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The impact of the new WHO antiretroviral treatment guidelines on HIV epidemic dynamics and cost in South Africa Jan Hontelez 1,2,3 , Sake de Vlas 1 , Frank Tanser 2 , Roel Bakker 1 , Till Bärnighausen 2 , Marie-Louise Newell 2 , Rob Baltussen 3 , Mark Lurie 4 1 Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands 2 Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa 3 Department of Primary and Community Care, Radboud University Nijmegen Medical Center, Netherlands 4 Department of Epidemiology and the International Health Institute, Warren Alpert Medical School, Brown University, Providence, RI, USA

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The impact of the new WHO antiretroviral treatment guidelines on HIV epidemic dynamics and cost in South Africa. Jan Hontelez 1,2,3 , Sake de Vlas 1 , Frank Tanser 2 , Roel Bakker 1 , Till Bärnighausen 2 , Marie-Louise Newell 2 , Rob Baltussen 3 , Mark Lurie 4 - PowerPoint PPT Presentation

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Page 1: Introduction

The impact of the new WHO antiretroviral treatment

guidelines on HIV epidemic dynamics and cost in South

AfricaJan Hontelez1,2,3, Sake de Vlas1, Frank Tanser2, Roel Bakker1, Till

Bärnighausen2, Marie-Louise Newell2, Rob Baltussen3, Mark Lurie4

1Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands

2Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa

3Department of Primary and Community Care, Radboud University Nijmegen Medical Center, Netherlands

4Department of Epidemiology and the International Health Institute, Warren Alpert Medical School, Brown University, Providence, RI, USA

Page 2: Introduction

Introduction

• WHO: treat patients at CD4+ cell counts of ≤350 cells/µL rather than ≤200 cells/µL

• What would be the impact of these new guidelines in South Africa?– HIV epidemic dynamics– ART program costs

Page 3: Introduction

Methods

• STDSIM: an established stochastic microsimulation model– Simulates individuals in a dynamic network of

sexual contacts

• Africa Centre for Health and Population Studies, KwaZulu-Natal, South Africa– Africa Centre Demographic Information System

(ACDIS)1

– Hlabisa Treatment and Care Programme21. Tanser F, Hosegood V, Bärnighausen T, et al. Cohort Profile: Africa Centre Demographic Information System (ACDIS) and

population-based HIV survey. Int J Epidemiol 2008;37:956-62.2. Houlihan CF, Bland R, Mutevedzi P, et al. Cohort Profile: Hlabisa HIV treatment and care programme. Int J Epidemiol 2010

Page 4: Introduction

Model quantification

• Demographic module– Published data from ACDIS

• Sexual behavior module– Published and unpublished data from ACDIS– Used to fine-tune predicted HIV epidemic

• Biological module– Same as in previous STDSIM studies

• Treatment module– Unpublished data form ART cohort

Page 5: Introduction

Methods• ART:

– Reduces infectiousness by 92% 1,2

– Increases survival by a factor 3– Introduced in 2004

• Drop-out rate 1.27%/year based on data3

• Other interventions like condom use, STI treatment, circumcision rates based on literature

1. Attia S, Egger M, Muller M, Zwahlen M, Low N. Sexual transmission of HIV according to viral load and antiretroviral therapy: systematic review and meta-analysis. AIDS 2009; 23:1397-404.

2. Donnell D, Baeten J, Kiarie J, et al. Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis. Lancet 2010; 375: 2092-2098

3. Houlihan CF, Bland R, Mutevedzi P, et al. Cohort Profile: Hlabisa HIV treatment and care programme. Int J Epidemiol 2010

Page 6: Introduction

Cost values

• One-time cost of dying• Costs for testing and treatment 201-350 in ≤200

scenario• Cost of CD4+ testing and monitoring for patients

>350

Annual ART costs (US$) CD4+ count

(cells/µl) at ART initiation

Pre-ART

First year

Second and third year

Subsequent years

0-100 495

3,664

1,435 1,095

101-200 495 3,060 1,284 1,095 201-350 495 2,304 1,095 1,095

1. Harling G, Wood R. The evolving cost of HIV in South Africa: changes in health care cost with duration on antiretroviral therapy for public sector patients. J Acquir Immune Defic Syndr 2007; 45:348-54.

2. Badri M, Maartens G, Mandalia S, et al. Cost-effectiveness of highly active antiretroviral therapy in South Africa. PLoS Med 2006; 3:e4

Page 7: Introduction
Page 8: Introduction

HIV prevalence (15-49)

Page 9: Introduction

Simulations

Effect of ART at ≤350 cells/µL in mid 2010 versus continued treatment at ≤200 cells/µL:

– Period: 2010 – 2040– 1000 model runs– Population size: 280,000

Page 10: Introduction

Epidemic dynamics

28%

30%

48%

37%

Page 11: Introduction

Annual treatment costs

ART at ≤200 cells/µL ART at ≤350 cells/µL

Page 12: Introduction

Cumulative net costs

Page 13: Introduction

Cumulative life-years saved

Page 14: Introduction

Conclusions

• New WHO treatment recommendations require limited initial investments, and result in net cost savings in a limited time-horizon

• Societal benefits are high due to increased number of life-years saved, and better health of treated individuals

Page 15: Introduction

Limitations

• Mathematical models always imprecise

• Cost values were from Cape Town– Studies indicate values are in same range in KwaZulu-

Natal

• Limited health care infrastructure and funding limit full implementation of WHO guidelines

Page 16: Introduction

Thank you for your attention!

For more information, please contact:[email protected]


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