Health benefits, costs, and cost-effectiveness of earlier eligibility for adult antiretroviral therapy and expanded treatment coverage: a combined analysis of 12 mathematical models
Background: New WHO guidelines recommend initiation of antiretroviral therapy for HIV-positive adults with CD4 counts of 500 cells per μL or less, a higher threshold than was previously recommended. Country decision makers have to decide whether to further expand eligibility for antiretroviral ther...
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Format: | Article |
Language: | English |
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Elsevier
2014-01-01
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Series: | The Lancet Global Health |
Online Access: | http://www.sciencedirect.com/science/article/pii/S2214109X13701724 |
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Jeffrey W Eaton, PhD Nicolas A Menzies, MPH John Stover, MA Valentina Cambiano, MS Leonid Chindelevitch, PhD Anne Cori, PhD Jan A C Hontelez, PhD Salal Humair, PhD Cliff C Kerr, PhD Daniel J Klein, PhD Sharmistha Mishra, MD Kate M Mitchell, PhD Brooke E Nichols, MS Prof. Peter Vickerman, DPhil Roel Bakker, PhD Till Bärnighausen, DSc Anna Bershteyn, PhD Prof. David E Bloom, PhD Marie-Claude Boily, PhD Stewart T Chang, PhD Ted Cohen, DPH Peter J Dodd, PhD Prof. Christophe Fraser, PhD Chaitra Gopalappa, PhD Prof. Jens Lundgren, DMSc Natasha K Martin, DPhil Evelinn Mikkelsen, MSc Elisa Mountain, MSc Quang D Pham, MD Michael Pickles, PhD Prof. Andrew Phillips, PhD Lucy Platt, PhD Carel Pretorius, PhD Holly J Prudden, MSc Prof. Joshua A Salomon, PhD David A M C van de Vijver, PhD Sake J de Vlas, PhD Bradley G Wagner, PhD Richard G White, PhD David P Wilson, PhD Lei Zhang, PhD John Blandford, PhD Gesine Meyer-Rath, PhD Michelle Remme, MSc Paul Revill, PhD Nalinee Sangrujee, PhD Fern Terris-Prestholt, PhD Meg Doherty, PhD Nathan Shaffer, MD Prof. Philippa J Easterbrook, MD Gottfried Hirnschall, MD Prof. Timothy B Hallett, PhD |
spellingShingle |
Jeffrey W Eaton, PhD Nicolas A Menzies, MPH John Stover, MA Valentina Cambiano, MS Leonid Chindelevitch, PhD Anne Cori, PhD Jan A C Hontelez, PhD Salal Humair, PhD Cliff C Kerr, PhD Daniel J Klein, PhD Sharmistha Mishra, MD Kate M Mitchell, PhD Brooke E Nichols, MS Prof. Peter Vickerman, DPhil Roel Bakker, PhD Till Bärnighausen, DSc Anna Bershteyn, PhD Prof. David E Bloom, PhD Marie-Claude Boily, PhD Stewart T Chang, PhD Ted Cohen, DPH Peter J Dodd, PhD Prof. Christophe Fraser, PhD Chaitra Gopalappa, PhD Prof. Jens Lundgren, DMSc Natasha K Martin, DPhil Evelinn Mikkelsen, MSc Elisa Mountain, MSc Quang D Pham, MD Michael Pickles, PhD Prof. Andrew Phillips, PhD Lucy Platt, PhD Carel Pretorius, PhD Holly J Prudden, MSc Prof. Joshua A Salomon, PhD David A M C van de Vijver, PhD Sake J de Vlas, PhD Bradley G Wagner, PhD Richard G White, PhD David P Wilson, PhD Lei Zhang, PhD John Blandford, PhD Gesine Meyer-Rath, PhD Michelle Remme, MSc Paul Revill, PhD Nalinee Sangrujee, PhD Fern Terris-Prestholt, PhD Meg Doherty, PhD Nathan Shaffer, MD Prof. Philippa J Easterbrook, MD Gottfried Hirnschall, MD Prof. Timothy B Hallett, PhD Health benefits, costs, and cost-effectiveness of earlier eligibility for adult antiretroviral therapy and expanded treatment coverage: a combined analysis of 12 mathematical models The Lancet Global Health |
author_facet |
Jeffrey W Eaton, PhD Nicolas A Menzies, MPH John Stover, MA Valentina Cambiano, MS Leonid Chindelevitch, PhD Anne Cori, PhD Jan A C Hontelez, PhD Salal Humair, PhD Cliff C Kerr, PhD Daniel J Klein, PhD Sharmistha Mishra, MD Kate M Mitchell, PhD Brooke E Nichols, MS Prof. Peter Vickerman, DPhil Roel Bakker, PhD Till Bärnighausen, DSc Anna Bershteyn, PhD Prof. David E Bloom, PhD Marie-Claude Boily, PhD Stewart T Chang, PhD Ted Cohen, DPH Peter J Dodd, PhD Prof. Christophe Fraser, PhD Chaitra Gopalappa, PhD Prof. Jens Lundgren, DMSc Natasha K Martin, DPhil Evelinn Mikkelsen, MSc Elisa Mountain, MSc Quang D Pham, MD Michael Pickles, PhD Prof. Andrew Phillips, PhD Lucy Platt, PhD Carel Pretorius, PhD Holly J Prudden, MSc Prof. Joshua A Salomon, PhD David A M C van de Vijver, PhD Sake J de Vlas, PhD Bradley G Wagner, PhD Richard G White, PhD David P Wilson, PhD Lei Zhang, PhD John Blandford, PhD Gesine Meyer-Rath, PhD Michelle Remme, MSc Paul Revill, PhD Nalinee Sangrujee, PhD Fern Terris-Prestholt, PhD Meg Doherty, PhD Nathan Shaffer, MD Prof. Philippa J Easterbrook, MD Gottfried Hirnschall, MD Prof. Timothy B Hallett, PhD |
