Cost effectiveness analysis of two alternative interventions for the integration of Tenofovir into South Africa's public sector First Line Antiretroviral treatment regimen
In 2003, South Africa's National Department of Health (DoH) initiated the roll out of antiretroviral therapy (ART) for HIV positive individuals in the public health sector. Based on World Health Organization (WHO) guidelines, South Africa's ART programme provides a first line regimen based on a backbone of two nucleoside reverse transcriptase enzyme inhibitors (NRTI) with one non-nucleoside reverse transcriptase inhibitor (NNRTI) while the second line regimen is based on a protease inhibitor (PI) with two NRTIs. Similar to many developing countries, South Africa's NRTI backbone in the first line treatment regimen is stavudine (d4T) combined with lamivudine (3TC), and the NNRTI which is either efavirenz (EFV) or nevirapine (NVP). In some cases, stavudine is replaced with the NRTI zidovudine (AZT) in the first line regimen. Both d4T and AZT have been recognized to contribute to drug related toxicities or side effects, particularly lactic acidosis, lypodystrophy, peripheral neuropathy, and anaemia. However, developing country governments have been limited to these NRTI choices due to the higher cost of alternative treatment options. There is compelling logic that the life long commitment of ART can be made more tolerable, and that adherence among patients and the success of a public sector ART programme can be increased through the provision of ART regimens with the fewest side effects. In addition, the costs and complications associated with treating and managing adverse events associated with d4T and AZT create further burden on the public health sector. By providing tenofovir as an alternative to d4T and AZT in first line ART therapy, the South African government would increase the chance of successful ART therapy for patients and the long-term success of the national ART programme. This cost effectiveness analysis will compare the currently available first line ART options (the status quo) to two alternative options in order to assess the costeffectiveness of the provision of tenofovir in place of d4T/AZT.
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