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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.

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.

SUBMITTER: Eaton JW

PROVIDER: S-EPMC4114402 | biostudies-literature | 2013 Dec

REPOSITORIES: biostudies-literature

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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.

Eaton Jeffrey W JW Menzies Nicolas A NA Stover John J Cambiano Valentina V Chindelevitch Leonid L Cori Anne A Hontelez Jan A C JA Humair Salal S Kerr Cliff C CC Klein Daniel J DJ Mishra Sharmistha S Mitchell Kate M KM Nichols Brooke E BE Vickerman Peter P Bakker Roel R Bärnighausen Till T Bershteyn Anna A Bloom David E DE Boily Marie-Claude MC Chang Stewart T ST Cohen Ted T Dodd Peter J PJ Fraser Christophe C Gopalappa Chaitra C Lundgren Jens J Martin Natasha K NK Mikkelsen Evelinn E Mountain Elisa E Pham Quang D QD Pickles Michael M Phillips Andrew A Platt Lucy L Pretorius Carel C Prudden Holly J HJ Salomon Joshua A JA van de Vijver David A M C DA de Vlas Sake J SJ Wagner Bradley G BG White Richard G RG Wilson David P DP Zhang Lei L Blandford John J Meyer-Rath Gesine G Remme Michelle M Revill Paul P Sangrujee Nalinee N Terris-Prestholt Fern F Doherty Meg M Shaffer Nathan N Easterbrook Philippa J PJ Hirnschall Gottfried G Hallett Timothy B TB

The Lancet. Global health 20131201 1

<h4>Background</h4>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.<h4>Methods</h4>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 cri ...[more]

PMID: 25083415

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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.

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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.

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