author_sort |
Jeffrey W Eaton, PhD |
title |
Health benefits, costs, and cost-effectiveness of earlier eligibility for adult antiretroviral therapy and expanded treatment coverage: a combined analysis of 12 mathematical models |
title_short |
Health benefits, costs, and cost-effectiveness of earlier eligibility for adult antiretroviral therapy and expanded treatment coverage: a combined analysis of 12 mathematical models |
title_full |
Health benefits, costs, and cost-effectiveness of earlier eligibility for adult antiretroviral therapy and expanded treatment coverage: a combined analysis of 12 mathematical models |
title_fullStr |
Health benefits, costs, and cost-effectiveness of earlier eligibility for adult antiretroviral therapy and expanded treatment coverage: a combined analysis of 12 mathematical models |
title_full_unstemmed |
Health benefits, costs, and cost-effectiveness of earlier eligibility for adult antiretroviral therapy and expanded treatment coverage: a combined analysis of 12 mathematical models |
title_sort |
health benefits, costs, and cost-effectiveness of earlier eligibility for adult antiretroviral therapy and expanded treatment coverage: a combined analysis of 12 mathematical models |
publisher |
Elsevier |
series |
The Lancet Global Health |
issn |
2214-109X |
publishDate |
2014-01-01 |
description |
Background: New WHO guidelines recommend initiation of antiretroviral therapy for HIV-positive adults with CD4 counts of 500 cells per μL or less, a higher threshold than was previously recommended. Country decision makers have to decide whether to further expand eligibility for antiretroviral therapy accordingly. We aimed to assess the potential health benefits, costs, and cost-effectiveness of various eligibility criteria for adult antiretroviral therapy and expanded treatment coverage.
Methods: We used several independent mathematical models in four settings—South Africa (generalised epidemic, moderate antiretroviral therapy coverage), Zambia (generalised epidemic, high antiretroviral therapy coverage), India (concentrated epidemic, moderate antiretroviral therapy coverage), and Vietnam (concentrated epidemic, low antiretroviral therapy coverage)—to assess the potential health benefits, costs, and cost-effectiveness of various eligibility criteria for adult antiretroviral therapy under scenarios of existing and expanded treatment coverage, with results projected over 20 years. Analyses assessed the extension of eligibility to include individuals with CD4 counts of 500 cells per μL or less, or all HIV-positive adults, compared with the previous (2010) recommendation of initiation with CD4 counts of 350 cells per μL or less. We assessed costs from a health-system perspective, and calculated the incremental cost (in US$) per disability-adjusted life-year (DALY) averted to compare competing strategies. Strategies were regarded very cost effective if the cost per DALY averted was less than the country's 2012 per-head gross domestic product (GDP; South Africa: $8040; Zambia: $1425; India: $1489; Vietnam: $1407) and cost effective if the cost per DALY averted was less than three times the per-head GDP.
Findings: In South Africa, the cost per DALY averted of extending eligibility for antiretroviral therapy to adult patients with CD4 counts of 500 cells per μL or less ranged from $237 to $1691 per DALY averted compared with 2010 guidelines. In Zambia, expansion of eligibility to adults with a CD4 count threshold of 500 cells per μL ranged from improving health outcomes while reducing costs (ie, dominating the previous guidelines) to $749 per DALY averted. In both countries results were similar for expansion of eligibility to all HIV-positive adults, and when substantially expanded treatment coverage was assumed. Expansion of treatment coverage in the general population was also cost effective. In India, the cost for extending eligibility to all HIV-positive adults ranged from $131 to $241 per DALY averted, and in Vietnam extending eligibility to patients with CD4 counts of 500 cells per μL or less cost $290 per DALY averted. In concentrated epidemics, expanded access for key populations was also cost effective.
