Abstract
We estimated the investment needs, population health gains, and cost-effectiveness of different policy options for scaling-up prevention and treatment of HIV in the 10 countries that currently comprise 80% of all people living with HIV in sub-Saharan Africa (Ethiopia, Kenya, Malawi, Mozambique, Nigeria, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe). We adapted the established STDSIM model to capture the health system dynamics: demand-side and supply-side constraints in the delivery of antiretroviral treatment (ART). We compared different scenarios of supply-side (i.e. health system capacity) and demand-side (i.e. health seeking behavior) constraints, and determined the impact of changing guidelines to ART eligibility at any CD4 cell count within these constraints. Continuing current scale-up would require US$178 billion by 2050. Changing guidelines to ART at any CD4 cell count is cost-effective under all constraints tested in the model, especially in demand-side constrained health systems because earlier initiation prevents loss-to-follow-up of patients not yet eligible. Changing guidelines under current demand-side constraints would avert 1.8 million infections at US$208 per life-year saved. Treatment eligibility at any CD4 cell count would be cost-effective, even under health system constraints. Excessive loss-to-follow-up and mortality in patients not eligible for treatment can be avoided by changing guidelines in demand-side constrained systems. The financial obligation for sustaining the AIDS response in sub-Saharan Africa over the next 35 years is substantial and requires strong, long-term commitment of policy-makers and donors to continue to allocate substantial parts of their budgets.
Highlights
The fight against HIV in sub-Saharan Africa (SSA) has a strong momentum with the scale-up of treatment and prevention interventions
Changing guidelines to antiretroviral treatment (ART) at any CD4þ cell count is cost-effective under all constraints tested in the model, especially in demand-side constrained health systems because earlier initiation prevents loss-to-follow-up of patients not yet eligible
The optimistic 90-90-90þ scenario provides the largest impact on incidence: from 320 000 per year to only 27 000 and 22 000 new infections
Summary
The fight against HIV in sub-Saharan Africa (SSA) has a strong momentum with the scale-up of treatment and prevention interventions. The number of people receiving antiretroviral treatment (ART) has increased from less than 100 000 in 2004 to almost 12 million in 2015 [1], vastly improving life-expectancy of the general population [2]. Despite these impressive achievements, the HIVepidemic is still very much an unfinished agenda. HIV incidence in SSA remains high [5], and the success of ART means increasing numbers of people require long-term treatment and care [6,7]. Long-term financial commitments through both donor contributions and increased domestic funding of treatment programs are critical if the fight against HIV is to be sustained and further expanded [8,9,10,11]
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