Is just one pill a day always the best way?
Treatment for HIV involves combining drugs from three different classes of anti-retroviral (ARVs) and there are single pill regimens that contain such combinations. Pills which only have to be taken with one or two others, and only once a day, are also available and are popular.
Drug company patents on single-pill treatments such as Atripla run into the late 2020s, but many of the ARVs in these single pills will be available as generics much sooner. Patents on tenofovir, darunavir and abacavir are due to expire in the next three years for example. Switching to generic drugs would deliver cost savings, but can we balance enthusiasm for savings with that for reducing pill burden? And what is best for the patient?
Andrew Hill and colleagues at Liverpool University have modelled potential cost savings to the NHS as more generics become available. They looked at a scenario where all people taking combined pills switch to equivalent or similar generic ARVs as patents are removed. This would mean one extra pill a day for most people on treatment, averaging at 3.6 pills a day, compared with the current 2.4. Over five years, estimated NHS cost savings would be in the region of £1.25billion.
The audience wasn't stumped for ideas as to what this could be spent on when this was presented in Glasgow - HIV prevention the most common suggestion. But in fact savings would probably be absorbed into the NHS budget, and may help to address some of the concerns relating to overspend in specialised commissioning such as that for HIV. But before we laugh all the way to the bank, we should consider an important perspective - that of the patient.
Do we compromise access to the newest, arguably best, treatments by looking at these options? Many find it easier to take and adhere to fewer pills, and for some only taking one pill is also a matter of personal significance, the medication representing HIV's impact on their life.
Should we always strive to reduce the pill burden? Well, some clinicians do actually question this. For example, for children the determining factor may be the size rather than number of tablets. And for many adults, the shift from taking three tablets to four a day is not significant as long as it doesn't change their combination or side effects. But it is still important that patients are not pressurised into changing the number of pills they take due to a shift in focus from simpler regimens to cheaper regimens. Essentially we cannot risk decisions being made that are not in the best interests of the patient.
What's a sensible approach? One option, for example, would be to use generics as standard but with appropriate safeguards in place for patients where this is not the best option. This could help the NHS to manage the increasing numbers of people accessing services, but such an approach needs to be fully debated. To do this without adverse effects it will involve combined effort from drug companies, commissioners, clinicians, and, critically, patient advocacy groups to ensure optimum outcomes. Generics therefore present opportunities, but also some real challenges.