Antiretroviral Reduction: Is It Time to Rethink the Unthinkable?

Jonathan Colasanti; Vincent C. Marconi; Babafemi Taiwo


AIDS. 2014;28(7):943-947. 

In This Article

Reductive Antiretroviral Therapy and Healthcare Policy

The global cost of antiretroviral drugs is towering at the same time that the indications for cART are being broadened in treatment guidelines.[14–16] As custodians of resource utilization and allocation, policy makers are programmed to select interventions that have the potential to lower costs, provided other outcomes are similar. Cost analyses of the MONotherapy in Europe with TMC114 trial (MONET) trial showed a cost reduction of 52% with darunavir–ritonavir monotherapy compared to standard triple therapy.[17] Similarly, a 38% reduction in cost was shown in a Spanish observational cohort when switching from triple therapy to PI/r monotherapy.[18] These published data are in line with our deduction of potential costs savings in the United States based on the recommended monthly wholesale cost for commonly used regimens.[14] For example, the listed annual cost of Atripla is $27 046.56, whereas for darunavir/ritonavir it is $18 465.60. Annual savings from using darunavir/ritonavir monotherapy instead of Atripla is $8580.96 or 32%. Of note, a comprehensive assessment of the costs of reductive ART must include those associated with excess treatment failure and resistance, if these actually occur. It will be important to also evaluate the costs associated with long-term adverse effects of treatment.

Guidelines from different parts of the globe diverge in their endorsement of reductive ART. Several European guidelines list reduction to PI/r as an option for treatment simplification or because of tolerability issues,[15,19,20] whereas the US Department of Health and Human Services (DHHS) does not.[14] Reductive ART may be particularly relevant in resource-limited settings, but there are scarce data and no supportive recommendations.[16] Interestingly, in a Spanish clinical setting where reductive strategies are being used, only nine of 92 patients (9.8%) had virologic rebound to above 50 copies/ml at 48 weeks after initiating darunavir/ritonavir monotherapy.[21,22] Overall, the time is ripe for studies and expert opinion to harmonize approaches to ART reduction globally. All constituencies must be prepared to rethink the unthinkable.