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Comparative Study
. 2012 Dec 26;109(52):21271-6.
doi: 10.1073/pnas.1209017110. Epub 2012 Dec 6.

Economics of antiretroviral treatment vs. circumcision for HIV prevention

Till Bärnighausen  1 , David E Bloom, Salal Humair
Affiliations
Comparative Study

Economics of antiretroviral treatment vs. circumcision for HIV prevention

Till Bärnighausen et al. Proc Natl Acad Sci U S A. .

Abstract

The HIV Prevention Trials Network (HPTN) 052 study, which showed the effectiveness of antiretroviral treatment in reducing HIV transmission, has been hailed as a "game changer" in the fight against HIV, prompting calls for scaling up treatment as prevention (TasP). However, it is unclear how TasP can be financed, given flat-lining support for global HIV programs. We assess whether TasP is indeed a game changer or if comparable benefits are obtainable at similar or lower cost by increasing coverage of medical male circumcision (MMC) and antiretroviral treatment (ART) at CD4 <350/μL. We develop a new mathematical model and apply it to South Africa, finding that high ART coverage combined with high MMC coverage provides approximately the same HIV incidence reduction as TasP, for $5 billion less over 2009-2020. MMC outperforms ART significantly in cost per infection averted ($1,096 vs. $6,790) and performs comparably in cost per death averted ($5,198 vs. $5,604). TasP is substantially less cost effective at $8,375 per infection and $7,739 per death averted. The prevention benefits of HIV treatment are largely reaped with high ART coverage. The most cost-effective HIV prevention strategy is to expand MMC coverage and then scale up ART, but the most cost-effective HIV-mortality reduction strategy is to scale up MMC and ART jointly. TasP is cost effective by commonly used absolute benchmarks but it is far less cost effective than MMC and ART. Given South Africa's current annual ART spending, the $5 billion in savings offered by MMC and ART over TasP in the next decade, for similar health benefits, challenges the widely hailed status of TasP as a game changer.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

Fig. 1.
Fig. 1.
The HIV infections model. New 15-y-old HIV-uninfected individuals flow into the HIV-uninfected pools (1). HIV-uninfected individuals participate in sexual activity with HIV-uninfected as well as HIV-infected individuals (2), giving rise to new HIV infections (3), which together with new HIV-infected 15 y olds (4), add to the HIV-infected pool. HIV-infected people progress through different stages of HIV infection (5) until reaching CD4 count <200 µL (6) (purple color indicates people receiving ART).
Fig. 2.
Fig. 2.
HIV incidence in 2020 and cumulative discounted costs 2009–2020 across all scenarios.
Fig. 3.
Fig. 3.
Mortality in HIV-infected people in 2020 and cumulative discounted costs 2009–2020 across all scenarios.
See this image and copyright information in PMC

References

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    1. Economist (June 2, 2011) AIDS: The 30 years war. The Economist.
    1. Hammer SM. Antiretroviral treatment as prevention. N Engl J Med. 2011;365(6):561–562. - PubMed

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