Identifying Key Drivers of the Impact of an HIV Cure Intervention in Sub-Saharan Africa

Abstract

Background: It is unknown what properties would be required to make an intervention in low income countries that can eradicate or control human immunodeficiency virus (HIV) without antiretroviral therapy (ART) cost-effective.

Methods: We used a model of HIV and ART to investigate the effect of introducing an ART-free viral suppression intervention in 2022 using Zimbabwe as an example country. We assumed that the intervention (cost: $500) would be accessible for 90% of the population, be given to those receiving effective ART, have sufficient efficacy to allow ART interruption in 95%, with a rate of viral rebound of 5% per year in the first 3 months, and a 50% decline in rate with each successive year.

Results: An ART-free viral suppression intervention with these properties would result in >0.53 million disability-adjusted-life-years averted over 2022-2042, with a reduction in HIV program costs of $300 million (8.7% saving). An intervention of this efficacy costing anything up to $1400 is likely to be cost-effective in this setting.

Conclusions: Interventions aimed at curing HIV infection have the potential to improve overall disease burden and to reduce costs. Given the effectiveness and cost of ART, such interventions would have to be inexpensive and highly effective.

Keywords: HIV; antiretroviral therapy; cure; economic evaluation; model.

Figure 1.

Overall program costs (in $m over 20 years; 2022–2042) according to whether or not the antiretroviral therapy (ART)–free viral suppression (AFVS) intervention is introduced (discounted at 3% per annum from 2015). Abbreviations: HIV, human immunodeficiency virus; VL, viral load; WHO, World Health Organization.

Figure 2.

Results of multiway sensitivity analysis showing the effects of (1) efficacy and access of the antiretroviral therapy (ART)–free viral suppression (AFVS) intervention and (2) unit costs, on cost-effectiveness and level of cost saving. In the context of the base case, highlighted—90% of persons with access, 50% reduction in viral rebound rate per year, $22 for cost of viral load (VL), $10 for cost of visits during AFVS—the threshold cost of the AFVS intervention to be cost-effective was $1400, and the threshold to be cost saving was $975. Abbreviation: DALYs, disability-adjusted life years.