India could shift from efavirenz to dolutegravir for HIV treatment – at no extra cost, new research suggests

At the moment, India recommends efavirenz (EFV)‐based antiretroviral treatment (ART) to treat HIV, which is currently cheaper than DTG-based ART. However, as pharmaceutical licences on DTG are now lifting in India, generic versions of DTG are likely to bring its cost close to that of EFV.

Research from the USA and Europe, where DTG is recommended as the first option for treatment, suggests DTG has more tolerable side effects, can enable people to suppress HIV levels quickly and is less likely to lead to drug resistance. As a result, DTG’s use in these countries has substantially reduced the number of people who fail first‐line treatment and are lost to care or require a switch to second‐line ART.

Using a mathematical simulation model of how HIV can advance and how it responds to treatment, the study, published by the Journal of International AIDS Society, examined the clinical and economic impact DTG could have on India’s HIV response in comparison to EFV.

Researchers found using DTG as the first option for HIV treatment would be cost‐effective, and potentially cost‐saving, for India’s public health system.

At 48 weeks, modelling suggests 90% of people on DTG would be virally suppressed compared to 82% of those on EFV. Longer term, DTG was projected to increase the proportion of people living with HIV on treatment who were still alive after five years from 76.7% to 83%.

Crucially, researchers found DTG had the potential to avert 13,000 new HIV infections over five years, equivalent to a 20% decrease in HIV incidence, resulting in a saving of US$800,000 in projected care costs.

When all factors are taken into account, care costs for the number of people initiating treatment on EFV were estimated to be US$139 million at two years and US$590 million at five years. In comparison, the care costs for DTG at two years was found to be lower at US$137 million and cost-neutral at five years at US$590 million. Cost increases linked to DTG were identified by the model, although these reflect the fact that more people are likely to live longer when on DTG, incurring greater lifetime care costs.

As a result, the authors recommend that when generic DTG becomes available in India, if priced at no more than $180 per person per year, it would be cost-effective for India to switch to DTG as first‐line treatment.

The research is particularly timely as India changed its treatment guidelines in 2017 to recommend that people living with HIV start treatment as soon as possible, regardless of their CD4 count. As a result, the cost of ART is becoming an increasingly central consideration to ensure treatment can be provided to all those now eligible.