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Economic Evaluation of Treatment Administration Strategies of Ganciclovir for Cytomegalovirus Retinitis in HIV/AIDS Patients in Thailand

A Simulation Study

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Abstract

Background

There are many effective interventions, via various routes (intravenous [IV], oral [OR], intravitreal injection [IVT] and intraocular implantation [IMP]), for treating cytomegalovirus retinitis (CMVR) that have become available. There are large variations in treating CMVR in clinical practice in Thailand.

Objective

To evaluate the incremental cost-effectiveness ratio (ICER) of providing (i) IVT, (ii) IV/OR and (iii) IMP ganciclovir to patients with HIV/AIDS and CMVR versus providing no treatment.

Design

A simulation study for which the input parameters were derived from a systematic review of the literature, a hospital-based survey and patient interviews.

Setting

The analysis assumed a Thai healthcare system perspective. However, the model was run using both societal and healthcare provider perspectives.

Results

Our results suggest that IVT ganciclovir was cost effective and the best option for treating patients with CMVR irrespective of whether patients received antiretroviral treatment (ART). In patients receiving ART, moving from IVT to IV/OR ganciclovir was also likely to be a cost-effective option. Offering IMP ganciclovir was not likely to be cost effective. Providing treatments for patients with bilateral CMVR was more cost effective than providing treatments for those with unilateral CMVR, and offering treatments for patients receiving ART was better value for money than treating patients without ART.

Conclusions

Our models suggest that IV/OR ganciclovir should be recommended for the treatment of unilateral and bilateral CMVR for patients receiving ART in the Thai healthcare system. IVT ganciclovir may also have a role in the treatment of CMVR patients not receiving ART.

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References

  1. Dunn JP, Jabs DA. Cytomegalovirus retinitis in AIDS: natural history, diagnosis, and treatment. AIDS Clin Rev 1995: 99–129

    Google Scholar 

  2. Roarty JD, Fisher EJ, Nussbaum JJ. Long-term visual morbidity of cytomegalovirus retinitis in patients with acquired immune deficiency syndrome. Ophthalmology 1993; 100 (11): 1685–1688

    PubMed  CAS  Google Scholar 

  3. Wu AW, Coleson LC, Holbrook J, et al. Measuring visual function and quality of life in patients with cytomegalovirus retinitis: development of a questionnaire. Studies of Ocular Complication of AIDS Research Group. Arch Ophthalmol 1996; 114 (7): 841–847

    Article  PubMed  CAS  Google Scholar 

  4. Kempen JH, Martin BK, Wu AW, et al. The effect of cytomegalovirus retinitis on the quality of life of patients with AIDS in the era of highly active antiretroviral therapy. Ophthalmology 2003; 110 (5): 987–995

    Article  PubMed  Google Scholar 

  5. Kahraman G, Krepler K, Franz C, et al. Seven years of HAART impact on ophthalmic management of HIV-infected patients. Ocul Immunol Inflamm 2005; 13 (2–3): 213–218

    Article  PubMed  Google Scholar 

  6. Vrabec TR, Baldassano VF, Whitcup SM. Discontinuation of maintenance therapy in patients with quiescent cytomegalovirus retinitis and elevated CD4+ counts. Ophthalmology 1998; 105 (7): 1259–1264

    Article  PubMed  CAS  Google Scholar 

  7. Bertelli D, Stellini R, Cadeo GP. Recurrence of cytomegalovirus retinitis in an HIV-infected patient responsive to highly active antiretroviral therapy late after discontinuation of gancyclovir. AIDS 1999; 13 (13): 1792–1794

    Article  PubMed  CAS  Google Scholar 

  8. Whitcup SM, Fortin E, Lindblad AS, et al. Discontinuation of anticytomegalovirus therapy in patients with HIV infection and cytomegalovirus retinitis. JAMA 1999; 282 (17): 1633–1637

    Article  PubMed  CAS  Google Scholar 

  9. Margolis TP. Discontinuation of anticytomegalovirus therapy in patients with HIV infection and cytomegalovirus retinitis. Surv Ophthalmol 2000; 44 (5): 455

    PubMed  CAS  Google Scholar 

  10. Jouan M, Saves M, Tubiana R, et al. Discontinuation of maintenance therapy for cytomegalovirus retinitis in HIV-infected patients receiving highly active antiretroviral therapy. AIDS 2001; 15 (1): 23–31

