The Impact of the New WHO Antiretroviral Treatment Guidelines on HIV Epidemic Dynamics and Cost in South Africa

Background: Since November 2009, WHO recommends that adults infected with HIV should initiate antiretroviral therapy (ART) at CD4+ cell counts of <= 350 cells/mu l rather than <= 200 cells/mu l. 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/mu l 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/mu l 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

Cost-effectiveness of trachoma control in seven world regions

BACKGROUND/AIMS: The fight against blinding trachoma is being addressed with an integrated strategy of surgery, antibiotics, hygiene promotion, and environmental improvement-the SAFE strategy, but its cost-effectiveness is largely unknown. This paper estimates the cost effectiveness of surgery and antibiotics in trachoma-endemic areas in seven world regions. METHODS: A population model was applied to follow the lifelong impact on individuals receiving trachoma control. Intervention costs and effectiveness estimates were based on a combination of primary data collection and literature review. RESULTS: Providing trichiasis surgery to 80% of those who need it would avert over 11 million DALYs per year globally, with cost effectiveness ranging from I$13 to I$78 per DALY averted across regions. Mass antibiotic treatment of all children using azythromycin at prevailing market prices would avert more than 4 million DALYs per year globally with cost-effectiveness ranging between I$9,000 and I$65,000 per DALY averted. The intervention is only cost-effective if azythromycin is donated or becomes available at reduced prices. Mass treatment of all children with tetracycline and targeted treatment with azythromycin are not cost-effective. CONCLUSIONS: As individual components of the SAFE strategy, trichiasis surgery for trachoma is a cost-effective way of restoring sight in all epidemiological sub-regions considered, as is the use of azythromycin, if donated or at reduced prices. Large study uncertainties do not change study conclusions. The results should be interpreted in the context of the overall SAFE strategy to address issues of sustainability