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Selection of pills and the words 'HIV/AIDS'

When broader health and societal impacts are considered, initially expensive treatments for HIV patients can offer surprisingly good value for money for low-income countries, NDPH research shows.

Talaromycosis is an invasive fungal infection and a major cause of HIV-related deaths in Southeast Asia. Current treatment options are limited to two drugs: amphotericin and itraconazole. International guidelines recommend amphotericin because it is more effective, however it is also considerably more expensive and requires intravenous administration. Consequently, in low-resource countries such as Vietnam, Myanmar, and India, itraconazole is used more frequently. Until now, it was unclear which treatment was the cost-effective option when the full impact of illness on patient health and productivity is considered.

Researchers from NDPH’s Health Economics Research Centre, together with colleagues at the Oxford University Clinical Research Unit and at Duke University School of Medicine, have rigorously assessed this in a new study published in Open Forum Infectious Diseases. Their results demonstrate that, despite high initial costs, amphotericin offers more value for money than itraconazole, particularly from a long-term, societal perspective.

The study was based on data from a randomised controlled trial, Itraconazole versus Amphotericin B for Penicilliosis (IVAP) conducted in Vietnam comparing itraconazole against amphotericin. The results, published in the New England Journal of Medicine, demonstrated that amphotericin was far superior in reducing deaths from talaromycosis in HIV patients, and was also associated with faster resolution of symptoms, lower rates of relapse, and fewer serious adverse events.

For the economic evaluation, the research team calculated the healthcare-associated costs for each participant in the clinical trial. This included costs for laboratory investigations, inpatient stays, outpatient appointments, interventions, and emergency care. These were then combined with wider societal costs, such as lost income from not being able to work, childcare costs, travel expenses, and over-the-counter medications.

The mean cost per patient in each study arm was then compared with the number of quality-adjusted life years (QALYs) gained to calculate the overall cost-effectiveness of amphotericin compared to itraconazole.

The results indicated that for treating HIV-associated talaromycosis in Vietnam:

  • From a purely healthcare perspective, amphotericin improved health outcomes but increased overall costs compared with itraconazole, with a 46% probability of being cost-effective.
  • When a broader perspective was considered that included societal impacts, amphotericin both improved health outcomes and reduced overall costs, with a 63% probability of being cost-effective. 
  • The higher initial cost of amphotericin treatment was offset by lower overall healthcare costs and reduced lost income during the follow up period, due to fewer disease complications.

Emeritus Professor Alastair Gray (NDPH, HERC) said ‘Our analysis shows that amphotericin is a cost-effective treatment for HIV patients with talaromycosis, but only when a broader range of patient costs and benefits are considered. This highlights the importance of rigorous economic evaluations to help resource-limited countries in managing healthcare budgets.’

Dr James Buchanan (NDPH, HERC), lead author of the study, said ‘The COVID-19 pandemic has put immense pressure on healthcare budgets around the world. For resource-limited countries, decisions about how to allocate stretched healthcare budgets can mean the difference between life and death for some patients. Impacts on quality of life, and in particular, patient productivity, are often overlooked in these settings. We show that when a broader perspective is adopted, treatments that initially look expensive may in fact offer surprisingly good value for money.’

Dr Thuy Le (Duke), Principal Investigator of the IVAP trial, said ‘As a clinician, I see first-hand the impact of amphotericin treatment: patients are able to return more quickly to wellbeing and to productive lives, as do their family members who are their carers. Our research demonstrates the benefit of considering patients, their families, the health system, and society as a whole, rather than just one of those perspectives. The onus is now on healthcare commissioners in Southeast Asia to improve access to amphotericin via sustained national procurement, and to ensure healthcare staff are trained to administer amphotericin.’