimen is initiated in patients whose present therapy appears to be failing.
The researchers decided to determine the clinical impact and cost-effectiveness of genotype resistance testing for treatment-naïve patients with chronic HIV infection. They used a state-transition model of HIV disease to project life expectancy, costs, and cost-effectiveness for these patients. They also used a baseline prevalence of drug resistance of 8.3%, based on a U.S. survey of treatment-naïve patients from the Centers for Disease Control and Prevention in Atlanta, and they assumed a genotype resistance test would cost $400.
The results, which were published in the Nov. 1 issue of Clinical Infectious Diseases, showed that genotype resistance testing at initial diagnosis of HIV infection increased per-person quality-adjusted life expectancy by one month, with an incremental cost-effectiveness ratio of $23,900 per quality-adjusted life-year gained, compared with no genotype testing. "The cost-effectiveness ratio for resistance testing remained less than $50,000 per quality-adjusted life-year gained, unless the prevalence of resistance was ≤1%, a level lower than those reported in most regions of the United States and Europe," the researchers say.
"This analysis suggests that, with a baseline prevalence of resistance of >1%, resistance testing at the time of HIV diagnosis — and, thus, before antiretroviral therapy is started — is a cost-effective strategy that can lead to selection of a more effective initial antiretroviral regimen and likely longer survival for patients who have drug-resistant virus," the researchers conclude.
On the basis of the available evidence and considering clinical benefits and costs, they say, "Geno-type resistance testing should be performed for all patients with newly diagnosed HIV infection in the United States, with the results used to guide the choice of antiretroviral regimen when treatment is indicated."
In an accompanying editorial, two physicians say they believe there is now sufficiently strong information to recommend genotypic resistance testing for all drug-naïve patients at the time of diagnosis. "Because HIV drug-resistance testing has little risk of causing harm to patients (other than the anxiety caused by knowledge that one has a drug-resistant variant), cost-effectiveness considerations are key," say Frederick M. Hecht, MD, associate clinical professor, and Robert M. Grant, MD, MPH, MS, assistant professor, both at the Department of Medicine at the University of California at San Francisco.
They caution, however, that some drug- resistant mutations may not be detectable with standard resistance assays. The mutations may be detectable using novel minor variant assays, but whether the additional cost is justified will be questioned.
A new study argues that genotypic drug-resistance testing in treatment-naïve human immunodeficiency virus (HIV) patients at the time of initial HIV diagnosis is cost-effective.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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