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Health benefits, costs, and cost-effectiveness of earlier eligibility for adult antiretroviral therapy and expanded treatment coverage: a combined analysis of 12 mathematical models.

By JW Eaton, NA Menzies, J Stover, V Cambiano, L Chindelevitch, A Cori, JA Hontelez, S Humair, CC Kerr, DJ Klein, S Mishra, KM Mitchell, BE Nichols, P Vickerman, R Bakker, T Bärnighausen, A Bershteyn, DE Bloom, MC Boily, ST Chang, T Cohen, PJ Dodd, C Fraser, C Gopalappa, J Lundgren, NK Martin, E Mikkelsen, E Mountain, QD Pham, M Pickles, A Phillips, L Platt, C Pretorius, HJ Prudden, JA Salomon, DA van de Vijver, SJ de Vlas, BG Wagner, RG White, DP Wilson, L Zhang, J Blandford, G Meyer-Rath, M Remme, P Revill, N Sangrujee, F Terris-Prestholt, M Doherty, N Shaffer, PJ Easterbrook, G Hirnschall and TB Hallett


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

Publisher: Elsevier
Year: 2013
OAI identifier:
Provided by: LSHTM Research Online

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