The epidemiological impact and cost-effectiveness of expanded eligibility for and access to adult

antiretroviral therapy in South Africa, Zambia, India and Vietnam: a twelve model analysis

JW Eaton, NA Menzies, J Stover, V Cambiano, L Chindelevitch, A Cori, JAC Hontelez, S Humair, CC Kerr, DJ Klein, S Mishra, KM Mitchell, BE Nichols, P Vickerman, T Bärnighausen,

A Bershteyn, DE Bloom, M-C Boily, ST Chang, T Cohen, PJ Dodd, C Fraser, C Gopalappa, J Lundgren, NK Martin, E Mountain, QD Pham, M Pickles, A Phillips, L Platt, C Pretorius,

HJ Prudden, JA Salomon, DAMC van de Vijver, BG Wagner, RG White, DP Wilson, L Zhang, J Blandford, G Meyer-Rath, M Remme, F Terris-Prestholt, P Revill, N Sangrujee, M Doherty,

P Easterbrook, G Hirnschall, TB Hallett

7th IAS Conference on HIV Pathogenesis, Treatment and PreventionKuala Lumpur Malaysia, 1 July 2013

Acknowledgements: Ellen McRobie Funding:

Questions for programmes• ART eligibility:

– Given an HIV+ person in care, should they be initiated on ART if they have a CD4 > 350 cells/µL?

• Program scale-up priorities:– Should programmes devote resources to (i) expanding

access following current ART guidelines, or (ii) immediately adopt new ART eligibility guidelines?

• Strategic prioritisation:– Are there certain populations that should be prioritised for

expanded access and earlier ART?

Model analyses

• Eligibility x access strategies projected over 20 years (2014–2033)• US$/DALY averted compared to current access & eligibility

ART eligibility• CD4 ≤350 (current)• CD4 ≤500, all HIV+• Pregnant women,

serodiscrodant couples, >50 years

• MSM, FSW, PWID

ART access• Status quo• Uniformly expanded access• Prioritized expanded

access

Health benefits• Infections averted• Adult mortality• DALYs averted

Costs• ART• Pre-ART• HIV testing & linkage• Other healthcare

Settings:

• South Africa (7 models)• Zambia (4 models)• India (3 models)• Vietnam (1 model)

Mathematical modelsModel Setting Type Age-

struct

General pop

Key populations

Drop-out ART

Goals SA/Zambia

determ.

✓ ✓ couples, preg., CSW, MSM, PWID

✗

STDSIM SA stoch. ✓ ✓ couples, preg., CSW, age > 50

✓

EMOD SA/Zambia

stoch. ✓ ✓ couples, preg, age>50

✓

BBH SA determ.

✗ ✓ CSW, MSM ✗

PopART SA/Zambia

determ.

✗ ✓ ✓

Synthesis SA stoch. ✓ ✓ ✓Menzies SA determ

.✗ ✓ ✗

Macha Zambia determ.

✗ ✓ ✓

Pruddell Bangalore determ.

✗ ✗ CSW, MSM ✓

Mishra Belgaum determ.

✗ ✓ CSW ✓

IDU Manipur

Manipur determ.

✗ ✗ PWID, HCV ✓

Prevtool Vietnam determ.

✗ ✓ CSW, MSM, PWID

✓

Impact on HIV incidenceSouth Africa

Zambia

Impact on HIV incidenceIndia – sexual tranmsission

India – injecting Vietnam

7

1. Cost Areas 2. Services3. Resource

Use4. Unit Costs

5. Total Costs

ART•ARVs (annual)•ART initiation•Non-ARV (annual)

Estimates by models

Reg dist x price

Volume X

Unit Cost,summed

over services and years

Bayesian evidence synthesis

Pre-ART •Pre-ART (annual)

Diagnosis and linkage to care

•HTC•Reaching high risk groups

Utilization in routine health system

•TB treatment•Advanced HIV care•Terminal illness

WHO-CHOICE

Higher-level program support

•Supply-chain mgmt•General support

% mark-up on other costs

Expert opinion Mark-up

Costing approach

8

500 1000 2000 5000 100000

200

400

600

800

Mean estimate from modelResidual from individual studiesSize proportional to sqrt sample size

ART (annual)

500 1000 2000 5000 100000

5

10

15

20

25 HTC (average across modalities)

500 1000 2000 5000 100000

200

400

600

800 Pre-ART (annual)

500 1000 2000 5000 100000

50

100

150

200 ART initiation

500 1000 2000 5000 100000

20406080

100120 Reaching high-risk groups

500 1000 2000 5000 100000

200

400

600

800 TB treatment (per course)

Uni

t Cos

t, 20

12 U

SD

Per Capita GDP (2012 USD)

Unit costs: predictions vs. data

Cost-effectiveness of earlier eligibility

Cost per DALY averted over 20 years (3% discount per annum):

Costs of program expansionIncremental cost of expanded eligibility and access (South Africa; 20 years, undiscounted):

Eligibility for All vs. Status Quo

Expanded Accessvs. Status Quo

Earlier eligibility or expanded access?

Uniform expansion of testing and immediate treatment for all

Treat all HIV-infected persons that in care/will enter care

Current eligibility criteria and testing levels.

Uniform expansion of testing and treat <500

Uniform expansion of testing with no change in eligibility

Treated persons with CD4<500 that are in care/will enter care.

$237/ DALY averted

$795/ DALY averted

Earlier eligibility or expanded access?

Prioritised access in concentrated epidemics

Vietnam: (GDP $1407 pppy)

$2043 / DALY

$24,610 / DALY

$290 / DALY

Conclusions

http://www.hivmodelling.org

• Expanded ART eligibility appears ‘cost-effective’ (CD4 ≤500 or all HIV+).

• Cost of initiating ART vs. waiting are small, given a patient in care.

• Expanded testing and linkage appears ‘cost-effective’ in generalised epidemic settings.

• In concentrated epidemic settings, immediate eligibility and expanded access to high-risk populations appears highly cost-effective.

• Consensus conclusions across many models increases confidence in policy recommendations based on modelling.

• Conclusions must be reevaluated when new data are available (esp. when-to-start trials, community combination prevention trials).

• Other considerations for programmes, e.g. equity.