Cost-effectiveness of single, high-dose, liposomal amphotericin regimen for HIV-associated cryptococcal meningitis in five countries in sub-Saharan Africa: an economic analysis of the AMBITION-cm trial
Date
2022Author
Lawrence, David S
Muthoga, Charles
Meya, David B
Tugume, Lillian
Williams, Darlisha
Rajasingham, Radha
Boulware, David R
Mwandumba, Henry C
Moyo, Melanie
Dziwani, Eltas N
Maheswaran, Hendramoorthy
Kanyama, Cecilia
Hosseinipour, Mina C
Chawinga, Chimwemwe
Meintjes, Graeme
Schutz, Charlotte
Comins, Kyla
Bango, Funeka
Muzoora, Conrad
Jjunju, Samuel
Nuwagira, Edwin
Mosepele, Mosepele
Leeme, Tshepo
Ndhlovu, Chiratidzo E
Hlupeni, Admire
Shamu, Shepherd
Boyer-Chammard, Timothée
Molloy, Síle F
Youssouf, Nabila
Chen, Tao
Shiri, Tinevimbo
Jaffar, Shabbar
Harrison, Thomas S
Jarvis, Joseph N
Niessen, Louis W
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Background HIV-associated cryptococcal meningitis is a leading cause of AIDS-related mortality. The AMBITION-cm trial showed that a regimen based on a single high dose of liposomal amphotericin B deoxycholate (AmBisome group) was non-inferior to the WHO-recommended treatment of seven daily doses of amphotericin B deoxycholate (control group) and was associated with fewer adverse events. We present a five-country cost-effectiveness analysis. Methods The AMBITION-cm trial enrolled patients with HIV-associated cryptococcal meningitis from eight hospitals in Botswana, Malawi, South Africa, Uganda, and Zimbabwe. Taking a health service perspective, we collected country-specific unit costs and individual resource-use data per participant over the 10-week trial period, calculating mean cost per participant by group, mean cost-difference between groups, and incremental cost-effectiveness ratio per life-year saved. Non-parametric bootstrapping and scenarios analyses were performed including hypothetical real-world resource use. The trial registration number is ISRCTN72509687, and the trial has been completed. Findings The AMBITION-cm trial enrolled 844 participants, and 814 were included in the intention-to-treat analysis (327 from Uganda, 225 from Malawi, 107 from South Africa, 84 from Botswana, and 71 from Zimbabwe) with 407 in each group, between Jan 31, 2018, and Feb 17, 2021. Using Malawi as a representative example, mean total costs per participant were US$1369 (95% CI 1314–1424) in the AmBisome group and $1237 (1181–1293) in the control group. The incremental cost-effectiveness ratio was $128 (59–257) per life-year saved. Excluding study protocol-driven cost, using a real-world toxicity monitoring schedule, the cost per life-year saved reduced to $80 (15–275). Changes in the duration of the hospital stay and antifungal medication cost showed the greatest effect in sensitivity analyses. Results were similar across countries, with the cost per life-year saved in the real-world scenario ranging from $71 in Botswana to $121 in Uganda. Interpretation The AmBisome regimen was cost-effective at a low incremental cost-effectiveness ratio. The regimen might be even less costly and potentially cost-saving in real-world implementation given the lower drug-related toxicity and the potential for shorter hospital stays.
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