Dataset Information

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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Publications

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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Dataset Information

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

Background

Methods

Findings

Interpretation

Funding

Publications

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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