Cost-Utility Analysis of Dolutegravir Versus Efavirenz-Based Regimens for HIV Treatment in Indonesia: A Model-Based Extrapolation From Primary Healthcare Settings

Abstract

OBJECTIVES: Dolutegravir-based therapy (tenofovir/lamivudine/dolutegravir [TLD]) is recommended by the World Health Organization as the preferred first-line regimen for HIV treatment due to its superior efficacy and safety profile. However, local economic evidence supporting this recommendation in Indonesia remains limited. This study evaluated the cost utility of TLD compared with efavirenz-based therapy (tenofovir/lamivudine/efavirenz [TLE]) using real-world data from primary healthcare settings. METHODS: A Markov model was developed to estimate lifetime costs and health outcomes of TLD and TLE from the healthcare payer's perspective. The model included 3 mutually exclusive health states: suppressed, unsuppressed, and death. Primary data on treatment outcomes were collected from multiple primary healthcare facilities in Bandung, Indonesia. Costs included drug acquisition and routine monitoring based on national tariffs. Costs and outcomes were discounted at 3% annually. Deterministic, probabilistic, and scenario analyses were conducted to assess uncertainty. RESULTS: In the base case, TLD was less costly and more effective than TLE, indicating dominance. Probabilistic sensitivity analysis demonstrated decision uncertainty, with simulations distributed across cost-effectiveness quadrants, although TLD was favored in most iterations. The cost-effectiveness acceptability curve showed a probability exceeding 90% across commonly used thresholds. Scenario analysis incorporating resistance-related switching produced consistent findings, with TLD remaining economically favorable. Results were most sensitive to treatment costs and baseline viral suppression. At a benchmark of approximately 1 × gross domestic product per capita (≈IDR 83 to 84 million per quality-adjusted life-years), TLD remained economically favorable. CONCLUSION: TLD is likely to be cost-effective for HIV management in Indonesia, while acknowledging decision uncertainty.

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