Health benefits, costs, and cost-effectiveness of earlier eligibility for adult antiretroviral therapy and expanded treatment coverage: a combined analysis of 12 mathematical models
Authors: Jeffrey W Eaton, Nicolas A Menzies, John Stover, Valentina Cambiano, Leonid Chindelevitch, Anne Cori, Jan A C Hontelez, Salal Humair, Cliff C Kerr, Daniel J Klein, Sharmistha Mishra, Kate M Mitchell, Brooke E Nichols, Peter Vickerman, Roel Bakker, Till Bärnighausen, Anna Bershteyn, David E Bloom, Marie-Claude Boily, Stewart T Chang, Ted Cohen, Peter J Dodd, Christophe Fraser, Chaitra Gopalappa, Jens Lundgren, Natasha K Martin, Evelinn Mikkelsen, Elisa Mountain, Quang D Pham, Michael Pickles, Andrew Phillips, Lucy Platt, Carel Pretorius, Holly J Prudden, Joshua A Salomon, David A M C van de Vijver, Sake J de Vlas, Bradley G Wagner, Richard G White, David P Wilson, Lei Zhang, John Blandford, Gesine Meyer-Rath, Michelle Remme, Paul Revill, Nalinee Sangrujee, Fern Terris-Prestholt, Meg Doherty, Nathan Shaffer, Philippa J Easterbrook, Gottfried Hirnschall, Timothy B Hallett
Journal: The Lancet Global Health (2013)

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.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.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.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.The Bill and Melinda Gates Foundation and World Health Organization.