Jeffrey W Eaton1, Nicolas A Menzies2, John Stover3, Valentina Cambiano4, Leonid Chindelevitch5, Anne Cori6, Jan A C Hontelez7, Salal Humair8, Cliff C Kerr9, Daniel J Klein10, Sharmistha Mishra11, Kate M Mitchell12, Brooke E Nichols13, Peter Vickerman12, Roel Bakker14, Till Bärnighausen15, Anna Bershteyn10, David E Bloom8, Marie-Claude Boily1, Stewart T Chang10, Ted Cohen16, Peter J Dodd17, Christophe Fraser6, Chaitra Gopalappa3, Jens Lundgren18, Natasha K Martin19, Evelinn Mikkelsen20, Elisa Mountain1, Quang D Pham9, Michael Pickles1, Andrew Phillips4, Lucy Platt12, Carel Pretorius3, Holly J Prudden12, Joshua A Salomon21, David A M C van de Vijver13, Sake J de Vlas14, Bradley G Wagner10, Richard G White17, David P Wilson9, Lei Zhang9, John Blandford22, Gesine Meyer-Rath23, Michelle Remme12, Paul Revill24, Nalinee Sangrujee22, Fern Terris-Prestholt12, Meg Doherty25, Nathan Shaffer25, Philippa J Easterbrook25, Gottfried Hirnschall25, Timothy B Hallett1. 1. Department of Infectious Disease Epidemiology, Imperial College London, London, UK. 2. Center for Health Decision Science, Harvard School of Public Health, Boston, MA, USA. 3. Futures Institute, Glastonbury, CT, USA. 4. Research Department of Infection and Population Health, University College London, London, UK. 5. Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA. 6. MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College London, London, UK. 7. Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands ; Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Mtubatuba, South Africa ; Nijmegen International Center for Health System Analysis and Education (NICHE), Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands. 8. Harvard School of Public Health, Boston, MA, USA. 9. Kirby Institute, University of New South Wales, Sydney, Australia. 10. Epidemiological Modeling Group, Intellectual Ventures Laboratory, Bellevue, WA, USA. 11. Department of Infectious Disease Epidemiology, Imperial College London, London, UK ; Division of Infectious Diseases, St. Michael's Hospital, University of Toronto, Canada. 12. Social and Mathematical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK. 13. Department of Virology, Erasmus Medical Center, Rotterdam, Netherlands. 14. Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands. 15. Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Mtubatuba, South Africa ; Harvard School of Public Health, Boston, MA, USA. 16. Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA ; Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA. 17. Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK. 18. Copenhagen University Hospital/Rigshospitalet, Copenhagen, Denmark ; University of Copenhagen, Copenhagen, Denmark. 19. School of Social and Community Medicine, University of Bristol, Bristol, UK ; Social and Mathematical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK. 20. Nijmegen International Center for Health System Analysis and Education (NICHE), Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands. 21. Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA ; Center for Health Decision Science, Harvard School of Public Health, Boston, MA, USA. 22. U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA. 23. Center for Global Health and Development, Boston University, Boston, MA, USA ; Health Economics and Epidemiology Research Office, Department of Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa. 24. Centre for Health Economics, University of York, York, UK. 25. Department of HIV/AIDS, World Health Organization, Geneva, Switzerland.
Abstract
BACKGROUND: New WHO guidelines recommend ART initiation for HIV-positive persons with CD4 cell counts ≤500 cells/µL, a higher threshold than was previously recommended. Country decision makers must consider whether to further expand ART eligibility accordingly. METHODS: We used multiple independent mathematical models in four settings-South Africa, Zambia, India, and Vietnam-to evaluate the potential health impact, costs, and cost-effectiveness of different adult ART eligibility criteria under scenarios of current and expanded treatment coverage, with results projected over 20 years. Analyses considered extending eligibility to include individuals with CD4 ≤500 cells/µL or all HIV-positive adults, compared to the previous recommendation of initiation with CD4 ≤350 cells/µL. We assessed costs from a health system perspective, and calculated the incremental cost per DALY averted ($/DALY) to compare competing strategies. Strategies were considered 'very cost-effective' if the $/DALY was less than the country's per capita gross domestic product (GDP; South Africa: $8040, Zambia: $1425, India: $1489, Vietnam: $1407) and 'cost-effective' if $/DALY was less than three times per capita GDP. FINDINGS: In South Africa, the cost per DALY averted of extending ART eligibility to CD4 ≤500 cells/µL ranged from $237 to $1691/DALY compared to 2010 guidelines; in Zambia, expanded eligibility ranged from improving health outcomes while reducing costs (i.e. dominating current guidelines) to $749/DALY. Results were similar in scenarios with substantially expanded treatment access and for expanding eligibility to all HIV-positive adults. Expanding treatment coverage in the general population was therefore found to be cost-effective. In India, eligibility for all HIV-positive persons ranged from $131 to $241/DALY and in Vietnam eligibility for CD4 ≤500 cells/µL cost $290/DALY. In concentrated epidemics, expanded access among key populations was also cost-effective. INTERPRETATION: Earlier ART eligibility is estimated to be very cost-effective in low- and middle-income settings, although these questions should be revisited as further information becomes available. Scaling-up ART should be considered among other high-priority health interventions competing for health budgets. FUNDING: The Bill and Melinda Gates Foundation and World Health Organization.
BACKGROUND: New WHO guidelines recommend ART initiation for HIV-positive persons with CD4 cell counts ≤500 cells/µL, a higher threshold than was previously recommended. Country decision makers must consider whether to further expand ART eligibility accordingly. METHODS: We used multiple independent mathematical models in four settings-South Africa, Zambia, India, and Vietnam-to evaluate the potential health impact, costs, and cost-effectiveness of different adult ART eligibility criteria under scenarios of current and expanded treatment coverage, with results projected over 20 years. Analyses considered extending eligibility to include individuals with CD4 ≤500 cells/µL or all HIV-positive adults, compared to the previous recommendation of initiation with CD4 ≤350 cells/µL. We assessed costs from a health system perspective, and calculated the incremental cost per DALY averted ($/DALY) to compare competing strategies. Strategies were considered 'very cost-effective' if the $/DALY was less than the country's per capita gross domestic product (GDP; South Africa: $8040, Zambia: $1425, India: $1489, Vietnam: $1407) and 'cost-effective' if $/DALY was less than three times per capita GDP. FINDINGS: In South Africa, the cost per DALY averted of extending ART eligibility to CD4 ≤500 cells/µL ranged from $237 to $1691/DALY compared to 2010 guidelines; in Zambia, expanded eligibility ranged from improving health outcomes while reducing costs (i.e. dominating current guidelines) to $749/DALY. Results were similar in scenarios with substantially expanded treatment access and for expanding eligibility to all HIV-positive adults. Expanding treatment coverage in the general population was therefore found to be cost-effective. In India, eligibility for all HIV-positive persons ranged from $131 to $241/DALY and in Vietnam eligibility for CD4 ≤500 cells/µL cost $290/DALY. In concentrated epidemics, expanded access among key populations was also cost-effective. INTERPRETATION: Earlier ART eligibility is estimated to be very cost-effective in low- and middle-income settings, although these questions should be revisited as further information becomes available. Scaling-up ART should be considered among other high-priority health interventions competing for health budgets. FUNDING: The Bill and Melinda Gates Foundation and World Health Organization.
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