A programme to encourage clinicians to switch people to generic antiretroviral drugs saved the NHS almost £10 million in the financial year 2016-2017, Dr Laura Waters of NHS England’s Clinical Reference Group for HIV services told the recent joint British HIV Association (BHIVA) and British Association for Sexual Health and HIV (BASHH) conference in Edinburgh.
However, the switch to new tablets has not been smooth for all patients, with several HIV clinics reporting a higher than expected number of people who did not make the expected switch or needed to go back to their original therapy after switching.
Around two-thirds of NHS England’s spending on HIV medical care is for antiretroviral drugs, with £429 million spent in 2015-2016. Because of the increasing number of people needing lifelong treatment, the drugs budget would continue to grow if action were not taken.
Across the NHS, around 70% of drugs prescribed are produced by generic manufacturers. As the patents of many anti-HIV drugs have now expired, generic versions of these drugs are now available. They have the same active ingredients as branded drugs but are cheaper.
Savings can also be made by switching people from protease inhibitors boosted with ritonavir to protease inhibitors boosted with cobicistat. The latter are now cheaper and are also available in fixed-dose combinations, therefore reducing pill burden. Although ritonavir and cobicistat perform similar functions, this is not a ‘like for like’ switch.
The HIV Clinical Reference Group identified a 'menu' of recommended changes of antiretroviral treatment. While making cost savings was one objective, Waters stressed that this was a programme driven by doctors and patient representatives, in which only clinically appropriate and acceptable switches were recommended. They were:
- Switching from branded abacavir/lamivudine (Kivexa) to a generic equivalent, with no change of pill burden
- Switching from prolonged-release nevirapine (Viramune) to a generic equivalent, with no change of pill burden
- Switching from branded efavirenz/tenofovir DF/emtricitabine (Atripla) to generic efavirenz + branded tenofovir DF/emtricitabine (Truvada), an increase from one pill to two
- Switching from darunavir (Prezista) + ritonavir (Norvir) to darunavir/cobicistat (Rezolsta), a decrease from two pills to one
- Switching from atazanavir (Reyataz) + ritonavir (Norvir) to atazanavir/cobicistat (Evotaz), a decrease from two pills to one.
Although these changes were not fully rolled out in all regions in 2015-2016, almost £10 million was saved in that year, with the greatest savings coming from abacavir/lamivudine (£6,947,000). The efavirenz switch also saved a considerable amount (£1,131,000).
The overall antiretroviral drug budget for NHS England in 2015-2016 was £414 million. This was 3.6% lower than in the previous year, more than the targeted saving of 2.5%. Two-thirds of the savings came from these switches and a third from renegotiating contracts with pharmaceutical companies, who were under pressure to lower prices. For example, the manufacturer of dolutegravir/abacavir/lamivudine (Triumeq) reduced its price to avoid people being switched away from it.