The macroeconomic consequences of renouncing to universal access to antiretroviral treatment for HIV in Africa: a micro-simulation model.

Bruno Ventelou,Erik Lamontagne,Robert Greener,Yves Arrighi,Patrizia Carrieri,Jean-Paul Moatti,John Conly

doi:10.1371/journal.pone.0034101

Abstract

AimPrevious economic literature on the cost-effectiveness of antiretroviral treatment (ART) programs has been mainly focused on the microeconomic consequences of alternative use of resources devoted to the fight against the HIV pandemic. We rather aim at forecasting the consequences of alternative scenarios for the macroeconomic performance of countries.MethodsWe used a micro-simulation model based on individuals aged 15–49 selected from nationally representative surveys (DHS for Cameroon, Tanzania and Swaziland) to compare alternative scenarios : 1-freezing of ART programs to current levels of access, 2- universal access (scaling up to 100% coverage by 2015, with two variants defining ART eligibility according to previous or current WHO guidelines). We introduced an “artificial” ageing process by programming methods. Individuals could evolve through different health states: HIV negative, HIV positive (with different stages of the syndrome). Scenarios of ART procurement determine this dynamics. The macroeconomic impact is obtained using sample weights that take into account the resulting age-structure of the population in each scenario and modeling of the consequences on total growth of the economy.ResultsIncreased levels of ART coverage result in decreasing HIV incidence and related mortality. Universal access to ART has a positive impact on workers' productivity; the evaluations performed for Swaziland and Cameroon show that universal access would imply net cost-savings at the scale of the society, when the full macroeconomic consequences are introduced in the calculations. In Tanzania, ART access programs imply a net cost for the economy, but 70% of costs are covered by GDP gains at the 2034 horizon, even in the extended coverage option promoted by WHO guidelines initiating ART at levels of 350 cc/mm3 CD4 cell counts.ConclusionUniversal Access ART scaling-up strategies, which are more costly in the short term, remain the best economic choice in the long term. Renouncing or significantly delaying the achievement of this goal, due to “legitimate” short term budgetary constraints would be a misguided choice.

Highlights

In its strategy for 2011–2015, UNAIDS states that ‘‘a renewed advocacy effort must be launched to encourage the continued commitment of the global North to support development efforts in the global South, with a focus on long-term predictable financing, through multilateral mechanisms’’ [1]
Four antiretroviral treatment (ART) procurement scenarios determine these dynamics through their consequences on survival rates of the affected population and on infection rates in the general population: No Access (S0), Aid Freeze (S1), Universal Access(S2a), and Extended Universal Access (S2b)
Microsimulation of life paths: an illustration Figure 2 presents health trajectories from a Tanzania HIV/AIDS Indicator Survey 2003–04 (THIS) 2003–04 subsample according to the four alternative scenarios

Summary

Introduction

In its strategy for 2011–2015, UNAIDS states that ‘‘a renewed advocacy effort must be launched to encourage the continued commitment of the global North to support development efforts in the global South, with a focus on long-term predictable financing, through multilateral mechanisms’’ [1]. Following the 2001 Declaration of Commitment of the United Nations General Assembly Special Session on HIV/AIDS (UNGASS) and its further 2006 recommendation to scale up services and interventions ‘‘towards the goal of providing universal access to HIV prevention, treatment and care by 2015’’, global funding for HIV programs has spectacularly increased from US$ 1.4 billion in 2000 to 15.6 billion in 2009. HIV infections are fewer than ten years ago, reflecting several factors that include the natural course of the epidemic and the impact of HIV prevention efforts. By the end of 2009, over five million people in low- and middle-income countries were reported to be receiving antiretroviral treatment (ART), including eight countries providing ART to at least 80% of patients in need and 21 additional ones with coverage rates higher than 50%, an achievement that would not have been deemed possible five years ago [3]. Progress has been most noticeable in sub-Saharan Africa the world’s region most hardly hit by the epidemic [4]

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