acknowledgements: ellen mcrobie
DESCRIPTION
The epidemiological impact and cost-effectiveness of expanded eligibility for and access to adult antiretroviral therapy in South Africa, Zambia, India and Vietnam: a twelve model analysis. - PowerPoint PPT PresentationTRANSCRIPT
The epidemiological impact and cost-effectiveness of expanded eligibility for and access to adult
antiretroviral therapy in South Africa, Zambia, India and Vietnam: a twelve model analysis
JW Eaton, NA Menzies, J Stover, V Cambiano, L Chindelevitch, A Cori, JAC Hontelez, S Humair, CC Kerr, DJ Klein, S Mishra, KM Mitchell, BE Nichols, P Vickerman, T Bärnighausen,
A Bershteyn, DE Bloom, M-C Boily, ST Chang, T Cohen, PJ Dodd, C Fraser, C Gopalappa, J Lundgren, NK Martin, E Mountain, QD Pham, M Pickles, A Phillips, L Platt, C Pretorius,
HJ Prudden, JA Salomon, DAMC van de Vijver, BG Wagner, RG White, DP Wilson, L Zhang, J Blandford, G Meyer-Rath, M Remme, F Terris-Prestholt, P Revill, N Sangrujee, M Doherty,
P Easterbrook, G Hirnschall, TB Hallett
7th IAS Conference on HIV Pathogenesis, Treatment and PreventionKuala Lumpur Malaysia, 1 July 2013
Acknowledgements: Ellen McRobie Funding:
Questions for programmes• ART eligibility:
– Given an HIV+ person in care, should they be initiated on ART if they have a CD4 > 350 cells/µL?
• Program scale-up priorities:– Should programmes devote resources to (i) expanding
access following current ART guidelines, or (ii) immediately adopt new ART eligibility guidelines?
• Strategic prioritisation:– Are there certain populations that should be prioritised for
expanded access and earlier ART?
Model analyses
• Eligibility x access strategies projected over 20 years (2014–2033)• US$/DALY averted compared to current access & eligibility
ART eligibility• CD4 ≤350 (current)• CD4 ≤500, all HIV+• Pregnant women,
serodiscrodant couples, >50 years
• MSM, FSW, PWID
ART access• Status quo• Uniformly expanded access• Prioritized expanded
access
Health benefits• Infections averted• Adult mortality• DALYs averted
Costs• ART• Pre-ART• HIV testing & linkage• Other healthcare
Settings:
• South Africa (7 models)• Zambia (4 models)• India (3 models)• Vietnam (1 model)
Mathematical modelsModel Setting Type Age-
struct
General pop
Key populations
Drop-out ART
Goals SA/Zambia
determ.
✓ ✓ couples, preg., CSW, MSM, PWID
✗
STDSIM SA stoch. ✓ ✓ couples, preg., CSW, age > 50
✓
EMOD SA/Zambia
stoch. ✓ ✓ couples, preg, age>50
✓
BBH SA determ.
✗ ✓ CSW, MSM ✗
PopART SA/Zambia
determ.
✗ ✓ ✓
Synthesis SA stoch. ✓ ✓ ✓Menzies SA determ
.✗ ✓ ✗
Macha Zambia determ.
✗ ✓ ✓
Pruddell Bangalore determ.
✗ ✗ CSW, MSM ✓
Mishra Belgaum determ.
✗ ✓ CSW ✓
IDU Manipur
Manipur determ.
✗ ✗ PWID, HCV ✓
Prevtool Vietnam determ.
✗ ✓ CSW, MSM, PWID
✓
Impact on HIV incidenceSouth Africa
Zambia
Impact on HIV incidenceIndia – sexual tranmsission
India – injecting Vietnam
7
1. Cost Areas 2. Services3. Resource
Use4. Unit Costs
5. Total Costs
ART•ARVs (annual)•ART initiation•Non-ARV (annual)
Estimates by models
Reg dist x price
Volume X
Unit Cost,summed
over services and years
Bayesian evidence synthesis
Pre-ART •Pre-ART (annual)
Diagnosis and linkage to care
•HTC•Reaching high risk groups
Utilization in routine health system
•TB treatment•Advanced HIV care•Terminal illness
WHO-CHOICE
Higher-level program support
•Supply-chain mgmt•General support
% mark-up on other costs
Expert opinion Mark-up
Costing approach
8
500 1000 2000 5000 100000
200
400
600
800
Mean estimate from modelResidual from individual studiesSize proportional to sqrt sample size
ART (annual)
500 1000 2000 5000 100000
5
10
15
20
25 HTC (average across modalities)
500 1000 2000 5000 100000
200
400
600
800 Pre-ART (annual)
500 1000 2000 5000 100000
50
100
150
200 ART initiation
500 1000 2000 5000 100000
20406080
100120 Reaching high-risk groups
500 1000 2000 5000 100000
200
400
600
800 TB treatment (per course)
Uni
t Cos
t, 20
12 U
SD
Per Capita GDP (2012 USD)
Unit costs: predictions vs. data
Cost-effectiveness of earlier eligibility
Cost per DALY averted over 20 years (3% discount per annum):
Costs of program expansionIncremental cost of expanded eligibility and access (South Africa; 20 years, undiscounted):
Eligibility for All vs. Status Quo
Expanded Accessvs. Status Quo
Earlier eligibility or expanded access?
Uniform expansion of testing and immediate treatment for all
Treat all HIV-infected persons that in care/will enter care
Current eligibility criteria and testing levels.
Uniform expansion of testing and treat <500
Uniform expansion of testing with no change in eligibility
Treated persons with CD4<500 that are in care/will enter care.
$237/ DALY averted
$795/ DALY averted
Earlier eligibility or expanded access?
Prioritised access in concentrated epidemics
Vietnam: (GDP $1407 pppy)
$2043 / DALY
$24,610 / DALY
$290 / DALY
Conclusions
http://www.hivmodelling.org
• Expanded ART eligibility appears ‘cost-effective’ (CD4 ≤500 or all HIV+).
• Cost of initiating ART vs. waiting are small, given a patient in care.
• Expanded testing and linkage appears ‘cost-effective’ in generalised epidemic settings.
• In concentrated epidemic settings, immediate eligibility and expanded access to high-risk populations appears highly cost-effective.
• Consensus conclusions across many models increases confidence in policy recommendations based on modelling.
• Conclusions must be reevaluated when new data are available (esp. when-to-start trials, community combination prevention trials).
• Other considerations for programmes, e.g. equity.