The Impact of the New WHO Antiretroviral Treatment Guidelines on HIV Epidemic Dynamics and Cost in South Africa

Jan A C Hontelez,Roel Bakker,Sake J De Vlas,Till Bärnighausen,Frank Tanser,Rob Baltussen,Mark N Lurie,Marie-Louise Newell,Landon Myer

doi:10.1371/journal.pone.0021919

Abstract

BackgroundSince November 2009, WHO recommends that adults infected with HIV should initiate antiretroviral therapy (ART) at CD4+ cell counts of ≤350 cells/µl rather than ≤200 cells/µl. South Africa decided to adopt this strategy for pregnant and TB co-infected patients only. We estimated the impact of fully adopting the new WHO guidelines on HIV epidemic dynamics and associated costs.Methods and FindingWe used an established model of the transmission and control of HIV in specified sexual networks and healthcare settings. We quantified the model to represent Hlabisa subdistrict, KwaZulu-Natal, South Africa. We predicted the HIV epidemic dynamics, number on ART and program costs under the new guidelines relative to treating patients at ≤200 cells/µl for the next 30 years. During the first five years, the new WHO treatment guidelines require about 7% extra annual investments, whereas 28% more patients receive treatment. Furthermore, there will be a more profound impact on HIV incidence, leading to relatively less annual costs after seven years. The resulting cumulative net costs reach a break-even point after on average 16 years.ConclusionsOur study strengthens the WHO recommendation of starting ART at ≤350 cells/µl for all HIV-infected patients. Apart from the benefits associated with many life-years saved, a modest frontloading appears to lead to net savings within a limited time-horizon. This finding is robust to alternative assumptions and foreseeable changes in ART prices and effectiveness. Therefore, South Africa should aim at rapidly expanding its healthcare infrastructure to fully embrace the new WHO guidelines.

Highlights

IntroductionWHO has recently (November 2009) adopted new guidelines calling for earlier initiation of antiretroviral therapy (ART) for people infected with HIV [1]
Apart from the benefits associated with many life-years saved, a modest frontloading appears to lead to net savings within a limited time-horizon
South Africa should aim at rapidly expanding its healthcare infrastructure to fully embrace the new WHO guidelines

Summary

Introduction

WHO has recently (November 2009) adopted new guidelines calling for earlier initiation of antiretroviral therapy (ART) for people infected with HIV [1]. In April 2010 [2], South Africa adopted the new WHO treatment guidelines for pregnant women and for patients with TB co-infection, but decided at this time that the country could not expand the eligibility to all patients as this would overburden the healthcare infrastructure. For non-pregnant and non-TB HIV infected patients, the old strategy of ART at CD4+ cell counts #200 cells/ml remains [3]. While initial costs of adopting the new guidelines will be greater because of the increased number of people eligible for treatment, in the long run costs may be saved because of the reduced number of new infections. We estimated the impact of fully adopting the new WHO guidelines on HIV epidemic dynamics and associated costs

Methods

Results

Discussion

Conclusion