Universal test, treat, and keep: improving ART retention is key in cost-effective HIV control in Uganda

Nicky Mccreesh,Ioannis Andrianakis,Ian Vernon,Trevelyan J Mckinley,Jeremy E Oakley,Richard G White,Michael Goldstein,Rebecca N Nsubuga,Mark Strong,Richard Hayes

doi:10.1186/s12879-017-2420-y

Abstract

BackgroundWith ambitious new UNAIDS targets to end AIDS by 2030, and new WHO treatment guidelines, there is increased interest in the best way to scale-up ART coverage. We investigate the cost-effectiveness of various ART scale-up options in Uganda.MethodsIndividual-based HIV/ART model of Uganda, calibrated using history matching. 22 ART scale-up strategies were simulated from 2016 to 2030, comprising different combinations of six single interventions (1. increased HIV testing rates, 2. no CD4 threshold for ART initiation, 3. improved ART retention, 4. increased ART restart rates, 5. improved linkage to care, 6. improved pre-ART care). The incremental net monetary benefit (NMB) of each intervention was calculated, for a wide range of different willingness/ability to pay (WTP) per DALY averted (health-service perspective, 3% discount rate).ResultsFor all WTP thresholds above $210, interventions including removing the CD4 threshold were likely to be most cost-effective. At a WTP of $715 (1 × per-capita-GDP) interventions to improve linkage to and retention/re-enrolment in HIV care were highly likely to be more cost-effective than interventions to increase rates of HIV testing. At higher WTP (> ~ $1690), the most cost-effective option was ‘Universal Test, Treat, and Keep’ (UTTK), which combines interventions 1–5 detailed above.ConclusionsOur results support new WHO guidelines to remove the CD4 threshold for ART initiation in Uganda. With additional resources, this could be supplemented with interventions aimed at improving linkage to and/or retention in HIV care. To achieve the greatest reductions in HIV incidence, a UTTK policy should be implemented.

Highlights

With ambitious new Joint United Nations Programme on Human immunodeficiency virus (HIV)/AIDS (UNAIDS) targets to end AIDS by 2030, and new World Health Organization (WHO) treatment guidelines, there is increased interest in the best way to scale-up Anti-retroviral therapy (ART) coverage
Data sources and analysis The model was fitted to data on demography and trends in HIV prevalence over time in Uganda; data on sexual behaviour from a rural general population cohort in South-West Uganda [23, 24]; and routinely collected national data on the proportion of HIV+ adults who were on ART, the proportion of ART initiators who started with a CD4 count of
Our results strongly suggest that an increase in the rates of HIV testing in the general population in Uganda is only likely to be a cost-effective option at high willingness/ability to pay (WTP) thresholds, and that it should not be prioritised above interventions to improve linkage to, and retention in, care

Summary

Introduction

With ambitious new UNAIDS targets to end AIDS by 2030, and new WHO treatment guidelines, there is increased interest in the best way to scale-up ART coverage. 2.1 million people were newly infected with HIV. Uganda had an adult (15–49 years) HIV prevalence of 7.3% at the time of the last prevalence survey in 2011, and it is estimated that around 95,000 people were newly infected with the virus in 2014 [2]. The Ugandan Ministry of Health targets are ambitious: their 2015/2016–2019/2020 National HIV and AIDS Strategic Plan sets the goal of a 70% reduction in adult HIV incidence by 2020 [4]. To achieve these goals, ART coverage in Uganda will need to increase dramatically over the few years

Methods

Results

Discussion

Conclusion