Expanding ART for Treatment and Prevention of HIV in South Africa: Estimated Cost and Cost-Effectiveness 2011-2050

Abstract

BackgroundAntiretroviral Treatment (ART) significantly reduces HIV transmission. We conducted a cost-effectiveness analysis of the impact of expanded ART in South Africa.MethodsWe model a best case scenario of 90% annual HIV testing coverage in adults 15–49 years old and four ART eligibility scenarios: CD4 count <200 cells/mm3 (current practice), CD4 count <350, CD4 count <500, all CD4 levels. 2011–2050 outcomes include deaths, disability adjusted life years (DALYs), HIV infections, cost, and cost per DALY averted. Service and ART costs reflect South African data and international generic prices. ART reduces transmission by 92%. We conducted sensitivity analyses.ResultsExpanding ART to CD4 count <350 cells/mm3 prevents an estimated 265,000 (17%) and 1.3 million (15%) new HIV infections over 5 and 40 years, respectively. Cumulative deaths decline 15%, from 12.5 to 10.6 million; DALYs by 14% from 109 to 93 million over 40 years. Costs drop $504 million over 5 years and $3.9 billion over 40 years with breakeven by 2013. Compared with the current scenario, expanding to <500 prevents an additional 585,000 and 3 million new HIV infections over 5 and 40 years, respectively. Expanding to all CD4 levels decreases HIV infections by 3.3 million (45%) and costs by $10 billion over 40 years, with breakeven by 2023. By 2050, using higher ART and monitoring costs, all CD4 levels saves $0.6 billion versus current; other ART scenarios cost $9–194 per DALY averted. If ART reduces transmission by 99%, savings from all CD4 levels reach $17.5 billion. Sensitivity analyses suggest that poor retention and predominant acute phase transmission reduce DALYs averted by 26% and savings by 7%.ConclusionIncreasing the provision of ART to <350 cells/mm3 may significantly reduce costs while reducing the HIV burden. Feasibility including HIV testing and ART uptake, retention, and adherence should be evaluated.

The World Must Build On Three Decades Of Scientific Advances To Enable A New Generation To Live Free Of HIV/AIDS

“…Virtually all of the interventions mentioned above have been assessed in computer models of varying sophistication to estimate their impact and cost-effectiveness in different settings. 10,[23][24][25]38,39,45 For example, as noted above, convincing modeling studies 38,39 suggest that widespread implementation of voluntary medical male circumcision in southern Africa and expanded services to prevent infections in infants represent good values in terms of efficacy and cost-effectiveness.…”

“…23,24 And cost-effectiveness analyses suggest that major cost savings resulting from averted HIV infections-$500 million after five years in South Africa alone-might be achieved with an aggressive effort to provide antiretroviral drug therapy to all those in need of it according to current guidelines. 25 Preexposure Prophylaxis Another variation of the use of antiretroviral drugs for prevention has shown promise: an approach called preexposure prophylaxis. A large study published in 2010 found that daily oral use of two antiretroviral drugs provided 44 percent more protection against HIV infection-compared to condom use and other safer sex measures alone-for men and transgendered women who were uninfected and had sex with men.…”

The Impact of the 2013 WHO Antiretroviral Therapy Guidelines on the Feasibility of HIV Population Prevention Trials

“…This result is consistent with fi ndings from prior trials of HIV prevention strategies such as microbicides, in which "overlap" of an intervention to the control note that the value of expanded HIV treatment and prevention programs will depend on their longterm population-level costs and clinical impact, not just their short-term impact on HIV transmission. [57][58][59] Thus, the results of this analysis, and of the cluster-randomized trials we have modeled, will be an imperfect indicator of the full, long-term benefi ts of treatment-as-prevention.…”

Antiretroviral therapy for prevention of HIV transmission: implications for Europe

“…Modelling studies have explored the widespread use of ART but mainly in sub-Saharan settings [72][73][74][75][76][77][78][79][80][81][82][83][84][85][86][87][88][89], in the United States [90;91], in China [92][93][94], Canada [95] and for some specific groups, such as MSM in Australia [36;96;97], in Peru, Ukraine, Kenya and Thailand [98] and in different cities in the United States [99][100][101][102][103]; only a few of them model the HIV epidemic in European countries (MSM in Amsterdam, the Netherlands [104] and in the UK [105][106][107] and people who inject drugs in Russia [108]). They varied in their conclusions, although most have suggested potential appreciable beneficial effects on HIV incidence of introducing ART initiation at a higher CD4 count as a policy at a population level.…”