Management of End Stage Renal Disease in Persons Living with HIV: A Cost-Effectiveness Analysis

BACKGROUND: HIV(+) kidney transplant (KT) for persons living with HIV (PLWH) is both safe and effective, with comparable patient and graft survival rates relative to HIV(-) KT. The objective of this study was to evaluate the cost-effectiveness of HIV(+) KT relative to HIV(-) KT and dialysis. METHODS: A decision-tree framework was used to assess the cost-effectiveness of the above treatment options for PLWH. Clinical outcomes at 3 years for KT and effectiveness data (expressed in QALYs) were abstracted from previous publications, when available. Costs were assigned from a payer’s perspective using the US Renal Data System and published literature (expressed in 2014 USD). This analysis assumed a three-year time horizon. Sensitivity analyses were explored to understand how changes in 1) acute KT rejection and 2) KT failure impact cost effectiveness. Limitations include small sample size and short follow up time in referenced studies and a lack of health utility data in HIV positive persons with renal failure. We used TreeAge Software (Williamstown, MA). RESULTS: HIV(+) KT was most cost effective ($299,904/QALY) while both HIV(-) KT ($329,676) and dialysis ($444,645) were dominated, meaning more costly and less effective. Results were sensitive to the higher KT failure (26% vs. 16%) and acute rejection (39% vs. 17%) observed with HIV(-) KT relative to HIV(+) KT. In sensitivity analysis, as HIV(+) KT rejection rates approach 20%, HIV(-) KT becomes a cost-effective option. As HIV(+) KT failure rates approach 26%, HIV(-) KT becomes cost effective. CONCLUSION: Despite its limitations, this analysis demonstrates that HIV(+) kidney transplantation is a cost-effective alternative for PLWH under certain conditions. As KT outcomes, like graft failure and acute rejection rates, continue to improve, it is likely that both HIV positive and negative KT will be cost-effective alternatives to dialysis. DISCLOSURES: All authors: No reported disclosures.