Expanding ART for treatment and prevention of HIV in South Africa: Estimated cost and costeffectiveness 2011-2050

[HIV Ethics & Policy]

From HIV This Week - Issue 98

Expanding ART for treatment and prevention of HIV in South Africa: Estimated cost and costeffectiveness

2011-2050

Granich R, Kahn JG, Bennett R, Holmes CB, Garg N, Serenata C, Sabin ML, Makhlouf-Obermeyer C, De Filippo

Mack C, Williams P, Jones L, Smyth C, Kutch KA, Ying-Ru L, Vitoria M, Souteyrand Y, Crowley S, Korenromp

EL, Williams BG. PLoS One. 2012;7(2):e30216. Epub 2012 Feb 13

Available: 

http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0030216

Antiretroviral treatment (ART) significantly reduces HIV transmission. Granich and colleagues conducted a

cost-effectiveness analysis of the impact of expanded antiretroviral treatment in South Africa. The authors

modelled a best case scenario of 90% annual HIV testing coverage in adults 15-49 years old and four

antiretroviral treatment eligibility scenarios: CD4 count <200 cells/mm(3) (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 antiretroviral treatment costs reflect

South African data and international generic prices. Antiretroviral treatment reduces transmission by 92%.

The authors conducted sensitivity analyses. Expanding antiretroviral treatment to CD4 count <350

cells/mm(3) 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 antiretroviral treatment and monitoring costs, all CD4 levels saves $0.6 billion versus current;

other antiretroviral treatment scenarios cost $9-194 per DALY averted. If antiretroviral treatment 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%.

Increasing the provision of antiretroviral treatment 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.

Abstract: http://www.ncbi.nlm.nih.gov/pubmed/22348000

Editor’s note: The 2010 WHO recommendations for antiretroviral treatment initiation increased the CD4

count eligibility level from under 200 cells/uL to under 350 cells/uL, after expert review of the scientific

evidence concluded that the benefits of earlier HIV treatment are tangible and valuable. This expanded the

numbers of those eligible for treatment globally by 50%, with the result that countries adopting the new

guidelines⎯and many did⎯saw their per cent achievement towards universal access for antiretroviral

treatment drop. South Africa opted to expand treatment at CD4 350 first to pregnant women and

tuberculosis-coinfected patients and then, in August 2011, to all those with CD4 counts at or below 350.

This economic analysis provides a vision of the potential costs of earlier treatment balanced against the

savings from lowered future treatment demand as a result of infections averted with this policy decision. The

analysis also examines the options of treatment initiation at 500 cells/uL and treatment initiation regardless

of CD4 count. Some of parameters seem unrealistic (e.g.1.5% annual programme drop-out, 5-year scale-up

horizon to 90% for sustained annual HIV testing and sustained 90% antiretroviral treatment coverage

[regardless of gender or HIV exposure risk], no consideration of the potential impact of antiretroviral drug

resistance, and no viral load testing to inform adherence counselling and the need for switching regimens in

the base case scenario. However, the case for front-loaded investment in earlier antiretroviral therapy is

compelling nonetheless. This model predicts that South Africa’s change to 350 cells/uL will pay for itself in 4

to 12 years as care shifts from inpatient to ambulatory HIV care and disease burden declines

---------- Forwarded message ----------
From: Hankins, Catherine <hank...@unaids.org>
Date: 13 May 2012 23:11
Subject: HIV This Week - Issue 98
To:

Hi everyone,
Welcome to the 98th issue of HIV This Week !  In this issue, we cover the following topics:

1.      Antiretroviral drug prices
•       Benchmarking antiretroviral drug prices in Latin America
2.      Sex work
•       HIV burden among 99,878 female sex workers in low-income and middle-income countries
•       Male sex workers in Abidjan, Cote d'Ivoire need tailored services
3.      Vaccines
•       How did the RV144 vaccine protect?
4.      Cost-effectiveness
•       Integrating HIV testing, malaria, and diarrhoea prevention in Kenya for maximum impact
•       Cost and cost-effectiveness of expanding antiretroviral treatment access in South Africa
5.      Alcohol
•       Sex for alcohol in South African drinking venues
6.      Breastfeeding
•       Increased risk of early death with perinatal compared to breastmilk-acquired HIV infection
•       Flash-heated breastmilk for HIV-exposed, uninfected infants in urban Tanzania
7.      Genotyping
•       How genotype assays could rationalise decisions about failing second-line treatment regimens
8.      Treatment
•       40% reduction in early mortality on antiretroviral treatment through clinician-nurse support
•       Your response 6 months after you start antiretroviral treatment can predict your outcome
9.      Condoms
•       11% condom breakage in sex work in Karnataka, India
10.     Health System Integration
•       Why don’t treatment-eligible women who test HIV-positive in pregnancy access treatment services?
11.     Workplace
•       Diversity management and HIV-positive employees in the Asian hospitality sector
•       What are the health-related causes of absenteeism among formal sector workers in Namibia?
12.     Ethics and equity
•       Scarcity, therapeutic rationality, and unfair process in antiretroviral treatment access
13.     Nutrition and People Living with HIV
•       Dietary intervention prevents antiretroviral therapy associated lipid problems in Brazil
•       Vitamin D deficiency in HIV-positive Iranians
14.     Monitoring and evaluation
•       Health system strengthening in sub-Saharan Africa means big evaluation challenges
•       Transitioning Avahan, the key population prevention programme to local ownership: the prospective evaluation design


Cate Hankins,   Science Adviser to UNAIDS
Sylvia Béké-Wilson, Assistant
Creative Consulting and Development Works,  Research Consultants


Catherine Hankins BA (Hons) MD MSc CCFP FRCPC
Science Adviser to UNAIDS
Honorary Professor, London School of Hygiene and Tropical Medicine
Email: hank...@unaids.org; catherin...@lshtm.ac.uk