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The impact of the new WHO antiretroviral treatment guidelines on HIV epidemic dynamics and cost in South Africa.

Hontelez JA, de Vlas SJ, Tanser F, Bakker R, Bärnighausen T, Newell ML, Baltussen R, Lurie MN - PLoS ONE (2011)

Bottom Line: Furthermore, there will be a more profound impact on HIV incidence, leading to relatively less annual costs after seven years.Apart from the benefits associated with many life-years saved, a modest frontloading appears to lead to net savings within a limited time-horizon.This finding is robust to alternative assumptions and foreseeable changes in ART prices and effectiveness.

View Article: PubMed Central - PubMed

Affiliation: Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands. j.hontelez@erasmusmc.nl

ABSTRACT

Background: Since November 2009, WHO recommends that adults infected with HIV should initiate antiretroviral therapy (ART) at CD4+ cell counts of ≤350 cells/µl rather than ≤200 cells/µl. South Africa decided to adopt this strategy for pregnant and TB co-infected patients only. We estimated the impact of fully adopting the new WHO guidelines on HIV epidemic dynamics and associated costs.

Methods and finding: We used an established model of the transmission and control of HIV in specified sexual networks and healthcare settings. We quantified the model to represent Hlabisa subdistrict, KwaZulu-Natal, South Africa. We predicted the HIV epidemic dynamics, number on ART and program costs under the new guidelines relative to treating patients at ≤200 cells/µl for the next 30 years. During the first five years, the new WHO treatment guidelines require about 7% extra annual investments, whereas 28% more patients receive treatment. Furthermore, there will be a more profound impact on HIV incidence, leading to relatively less annual costs after seven years. The resulting cumulative net costs reach a break-even point after on average 16 years.

Conclusions: Our study strengthens the WHO recommendation of starting ART at ≤350 cells/µl for all HIV-infected patients. Apart from the benefits associated with many life-years saved, a modest frontloading appears to lead to net savings within a limited time-horizon. This finding is robust to alternative assumptions and foreseeable changes in ART prices and effectiveness. Therefore, South Africa should aim at rapidly expanding its healthcare infrastructure to fully embrace the new WHO guidelines.

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Related in: MedlinePlus

Projected impact of ART at CD4+ cell counts of ≤200 /µl (black) and the new WHO treatment guidelines of ART at CD4+ cell counts of ≤350 /µl (gray) on HIV epidemic dynamics in the Hlabisa subdistrict of the Umkhanyakunde District, KwaZulu/Natal, South Africa, 1990–2040.A. HIV prevalence; B. HIV incidence; C. HIV mortality; D. Total number of people on ART. The results reflect the average of 1000 model runs and concern adults (≥15 years). The bar indicates the timing of the initial start of ART distribution in the first clinic (end 2004) till full coverage of all 17 clinics in the area (mid 2010).
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pone-0021919-g002: Projected impact of ART at CD4+ cell counts of ≤200 /µl (black) and the new WHO treatment guidelines of ART at CD4+ cell counts of ≤350 /µl (gray) on HIV epidemic dynamics in the Hlabisa subdistrict of the Umkhanyakunde District, KwaZulu/Natal, South Africa, 1990–2040.A. HIV prevalence; B. HIV incidence; C. HIV mortality; D. Total number of people on ART. The results reflect the average of 1000 model runs and concern adults (≥15 years). The bar indicates the timing of the initial start of ART distribution in the first clinic (end 2004) till full coverage of all 17 clinics in the area (mid 2010).

Mentions: Figure 2 indicates that continued initiation of ART at CD4+ cell counts of ≤200 cells/µl will result in a modest decline of the HIV epidemic over the coming years. After peaking at 24% in 2015, HIV prevalence in adults (aged 15+) is predicted to reduce to 20% in 2040 (figure 2A). Incidence will continuously decrease from 2.6/100 person years in 2010 to 2.0/100 person years in 2040 (figure 2B). Although mortality rates were almost halved over the period 2004–2009, which is consistent with observations [18], we predict a rebound in 2010, associated with mortality in patients on ART (figure 2C). We expect that by 2018 the number of people on ART would have peaked at 11,000, up from 8,000 on treatment in 2010 (figure 2D). The new WHO guidelines of treating patients at ≤350 cells will have a more substantial effect on the epidemic, reducing prevalence to 14% and incidence to 1.5/100 person-years in 2040. Although initially the number of people on ART will peak at about 16,000 in 2018, it will rapidly decline to nearly the same number on treatment in 2040 compared to treatment at ≤200 cells/µl (figure 2D).


