Was the pain worth the gain? Antiretroviral savings from the ‘Improving value’ project and generics use in England

Laura Waters; Philip Aubrey; Janette Harper; Sarah Schoeman; Heather Leake Date; Lizzie Jordan; Peter Sharott; Tracy Palmer; Ian Harrison; Ian Williams

doi:10.7861/clinmedicine.19-2-s76

Aims

Antiretrovirals (ARVs) have transformed HIV prognosis; most individuals will take treatment lifelong and will enjoy a normal life expectancy. Based on 2015/6 ARV expenditure of £429 million in England, the HIV Clinical Reference Group (CRG) and NHS England (NHSE) developed an improving value (IV) scheme for ARVs. This identified a range of ARV switches aiming, where clinically appropriate and acceptable, to yield a 2.5% annual spending reduction over 2 years. Increasing availability of generic drugs also has the potential to reduce drug costs.

Methods

The HIV CRG, a multidisciplinary group including representatives from four England regions, community and specialty societies, developed a menu of switch choices and targets for implementation in 2016/7 and 2017/8, including patient information. Pharmacy submissions were analysed to estimate the impact of the IV project and like-for-like branded to generic switches on drug spend nationally and regionally. We present the impact of three IV switches and two generic switches for 2016/7.

Results

For the 2016/7 financial year, total ARV spend for England was £413.7 million, a 3.56% saving compared with 2015/6; savings ranged from 1.7% in the south to 5.0% in London. Thirty-three per cent of the savings were due to regional contract savings, 50% the nevirapine prolonged-release and abacavir/lamivudine generics substitutions and 17% the three analysed IV switches (equivalent to savings versus 2015/6 of 1.19%, 1.78% and 0.59%, respectively). The value of individual switches for England overall is summarised in Table 1.

View this table:

Table 1.

Value of antiretroviral switches

Focusing on combined savings secondary to only IV switches by region these were: £416,163 in the north, £247,929 in the south, £349,097 in midlands and east and £1,110,599 in London. Uptake of switches was high indicating acceptability to patients, and the importance of community engagement and support.

Conclusion

In England, ARV savings in 2016/7 exceeded the 2.5% target despite more people on treatment. In addition to significant savings secondary to regional contract negotiations and the ‘natural’ switch from branded drugs to generic equivalents, targeted changes of drug formulations, including changes in pill burden, can yield additional large ARV savings. In the current NHS climate we have a duty to work with patients to optimise prescribing efficiency but implementing appropriate, acceptable ARV switch strategies.