changes to the range of anti-HIV drugs which are most commonly prescribed in
London have resulted in a £7.2 million saving over two years, with no sign of
reduced patient satisfaction or poorer clinical outcomes, Dr Paul Benn told the
British HIV Association (BHIVA) conference on Friday.
to political pressures to reduce spending on the NHS, increasing numbers of
people living with HIV and the high cost of antiretroviral drugs (19% of all
NHA spending on medicines for all conditions in London), in April 2011 NHS commissioners in London
announced changes in prescribing practice for people starting or switching
negotiations with pharmaceutical companies and agreements on reduced prices on
specific drugs (as long as guaranteed quantities were purchased), clinicians
were strongly encouraged to prescribe those drugs, as long as it was clinically
appropriate to do so. Although financial savings were an important driver of
the changes, the ‘recommended’ drugs were all judged to be clinically
equivalent to more expensive alternatives and their use was supported by BHIVA
people beginning antiretroviral therapy for the first time would normally
take efavirenz (Sustiva), with
abacavir and 3TC (Kivexa) as the
nucleoside backbone. This meant that fewer new patients would take tenofovir
and FTC (Truvada), or be prescribed Atripla, which combines efavirenz,
tenofovir and FTC into a single pill.
patients taking a protease inhibitor were recommended to switch to ritonavir-boosted
atazanavir (Reyataz) unless there were
clinical reasons not to. They would not be asked to switch nucleoside backbone.
Moreover, people taking non-protease inhibitor regimens were not meant to be
encouraged to switch.
the BHIVA conference, Paul Benn presented data on the results from April 2011
to December 2012. During this time, 3606 people started treatment for the
first time (12% of all London patients) and 4956 switched regimen (16% of
starting, 53.2% of patients were prescribed efavirenz and 22.4% were prescribed
Kivexa. When switching, 27.6% of
patients were given atazanavir.
2011, use of Kivexa has increased by
28%. But this is from a relatively low base and overall use of Truvada and Atripla remains significantly greater.
use of atazanavir has increased by 41%. While similar numbers of people are
prescribed darunavir, the growth in its usage is slower than it was before the
prescribing changes. Boosted lopinavir (Kaletra)
has lost most of its market share.
treatment switches were motivated by side-effects – in only 8% of cases were
the prescribing guidelines the cause.
to 2012, half of all people starting or switching treatments were asked to
complete a questionnaire. The available responses (from just over 1400
people) suggest very high levels of patient satisfaction. In the list below,
the first figure reflects responses from individuals whose new prescription was
in line with the new guidelines; the second figure is for patients whose
prescription was ‘other’.
- “I was as involved as I wanted to be in this
decision” – 92% and 90% agreed.
potential risks and benefits of the new treatment were explained clearly” – 89%
and 91% agreed.
- “I am happy
with how my clinic managed this aspect of my care” – 95% and 92% agreed.
In terms of
clinical outcomes, Benn presented some key figures, based on just a few months
follow-up. Nonetheless, these are encouraging.
starting HIV treatment with either Kivexa
(as encouraged) or Truvada had
similar baseline viral loads, increases in CD4 cell count and achievement of an
undetectable viral load.
people starting HIV treatment with Truvada,
those starting with Kivexa were just
as likely to have a viral load below 400 copies/ml four months later (91% and
92% respectively). Baseline viral loads and increases in CD4 cell count were
compared to people switching to other drugs, those switching to atazanavir had
the same rate of virological suppression (95% and 95% respectively). Baseline
viral loads and increases in CD4 cell count were also similar.
data do not shed light on some aspects of the prescribing changes that people
were anxious about – for example, whether people on non-protease inhibitor
regimens were asked to switch, whether people with a raised risk of heart
attack were prescribed abacavir (they should be given tenofovir), and whether
there are more long-term side-effects as a result of the changes.
years, £7.2 million has been saved, with implementation across London’s HIV
clinics, Benn said. The approach taken was feasible and showed how
commissioners, clinicians and service users can collaborate to make significant
savings, he concluded.