Interpretation: Our estimates suggest that earlier eligibility for antiretroviral therapy is very cost effective in low-income and middle-income settings, although these estimates should be revisited when more data become available. Scaling up antiretroviral therapy through earlier eligibility and expanded coverage should be considered alongside other high-priority health interventions competing for health budgets.
Funding: Bill & Melinda Gates Foundation, WHO.
|
url |
http://www.sciencedirect.com/science/article/pii/S2214109X13701724 |
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doaj-9bd6c2f8c1b9479a8165b343ebb7c4e92020-11-25T01:54:28ZengElsevierThe Lancet Global Health2214-109X2014-01-0121e23e3410.1016/S2214-109X(13)70172-4Health benefits, costs, and cost-effectiveness of earlier eligibility for adult antiretroviral therapy and expanded treatment coverage: a combined analysis of 12 mathematical modelsJeffrey W Eaton, PhD0Nicolas A Menzies, MPH1John Stover, MA2Valentina Cambiano, MS3Leonid Chindelevitch, PhD4Anne Cori, PhD5Jan A C Hontelez, PhD6Salal Humair, PhD7Cliff C Kerr, PhD8Daniel J Klein, PhD9Sharmistha Mishra, MD10Kate M Mitchell, PhD11Brooke E Nichols, MS12Prof. Peter Vickerman, DPhil13Roel Bakker, PhD14Till Bärnighausen, DSc15Anna Bershteyn, PhD16Prof. David E Bloom, PhD17Marie-Claude Boily, PhD18Stewart T Chang, PhD19Ted Cohen, DPH20Peter J Dodd, PhD21Prof. Christophe Fraser, PhD22Chaitra Gopalappa, PhD23Prof. Jens Lundgren, DMSc24Natasha K Martin, DPhil25Evelinn Mikkelsen, MSc26Elisa Mountain, MSc27Quang D Pham, MD28Michael Pickles, PhD29Prof. Andrew Phillips, PhD30Lucy Platt, PhD31Carel Pretorius, PhD32Holly J Prudden, MSc33Prof. Joshua A Salomon, PhD34David A M C van de Vijver, PhD35Sake J de Vlas, PhD36Bradley G Wagner, PhD37Richard G White, PhD38David P Wilson, PhD39Lei Zhang, PhD40John Blandford, PhD41Gesine Meyer-Rath, PhD42Michelle Remme, MSc43Paul Revill, PhD44Nalinee Sangrujee, PhD45Fern Terris-Prestholt, PhD46Meg Doherty, PhD47Nathan Shaffer, MD48Prof. Philippa J Easterbrook, MD49Gottfried Hirnschall, MD50Prof. Timothy B Hallett, PhD51Department of Infectious Disease Epidemiology, Imperial College London, London, UKCenter for Health Decision Science, Harvard School of Public Health, Boston, MA, USAFutures Institute, Glastonbury, CT, USAResearch Department of Infection and Population Health, University College London, London, UKDepartment of Global Health and Population, Harvard School of Public Health, Boston, MA, USAMRC Centre for Outbreak Analysis and Modelling, Imperial College London, London, UKDepartment of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, NetherlandsDepartment of Global Health and Population, Harvard School of Public Health, Boston, MA, USAKirby Institute, University of New South Wales, Sydney, AustraliaInstitute for Disease Modelling, Intellectual Ventures Laboratory, Bellevue, WA, USADepartment of Infectious Disease Epidemiology, Imperial College London, London, UKSocial and Mathematical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UKDepartment of Virology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, NetherlandsSocial and Mathematical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UKDepartment of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, NetherlandsDepartment of Global Health and Population, Harvard School of Public Health, Boston, MA, USAInstitute for Disease Modelling, Intellectual Ventures Laboratory, Bellevue, WA, USADepartment of Global Health and Population, Harvard School of Public Health, Boston, MA, USADepartment of Infectious Disease Epidemiology, Imperial College London, London, UKInstitute for Disease Modelling, Intellectual Ventures Laboratory, Bellevue, WA, USADepartment of Epidemiology, Harvard School of Public Health, Boston, MA, USADepartment of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UKMRC Centre for Outbreak Analysis and Modelling, Imperial College London, London, UKFutures Institute, Glastonbury, CT, USACentre for Viral Diseases, Department of Infectious Diseases, Rigshospitalet–Copenhagen University Hospital, Copenhagen, DenmarkSocial and Mathematical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UKNijmegen International Center for Health System Analysis and Education (NICHE), Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, NetherlandsDepartment of Infectious Disease Epidemiology, Imperial College London, London, UKKirby Institute, University of New South Wales, Sydney, AustraliaDepartment of Infectious Disease Epidemiology, Imperial College London, London, UKResearch Department of Infection and Population Health, University College London, London, UKSocial and Mathematical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UKFutures