    Article  PubMed  CAS  Google Scholar 

  11. Berenguer J, Gonzalez J, Pulido F, et al. Discontinuation of secondary prophylaxis in patients with cytomegalovirus retinitis who have responded to highly active antiretroviral therapy. Clin Infect Dis 2002; 34 (3): 394–397

    Article  PubMed  Google Scholar 

  12. Wohl DA, Kendall MA, Owens S, et al. The safety of discontinuation of maintenance therapy for cytomegalovirus (CMV) retinitis and incidence of immune recovery uveitis following potent antiretroviral therapy. HIV Clin Trials 2005; 6 (3): 136–146

    Article  PubMed  CAS  Google Scholar 

  13. Holland GN. New strategies for the management of AIDS-related CMV retinitis in the era of potent antiretroviral therapy. Ocul Immunol Inflamm 1999; 7 (3–4): 179–188

    Article  PubMed  CAS  Google Scholar 

  14. Palestine AG. Intraocular therapy for cytomegalovirus retinitis. J Int Assoc Physicians AIDS Care 1996; 2 (5): 25–28

    PubMed  CAS  Google Scholar 

  15. Muccioli C, Belfort R Jr. Treatment of cytomegalovirus retinitis with an intraocular sustained-release ganciclovir implant. Braz J Med Biol Res 2000; 33 (7): 779–789

    Article  PubMed  CAS  Google Scholar 

  16. Martin DF, Dunn JP, Davis JL, et al. Use of the ganciclovir implant for the treatment of cytomegalovirus retinitis in the era of potent antiretroviral therapy: recommendations of the International AIDS Society — USA panel. Am J Ophthalmol 1999; 127 (3): 329–339

    Article  PubMed  CAS  Google Scholar 

  17. Sullivan SD, Mozaffari E, Johnson ES, et al. An economic evaluation of oral compared with intravenous ganciclovir for maintenance treatment of newly diagnosed cytomegalovirus retinitis in AIDS patients. Clin Ther 1996; 18 (3): 546–558

    Article  PubMed  CAS  Google Scholar 

  18. Griffiths RI, Bleecker GC, Jabs DA, et al. Pharmacoeconomic analysis of 3 treatment strategies for cytomegalovirus retinitis in patients with AIDS. Pharmacoeconomics 1998; 13 (4): 461–474

    Article  PubMed  CAS  Google Scholar 

  19. Rachlis A, Smaill F, Walker V, et al. Incremental cost-effectiveness analysis of intravenous ganciclovir versus oral ganciclovir in the maintenance treatment of newly diagnosed cytomegalovirus retinitis in patients with AIDS. Pharmacoeconomics 1999; 16 (1): 71–84

    Article  PubMed  CAS  Google Scholar 

  20. Lee TA, Sullivan SD, Veenstra DL, et al. Economic evaluation of systemic treatments for cytomegalovirus retinitis in patients with AIDS. Pharmacoeconomics 2001; 19 (5 Pt 2): 535–550

    Article  PubMed  CAS  Google Scholar 

  21. Martin BK, Gilpin AMK, Jabs DA, et al. Reliability, validity, and responsiveness of general and disease-specific quality of life measures in a clinical trial for cytomegalovirus retinitis. J Clin Epidemiol 2001; 54 (4): 376–386

    Article  PubMed  CAS  Google Scholar 

  22. Bass EB, Marsh MJ, Mangione CM, et al. Patients’ perceptions of the value of current vision: assessment of preference values among patients with subfoveal choroidal neovascularization. The Submacular Surgery Trials Vision Preference Value Scale: SST Report No. 6. Arch Ophthalmon 2004; 122 (12): 1856–1867

    Article  Google Scholar 

  23. Ministry of Health. Bundhamcharoen K, Teerawattananon Y, Theo V, et al. (editors). Burden of disease and injuries in Thailand: priority setting for policy. The Thai Working Group on Burden of Disease and Injuries. Nonthabury (Thailand): Ministry of Health, 2002 [online]. Available from URL: http:// 203.157.19.191/BURDEN.pdf [Accessed 2007 Feb 22]

  24. Tangcharoensathien V, Tantivess S, Teerawattananon Y, et al. Universal coverage and its impact on reproductive health services in Thailand. Reprod Health Matters 2002; 10 (20): 59–69