The impact of the new WHO antiretroviral treatment guidelines on HIV epidemic dynamics and cost in South Africa.

Hontelez JA, de Vlas SJ, Tanser F, Bakker R, Bärnighausen T, Newell ML, Baltussen R, Lurie MN - PLoS ONE (2011)

Projected impact of ART at CD4+ cell counts of ≤200 /µl (black) and the new WHO treatment guidelines of ART at CD4+ cell counts of ≤350 /µl (gray) on HIV epidemic dynamics in the Hlabisa subdistrict of the Umkhanyakunde District, KwaZulu/Natal, South Africa, 1990–2040.A. HIV prevalence; B. HIV incidence; C. HIV mortality; D. Total number of people on ART. The results reflect the average of 1000 model runs and concern adults (≥15 years). The bar indicates the timing of the initial start of ART distribution in the first clinic (end 2004) till full coverage of all 17 clinics in the area (mid 2010).
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3140490&req=5

pone-0021919-g002: Projected impact of ART at CD4+ cell counts of ≤200 /µl (black) and the new WHO treatment guidelines of ART at CD4+ cell counts of ≤350 /µl (gray) on HIV epidemic dynamics in the Hlabisa subdistrict of the Umkhanyakunde District, KwaZulu/Natal, South Africa, 1990–2040.A. HIV prevalence; B. HIV incidence; C. HIV mortality; D. Total number of people on ART. The results reflect the average of 1000 model runs and concern adults (≥15 years). The bar indicates the timing of the initial start of ART distribution in the first clinic (end 2004) till full coverage of all 17 clinics in the area (mid 2010).
Mentions: Figure 2 indicates that continued initiation of ART at CD4+ cell counts of ≤200 cells/µl will result in a modest decline of the HIV epidemic over the coming years. After peaking at 24% in 2015, HIV prevalence in adults (aged 15+) is predicted to reduce to 20% in 2040 (figure 2A). Incidence will continuously decrease from 2.6/100 person years in 2010 to 2.0/100 person years in 2040 (figure 2B). Although mortality rates were almost halved over the period 2004–2009, which is consistent with observations [18], we predict a rebound in 2010, associated with mortality in patients on ART (figure 2C). We expect that by 2018 the number of people on ART would have peaked at 11,000, up from 8,000 on treatment in 2010 (figure 2D). The new WHO guidelines of treating patients at ≤350 cells will have a more substantial effect on the epidemic, reducing prevalence to 14% and incidence to 1.5/100 person-years in 2040. Although initially the number of people on ART will peak at about 16,000 in 2018, it will rapidly decline to nearly the same number on treatment in 2040 compared to treatment at ≤200 cells/µl (figure 2D).

Bottom Line: Furthermore, there will be a more profound impact on HIV incidence, leading to relatively less annual costs after seven years.Apart from the benefits associated with many life-years saved, a modest frontloading appears to lead to net savings within a limited time-horizon.This finding is robust to alternative assumptions and foreseeable changes in ART prices and effectiveness.

View Article: PubMed Central - PubMed

Affiliation: Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands. j.hontelez@erasmusmc.nl

ABSTRACT

Background: Since November 2009, WHO recommends that adults infected with HIV should initiate antiretroviral therapy (ART) at CD4+ cell counts of ≤350 cells/µl rather than ≤200 cells/µl. South Africa decided to adopt this strategy for pregnant and TB co-infected patients only. We estimated the impact of fully adopting the new WHO guidelines on HIV epidemic dynamics and associated costs.

Methods and finding: We used an established model of the transmission and control of HIV in specified sexual networks and healthcare settings. We quantified the model to represent Hlabisa subdistrict, KwaZulu-Natal, South Africa. We predicted the HIV epidemic dynamics, number on ART and program costs under the new guidelines relative to treating patients at ≤200 cells/µl for the next 30 years. During the first five years, the new WHO treatment guidelines require about 7% extra annual investments, whereas 28% more patients receive treatment. Furthermore, there will be a more profound impact on HIV incidence, leading to relatively less annual costs after seven years. The resulting cumulative net costs reach a break-even point after on average 16 years.

Conclusions: Our study strengthens the WHO recommendation of starting ART at ≤350 cells/µl for all HIV-infected patients. Apart from the benefits associated with many life-years saved, a modest frontloading appears to lead to net savings within a limited time-horizon. This finding is robust to alternative assumptions and foreseeable changes in ART prices and effectiveness. Therefore, South Africa should aim at rapidly expanding its healthcare infrastructure to fully embrace the new WHO guidelines.

Show MeSH
Related in: MedlinePlus