final program.qxd - Parallels Plesk Panel

PP 4.20
Arising questions on a cost-effectiveness and pharmacoeconomic investigation
focused on diagnosis, management and prevention of osteopenia and
osteoporosis in the setting of HIV disease treated with HAART
Roberto Manfredi, Leonardo Calza
Infectious Diseases, University of Bologna, Italy
Introduction
Osteopenia and/or osteoporosis are emerging untoward effects of HIV infection,
especially when treated with HAART. The pathogenesis is multifactorial, involving all
classes of anti-HIV drugs, although protease inhibitor use, overall HAART duration, and
the male sex, seem related to a greater risk.
Epidemiological and clinical data
In an ongoing study at our Centre where over 1,000 HIV-infected patients (p) are followed,
bone mineral density was assessed in lumbar spine and femural head, by a dual energy
X-ray absorptiometry (DEXA) exam, in order to estimate the prevalence of osteopenia
and/or osteoporosis. In a preliminary screening of around 100 p, the frequency of
osteopenia and osteoporosis (based on lumbar T-score) was around 38% and around
10%, respectively. An increased risk was found in p treated with protease inhibitors
versus those receiving non-nucleoside reverse transcriptase inhibitors or triple
nucleoside/nucleotide analogue combinations.
Discussion and Future Insights
Prospective studies of extensive p samples are needed, to elucidate the epidemiology,
pathogenesis,clinical issues, and evolution of HIV-associated bone metabolism
abnormalities. When planning strategies for their early diagnosis, prevention, and
management, also cost-effectiveness issues should be taken into careful consideration,
since no pharmacoeconomic data still exist in this setting. Although severe consequences
(e.g. pathological fractures, prosthetic implants), are expected to be infrequent, their
consequences in terms of length and intensity of hospitalization,related costs, and
especially severe consequences on the patient's quality of life, play a notable role.
Anyway,the most reliable diagnostic procedure (DEXA) has affordable costs (around Euro
43.40 for a total-body scan which also offers a body composition assessment), as well as
the first-line drugs for osteopenia, e.g. supplementation with calcium (Euro 5-6.5/month),
and vitamin D (Euro 7/month). These costs cannot be compared with the costs of a
standard care of an asymptomatic HAART-treated p (Euro 471 to Euro 774/month), and
the immunological, virological, laboratory, and clinical controls made at least quarterly in
these patients. Like postmenopausal osteopenia and osteoporosis (burdened by a
greater risk of bone mass anomalies), also HIV disease should be investigated from
multiple cost-effectiveness points of view, to establish which p are the preferred
candidates for a DEXA screening, when this examination is more useful during HIV
disease course and therapy, when the exam should be repeated, and when and how to
intervene pharmacologically, to prevent serious and potentially invalidating complications.
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