    Article  PubMed  Google Scholar 

  25. Drew WL, Chou S, Miner RC, et al. Cytomegalovirus glycoprotein B groups in human immunodeficiency virus-infected patients with incident retinitis. J Infect Dis 2002; 186 (1): 114–117

    Article  PubMed  Google Scholar 

  26. Squires KE. Oral ganciclovir for cytomegalovirus retinitis in patients with AIDS: results of two randomized studies. AIDS 1996; 10 Suppl. 4: S13–S18

    PubMed  CAS  Google Scholar 

  27. Ausayakhun S, Yuvaves P, Ngamtiphakorn S, et al. Treatment of cytomegalovirus retinitis in AIDS patients with intravitreal ganciclovir. J Med Assoc Thai 2005; 88 Suppl. 9: S15–S20

    PubMed  Google Scholar 

  28. Musch DC, Martin DF, Gordon JF, et al. Treatment of cytomegalovirus retinitis with a sustained-release ganciclovir implant: the Ganciclovir Implant Study Group. N Engl J Med 1997; 337 (2): 83–90

    Article  PubMed  CAS  Google Scholar 

  29. Thorne JE, Jabs DA, Vitale S, et al. Catheter complications in AIDS patients treated for cytomegalovirus retinitis. AIDS 1998; 12 (17): 2321–2327

    Article  PubMed  CAS  Google Scholar 

  30. Jabs DA, Enger C, Haller J, et al. Retinal detachments in patients with cytomegalovirus retinitis. Arch Ophthalmol 1991; 109 (6): 794–799

    Article  PubMed  CAS  Google Scholar 

  31. Drew WL, Ives D, Lalezari JP, et al. Oral ganciclovir as maintenance treatment for cytomegalovirus retinitis in patients with AIDS. N Engl J Med 1995; 333 (10): 615–620

    Article  PubMed  CAS  Google Scholar 

  32. Salzberger B, Hartmann P, Hanses F, et al. Incidence and prognosis of CMV disease in HIV-infected patients before and after introduction of combination antiretroviral therapy. Infection 2005; 33 (5–6): 345–349

    Article  PubMed  CAS  Google Scholar 

  33. Cheong I, Flegg PJ, Brettle RP, et al. Cytomegalovirus disease in AIDS: the Edinburgh experience. Int J STD AIDS 1992; 3 (5): 324–328

    PubMed  CAS  Google Scholar 

  34. Lewis RA, Carr LM, Doyle K, et al. Long-term follow-up of patients with AIDS treated with parenteral cidofovir for cytomegalovirus retinitis: the HPMPC Peripheral Cytomegalovirus Retinitis Trial. The Studies of Ocular Complications of AIDS Research Group in collaboration with the AIDS Clinical Trials Group. AIDS 2000; 14 (11): 1571–1581

    Article  Google Scholar 

  35. Lertiendumrong J, Yenjitr C, Tangcharoensathien V. Costs and consequences of ART policy in Thailand. Nonthaburi: International Health Policy Program, 2004

    Google Scholar 

  36. Johnson ES, Sullivan SD, Mozaffari E, et al. A utility assessment of oral and intravenous ganciclovir for the maintenance treatment of AIDS-related cytomegalovirus retinitis. Pharmacoeconomics 1996; 10 (6): 623–629

    Article  PubMed  CAS  Google Scholar 

  37. Yenjitr W, Wiriyalapha C, Sribenjarat B, et al. Costs of eye surgery. Thai J Pub Health Ophthalmol 2004; 18 (1): 35–40

    Google Scholar 

  38. Singalavanija A, Sathornsumelee B, Suvette N, et al. Unit cost of retinal detachment surgery. Thai J Pub Health Ophthalmol 2001; 15 (2): 131–137

    Google Scholar 

  39. Whitcup SM. Cytomegalovirus retinitis in the era of highly active antiretroviral therapy. JAMA 2000; 283 (5): 653–657

    Article  PubMed  CAS  Google Scholar 

  40. Teerawattananon Y, Mugford M. Is it worth offering a routine laparoscopic cholecystectomy in developing countries? A Thailand case study. Cost Eff Resour Alloc 2005; 3: 10

    Article  PubMed  Google Scholar 

  41. Teerawattananon Y, Mugford M, Tangcharoensathien V. Economic evaluation of palliative management versus peritoneal dialysis and hemodialysis for end-stage renal disease: evidence for coverage decisions in Thailand. Value Health 2007; 10 (1): 61–72

