1. Antiretroviral Drugs Data Analysis Peter Sharott

2. High–Level Drug Expenditure Analysis Data sources: – Drug purchase data for 2009: Pharmex database managed by the NHS Commercial Unit – HPA SOPHID patient data for 2008 Analysis: – SHA & Provider level – Expenditure calculated using Basic NHS Prices and contract prices (at either SHA and provider level) – Expenditure including and excluding VAT (NB: no individual provider data will be used in final reports)

3. ARV Data Quality Issues Patient Data – relates 2008 SOPHID data to 2009 drug expenditure and, therefore, does not take account of patient number growth during 2009 Drug Expenditure Data – excludes homecare supplies not processed through pharmacy computer systems – excludes drugs dispensed on hospital and GP FP10 prescriptions and dispensed either by community pharmacies or homecare suppliers (not common practice at present) – excludes drugs supplied by third parties contracted to provide outpatient dispensing service – excludes existing and new drugs used in clinical trials/studies – includes all non-HIV uses such as PEPSE/PEP, Hepatitis B – includes additional prescriptions during swine flu pandemic alert in 2009 – VAT rate in 2009 was 15%, increased back to 17.5% in January 2010

4. Possible Next Steps for Drug Expenditure Data Collection Collect actual drug expenditure data from providers, with a split between hospital supply (to include VAT) and homecare (to exclude VAT) - which time period? Identify numbers and percentage of ART patients on homecare Calculate average costs for homecare service charges (dispensing and delivery) Calculate patient costs using SOPHID 2009 data or Consider an alternative approach based on agreed regimens, stratified for complexity and inclusion of VAT for hospital supplied patients and inclusion of services charges for homecare patients

5. Comparison of ART Regimen Costs RegimenRegimen DrugsMean Annual Cost (excluding VAT) Difference Between Lowest and Highest Annual Cost First LineKivexa + Nevirapine 400 Kivexa + Efavirenz 600 Atripla £5,386 £5,648 £7,290 29.6% 32.3% 41.9% Second LineTruvada + Atazanavir 300 + Ritonavir 100 £8,57240.7% Toxicity Switch Truvada + Raltegravir 800 £11,99263.1% Third Line Multi Drug Resistance Darunavir 1200 + Ritonavir 200 + Etravirine 400 + Raltegravir 800 + Lavimudine 300 + £18,94526.8%

6. National vs Drug Pricing Development of national tariffs, as opposed to local tariffs, raises questions about the need for national drug prices General rule: – generic drugs: prices are contracted at a national level – branded drugs: prices are contracted at a regional level (preferred approach) or at provider level (usually because manufacturers will not tender at regional level) Little incentive for manufacturers to provide lower prices for branded drugs at a national level as there would be no clinical buy-in which could be linked volume commitments For ARVs, a careful risk assessment would be needed to determine whether national contracting would lead to an overall increase in drug prices, rather than a redistribution of current expenditure across England Better approach might be to consider establishing a number of consortia (in addition to London) to undertake a therapeutic tender involving clinicians and commissioners and volume commitments linked to price