Changing HIV treatment eligibility under health system constraints in sub-Saharan Africa: investment needs, population health gains, and cost-effectiveness

Abstract

Objective: We estimated the investment needs, population health gains, and cost-effectiveness of different policy options for scaling-up prevention and treatment of HIV in the 10 countries that currently comprise 80% of all people living with HIV in sub-Saharan Africa (Ethiopia, Kenya, Malawi, Mozambique, Nigeria, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe).

Design: We adapted the established STDSIM model to capture the health system dynamics: demand-side and supply-side constraints in the delivery of antiretroviral treatment (ART).

Methods: We compared different scenarios of supply-side (i.e. health system capacity) and demand-side (i.e. health seeking behavior) constraints, and determined the impact of changing guidelines to ART eligibility at any CD4 cell count within these constraints.

Results: Continuing current scale-up would require US$178 billion by 2050. Changing guidelines to ART at any CD4 cell count is cost-effective under all constraints tested in the model, especially in demand-side constrained health systems because earlier initiation prevents loss-to-follow-up of patients not yet eligible. Changing guidelines under current demand-side constraints would avert 1.8 million infections at US$208 per life-year saved.

Conclusion: Treatment eligibility at any CD4 cell count would be cost-effective, even under health system constraints. Excessive loss-to-follow-up and mortality in patients not eligible for treatment can be avoided by changing guidelines in demand-side constrained systems. The financial obligation for sustaining the AIDS response in sub-Saharan Africa over the next 35 years is substantial and requires strong, long-term commitment of policy-makers and donors to continue to allocate substantial parts of their budgets.

Fig. 1

Predicted trends in number of people living with HIV, new HIV infections, people on antiretroviral treatment, and life-years saved (compared with the liability scenario) over the period 2015–2050 for the 10 countries with the largest HIV epidemics in sub-Saharan Africa.

Fig. 2

Average annual HIV treatment and prevention costs in the 10 countries with the largest HIV epidemic in sub-Saharan Africa.

Fig. 3

Incremental costs and life-years of changing guidelines from antiretroviral treatment at CD4⁺ cell counts of 500 cells/μl or less to antiretroviral treatment at any CD4⁺ cell count in the 10 countries with the largest HIV epidemic in sub-Saharan Africa, for five scenarios.