    Article  PubMed  Google Scholar 

  42. Walsh JC, Jones CD, Barnes EA, et al. Increasing survival in AIDS patients with cytomegalovirus retinitis treated with combination antiretroviral therapy including HIV protease inhibitors. AIDS 1998; 12 (6): 613–618

    Article  PubMed  CAS  Google Scholar 

  43. Petruckevitch A, Del Amo J, Phillips AN, et al. Disease progression and survival following specific AIDS-defining conditions: a retrospective cohort study of 2048 HIV-infected persons in London. AIDS 1998; 12 (9): 1007–1013

    Article  PubMed  CAS  Google Scholar 

  44. Deayton JR, Wilson P, Sabin CA, et al. Changes in the natural history of cytomegalovirus retinitis following the introduction of highly active antiretroviral therapy. AIDS 2000; 14 (9): 1163–1170

    Article  PubMed  CAS  Google Scholar 

  45. International Monetary Fund. The World Economic Outlook Database. Washington, DC, 2004 [online]. Available from URL: http://www.imf.org/external/pubs/ft/weo/2004/01/pdf/front.pdf [Accessed 2007 Mar 26]

  46. Bureau of Trade and Economic Indices [online]. Available from URL: http://www.price.moc.go.th/web4_e/cpi/index.asp [Accessed 2007 Mar 24]

  47. Briggs AH. Handling uncertainty in cost-effectiveness models. Pharmacoeconomics 2000; 17 (5): 479–500

    Article  PubMed  CAS  Google Scholar 

  48. Teerawattananon Y, Tangcharoensathien V. Designing a reproductive health services package in the universal health insurance scheme in Thailand: match and mismatch of need, demand and supply. Health Policy Plan 2004; 19 Suppl. 1: i31–i39

    Article  PubMed  Google Scholar 

  49. Teerawattananon Y, Vos T, Tangcharoensathien V, et al. Cost-effectiveness of models for prevention of vertical HIV transmission: voluntary counseling and testing and choices of drug regimen. Cost Eff Resour Alloc 2005; 3 (1): 7

    Article  PubMed  Google Scholar 

  50. The Commission on Macroeconomics and Health. Macroeconomics and health: investing in health for economic development. Geneva: World Health Organization; 2001

    Google Scholar 

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Acknowledgements

The authors have no conflicts of interest that are directly relevant to the content of this study.

Y. Teerawattananon is the leader of the Health Intervention and Technology Assessment Program (HITAP), which is a research agency responsible for appraising a wide range of health technologies in Thailand. The programme is jointly funded by the Thai Health Foundation, Health System Research Institute, National Health Security Office and the Ministry of Public Health.

The authors appreciate grant support from the National Health Security Office, which is a public agency responsible for the management of the universal health insurance scheme in Thailand.

The authors would especially like to acknowledge and thank Dr Juthalai Tantaterdthum from Siriraj Hospital, Bangkok and Dr Somchai Samaiporn from Lumpang Hospital, Lumpang province, whose expertise was invaluable throughout this study. The authors also thank Miss Sanya Srirattana for her excellent fieldwork, including interviews with study participants. The authors thank all the study participants for their time and contributions to this work.

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Authors and Affiliations

  1. Ophthalmology Unit, Chiangkhum Hospital, Phayao, Thailand

    Kanlaya Teerawattananon & Saniorn Iewsakul

  2. International Health Policy Program, Ministry of Public Health, Nonthaburi, 11000, Thailand

    Chawewan Yenjitr & Yot Teerawattananon

  3. Ophthalmology Department, Chiangmai University, Chiangmai, Thailand

    Somsanguan Ausayakhun

  4. Ophthalmology Unit, Priest Hospital, Bangkok, Thailand

    Watanee Yenjitr

  5. School of Medicine, Health Policy and Practice, University of East Anglia, Norwich, England

    Miranda Mugford

  6. Health Intervention and Technology Assessment Program (HITAP), Nonthaburi, Thailand

    Yot Teerawattananon

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Teerawattananon, K., Iewsakul, S., Yenjitr, C. et al. Economic Evaluation of Treatment Administration Strategies of Ganciclovir for Cytomegalovirus Retinitis in HIV/AIDS Patients in Thailand. Pharmacoeconomics 25, 413–428 (2007). https://doi.org/10.2165/00019053-200725050-00005

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