Editors' ChoiceAIDS

Antiretroviral Therapy as Prevention in South Africa

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Science Translational Medicine  07 Mar 2012:
Vol. 4, Issue 124, pp. 124ec40
DOI: 10.1126/scitranslmed.3003951

Antiretroviral therapy (ART) is the good news in the long, heartbreaking story of the HIV pandemic. An estimated 34 million people live with HIV—almost 70% of them in sub-Saharan Africa. But even when resources are poor, ART can increase the life expectancy of HIV-infected people to almost that of their healthy counterparts. And even better were the recent findings that ART can also decrease HIV transmission by 96%. Almost immediately, however, questions were raised about how to best apply this information when resources are limited.

To answer this question, Granich and colleagues modeled the effect of expanding ART for treatment and prevention of HIV in South Africa and estimated the cost-effectiveness. Fortunately for South Africans, this study coincides with a policy change by the South African government: Patients with a CD4 count of ≤350 (rather than the previous value of ≤200) will be eligible for ART, expanding the number of people receiving treatment. (The CD4 count is a marker of immune function and falls as HIV disease progresses.) How will this change the cost-benefit analysis? The authors modeled the best-case scenario, in which 90% of adults are tested and ART is initiated for those with CD4 counts <200, <350, <500, or at all CD4 counts (treating at all CD4 counts is known as “test and treat”) from 2011 to 2050. They estimated that increasing the ART initiation criteria to CD4 <350 would prevent 265,000 (17%) new HIV infections over 5 years and 1.3 million infections over 40 years. Costs drop $504 million over 5 years and $3.9 billion over 40 years, with break-even by 2013. They also estimate that further expanding ART eligibility will prevent more infections and eventually be cost-saving.

These analyses should buoy the confidence of the South African government and their partners as they implement the new National Strategic Plan on HIV, sexually transmitted diseases, and tuberculosis—a task not for the faint-hearted. But the results of the Granich paper mean that testing coverage will need to be high, and linkage to care sustained and robust, for the tide of the HIV epidemic to change.

R. Granich et al., Expanding ART for treatment and prevention of HIV in South Africa: Estimated cost and cost-effectiveness 2011–2050. PLoS ONE 7, e30216 (2012). [Full Text]

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