London HIV drug prescribing changes – patient satisfaction and clinical outcomes maintained

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Controversial 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.

In response 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 treatment regimens.

Following 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 guidelines.

Glossary

nucleoside

A precursor to a building block of DNA or RNA. Nucleosides must be chemically changed into nucleotides before they can be used to make DNA or RNA. 

boosting agent

Booster drugs are used to ‘boost’ the effects of protease inhibitors and some other antiretrovirals. Adding a small dose of a booster drug to an antiretroviral makes the liver break down the primary drug more slowly, which means that it stays in the body for longer times or at higher levels. Without the boosting agent, the prescribed dose of the primary drug would be ineffective.

equivalence trial

A clinical trial which aims to demonstrate that a new treatment is no better or worse than an existing treatment. While the two drugs may have similar results in terms of virological response, the new drug may have fewer side-effects, be cheaper or have other advantages. 

virological suppression

Halting of the function or replication of a virus. In HIV, optimal viral suppression is measured as the reduction of viral load (HIV RNA) to undetectable levels and is the goal of antiretroviral therapy.

Specifically, 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.

All 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.

Speaking to 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 London patients).

When starting, 53.2% of patients were prescribed efavirenz and 22.4% were prescribed Kivexa. When switching, 27.6% of patients were given atazanavir.

Since April 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.

Similarly, 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.

Most treatment switches were motivated by side-effects – in only 8% of cases were the prescribing guidelines the cause.

During 2011 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.
  • “The 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.

People 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.

Compared to 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 also similar.

Similarly, 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.

But these 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.

Over two 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.

References

Benn P et al. Therapeutic tendering: an innovative strategy to reduce the cost of antiretroviral therapy. British HIV Association conference, Manchester, abstract O26, April 2013.