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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 cost of the ART treatment and care program in the Hlabisa subdistrict of the Umkhanyakunde District, KwaZulu/Natal, South Africa, 2010–2040.A. Annual cost when ART is initiated at ≤200 cells/µl. B. Annual cost when ART is initiated at ≤350 cells/µ. All ART costs concern adults aged 15+ and are stratified by CD4+ cell count at initiation and number of years on ART.
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pone-0021919-g003: Projected cost of the ART treatment and care program in the Hlabisa subdistrict of the Umkhanyakunde District, KwaZulu/Natal, South Africa, 2010–2040.A. Annual cost when ART is initiated at ≤200 cells/µl. B. Annual cost when ART is initiated at ≤350 cells/µ. All ART costs concern adults aged 15+ and are stratified by CD4+ cell count at initiation and number of years on ART.

Mentions: Figures 3A and 3B show the annual costs of treating patients at ≤200 cells/µl and ≤350 cells/µl respectively. Even though the average number of people on ART during the first five years (2011 to 2015) is predicted to be 28% higher under the new guidelines (14,000 versus 11,000, figure 2D), the average estimated annual costs are only 7% higher (US$28.6 million versus $ 26.8 million). This is because costs are mostly incurred by people initiating treatment at ≤100 cells/µl, and under the new WHO guidelines there will be significantly fewer people in this category (figure 3B in red). We predict that annual costs of treating patients at ≤350 cells/µl or ≤200 cells/µl will become equal in 2017 (figure 3), and the cumulative net costs will reach a break-even point in 2026 (figure 4A). Thereafter putting people on ART starting at CD4+ cell counts of ≤350 cells/µl will lead to net cost-savings. This break-even point is subject to stochasticity in the model and may be reached between 2020 and 2033 (gray lines in figure 4). In addition to these cost-savings, the new WHO treatment guidelines will yield about 160,000 life-years saved by 2040 (figure 4B).


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 cost of the ART treatment and care program in the Hlabisa subdistrict of the Umkhanyakunde District, KwaZulu/Natal, South Africa, 2010–2040.A. Annual cost when ART is initiated at ≤200 cells/µl. B. Annual cost when ART is initiated at ≤350 cells/µ. All ART costs concern adults aged 15+ and are stratified by CD4+ cell count at initiation and number of years on ART.
© Copyright Policy
Related In: Results  -  Collection

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

pone-0021919-g003: Projected cost of the ART treatment and care program in the Hlabisa subdistrict of the Umkhanyakunde District, KwaZulu/Natal, South Africa, 2010–2040.A. Annual cost when ART is initiated at ≤200 cells/µl. B. Annual cost when ART is initiated at ≤350 cells/µ. All ART costs concern adults aged 15+ and are stratified by CD4+ cell count at initiation and number of years on ART.
Mentions: Figures 3A and 3B show the annual costs of treating patients at ≤200 cells/µl and ≤350 cells/µl respectively. Even though the average number of people on ART during the first five years (2011 to 2015) is predicted to be 28% higher under the new guidelines (14,000 versus 11,000, figure 2D), the average estimated annual costs are only 7% higher (US$28.6 million versus $ 26.8 million). This is because costs are mostly incurred by people initiating treatment at ≤100 cells/µl, and under the new WHO guidelines there will be significantly fewer people in this category (figure 3B in red). We predict that annual costs of treating patients at ≤350 cells/µl or ≤200 cells/µl will become equal in 2017 (figure 3), and the cumulative net costs will reach a break-even point in 2026 (figure 4A). Thereafter putting people on ART starting at CD4+ cell counts of ≤350 cells/µl will lead to net cost-savings. This break-even point is subject to stochasticity in the model and may be reached between 2020 and 2033 (gray lines in figure 4). In addition to these cost-savings, the new WHO treatment guidelines will yield about 160,000 life-years saved by 2040 (figure 4B).

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