Institute, Glastonbury, CT, USASocial and Mathematical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UKCenter for Health Decision Science, Harvard School of Public Health, Boston, MA, USADepartment of Virology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, NetherlandsDepartment of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, NetherlandsInstitute for Disease Modelling, Intellectual Ventures Laboratory, Bellevue, WA, USADepartment of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UKKirby Institute, University of New South Wales, Sydney, AustraliaKirby Institute, University of New South Wales, Sydney, AustraliaDivision of Global HIV/AIDS, US Centers for Disease Control and Prevention, Atlanta, GA, USACenter for Global Health and Development, Boston University, Boston, MA, USASocial and Mathematical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UKCentre for Health Economics, University of York, York, UKDivision of Global HIV/AIDS, US Centers for Disease Control and Prevention, Atlanta, GA, USASocial and Mathematical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UKDepartment of HIV/AIDS, WHO, Geneva, SwitzerlandDepartment of HIV/AIDS, WHO, Geneva, SwitzerlandDepartment of HIV/AIDS, WHO, Geneva, SwitzerlandDepartment of HIV/AIDS, WHO, Geneva, SwitzerlandDepartment of Infectious Disease Epidemiology, Imperial College London, London, UK Background: New WHO guidelines recommend initiation of antiretroviral therapy for HIV-positive adults with CD4 counts of 500 cells per μL or less, a higher threshold than was previously recommended. Country decision makers have to decide whether to further expand eligibility for antiretroviral therapy accordingly. We aimed to assess the potential health benefits, costs, and cost-effectiveness of various eligibility criteria for adult antiretroviral therapy and expanded treatment coverage. Methods: We used several independent mathematical models in four settings—South Africa (generalised epidemic, moderate antiretroviral therapy coverage), Zambia (generalised epidemic, high antiretroviral therapy coverage), India (concentrated epidemic, moderate antiretroviral therapy coverage), and Vietnam (concentrated epidemic, low antiretroviral therapy coverage)—to assess the potential health benefits, costs, and cost-effectiveness of various eligibility criteria for adult antiretroviral therapy under scenarios of existing and expanded treatment coverage, with results projected over 20 years. Analyses assessed the extension of eligibility to include individuals with CD4 counts of 500 cells per μL or less, or all HIV-positive adults, compared with the previous (2010) recommendation of initiation with CD4 counts of 350 cells per μL or less. We assessed costs from a health-system perspective, and calculated the incremental cost (in US$) per disability-adjusted life-year (DALY) averted to compare competing strategies. Strategies were regarded very cost effective if the cost per DALY averted was less than the country's 2012 per-head gross domestic product (GDP; South Africa: $8040; Zambia: $1425; India: $1489; Vietnam: $1407) and cost effective if the cost per DALY averted was less than three times the per-head GDP. Findings: In South Africa, the cost per DALY averted of extending eligibility for antiretroviral therapy to adult patients with CD4 counts of 500 cells per μL or less ranged from $237 to $1691 per DALY averted compared with 2010 guidelines. In Zambia, expansion of eligibility to adults with a CD4 count threshold of 500 cells per μL ranged from improving health outcomes while reducing costs (ie, dominating the previous guidelines) to $749 per DALY averted. In both countries results were similar for expansion of eligibility to all HIV-positive adults, and when substantially expanded treatment coverage was assumed. Expansion of treatment coverage in the general population was also cost effective. In India, the cost for extending eligibility to all HIV-positive adults ranged from $131 to $241 per DALY averted, and in Vietnam extending eligibility to patients with CD4 counts of 500 cells per μL or less cost $290 per DALY averted. In concentrated epidemics, expanded access for key populations was also cost effective. Interpretation: Our estimates suggest that earlier eligibility for antiretroviral therapy is very cost effective in low-income and middle-income settings, although these estimates should be revisited when more data become available. Scaling up antiretroviral therapy through earlier eligibility and expanded coverage should be considered alongside other high-priority health interventions competing for health budgets. Funding: Bill & Melinda Gates Foundation, WHO. http://www.sciencedirect.com/science/article/pii/S2214109X13701724 |