Health benefits, costs, and cost-effectiveness of earlier eligibility for adult antiretroviral therapy and expanded treatment coverage: a combined analysis of 12 mathematical models

Jeffrey W Eaton; Nicolas A Menzies; John Stover; Valentina Cambiano; Leonid Chindelevitch; Anne Cori; Jan A C Hontelez; Salal Humair; Cliff C Kerr; Daniel J Klein; Sharmistha Mishra; Kate M Mitchell; Brooke E Nichols; Peter Vickerman; Roel Bakker; Till Bärnighausen; Anna Bershteyn; David E Bloom; Marie-Claude Boily; Stewart T Chang; Ted Cohen; Peter J Dodd; Christophe Fraser; Chaitra Gopalappa; Jens Lundgren; Natasha K Martin; Evelinn Mikkelsen; Elisa Mountain; Quang D Pham; Michael Pickles; Andrew Phillips; Lucy Platt; Carel Pretorius; Holly J Prudden; Joshua A Salomon; David A M C van de Vijver; Sake J de Vlas; Bradley G Wagner; Richard G White; David P Wilson; Lei Zhang; John Blandford; Gesine Meyer-Rath; Michelle Remme; Paul Revill; Nalinee Sangrujee; Fern Terris-Prestholt; Meg Doherty; Nathan Shaffer; Philippa J Easterbrook; Gottfried Hirnschall; Timothy B Hallett

doi:10.1016/S2214-109X(13)70172-4

Health benefits, costs, and cost-effectiveness of earlier eligibility for adult antiretroviral therapy and expanded treatment coverage: a combined analysis of 12 mathematical models

Jeffrey W Eaton, Nicolas A Menzies, John Stover, Valentina Cambiano, Leonid Chindelevitch, Anne Cori, Jan A C Hontelez, Salal Humair, Cliff C Kerr, Daniel J Klein, Sharmistha Mishra, Kate M Mitchell, Brooke E Nichols, Peter Vickerman, Roel Bakker, Till Bärnighausen, Anna Bershteyn, David E Bloom, Marie-Claude Boily, Stewart T ChangTed Cohen, Peter J Dodd, Christophe Fraser, Chaitra Gopalappa, Jens Lundgren, Natasha K Martin, Evelinn Mikkelsen, Elisa Mountain, Quang D Pham, Michael Pickles, Andrew Phillips, Lucy Platt, Carel Pretorius, Holly J Prudden, Joshua A Salomon, David A M C van de Vijver, Sake J de Vlas, Bradley G Wagner, Richard G White, David P Wilson, Lei Zhang, John Blandford, Gesine Meyer-Rath, Michelle Remme, Paul Revill, Nalinee Sangrujee, Fern Terris-Prestholt, Meg Doherty, Nathan Shaffer, Philippa J Easterbrook, Gottfried Hirnschall, Timothy B Hallett

Institut for Klinisk Medicin

145 Citationer (Scopus)

Abstract

BACKGROUND: New WHO guidelines recommend initiation of antiretroviral therapy for HIV-positive adults with CD4 counts of 500 cells per μL or less, a higher threshold than was previously recommended. Country decision makers have to decide whether to further expand eligibility for antiretroviral therapy accordingly. We aimed to assess the potential health benefits, costs, and cost-effectiveness of various eligibility criteria for adult antiretroviral therapy and expanded treatment coverage.

METHODS: We used several independent mathematical models in four settings-South Africa (generalised epidemic, moderate antiretroviral therapy coverage), Zambia (generalised epidemic, high antiretroviral therapy coverage), India (concentrated epidemic, moderate antiretroviral therapy coverage), and Vietnam (concentrated epidemic, low antiretroviral therapy coverage)-to assess the potential health benefits, costs, and cost-effectiveness of various eligibility criteria for adult antiretroviral therapy under scenarios of existing and expanded treatment coverage, with results projected over 20 years. Analyses assessed the extension of eligibility to include individuals with CD4 counts of 500 cells per μL or less, or all HIV-positive adults, compared with the previous (2010) recommendation of initiation with CD4 counts of 350 cells per μL or less. We assessed costs from a health-system perspective, and calculated the incremental cost (in US$) per disability-adjusted life-year (DALY) averted to compare competing strategies. Strategies were regarded very cost effective if the cost per DALY averted was less than the country's 2012 per-head gross domestic product (GDP; South Africa: $8040; Zambia: $1425; India: $1489; Vietnam: $1407) and cost effective if the cost per DALY averted was less than three times the per-head GDP.

FINDINGS: In South Africa, the cost per DALY averted of extending eligibility for antiretroviral therapy to adult patients with CD4 counts of 500 cells per μL or less ranged from $237 to $1691 per DALY averted compared with 2010 guidelines. In Zambia, expansion of eligibility to adults with a CD4 count threshold of 500 cells per μL ranged from improving health outcomes while reducing costs (ie, dominating the previous guidelines) to $749 per DALY averted. In both countries results were similar for expansion of eligibility to all HIV-positive adults, and when substantially expanded treatment coverage was assumed. Expansion of treatment coverage in the general population was also cost effective. In India, the cost for extending eligibility to all HIV-positive adults ranged from $131 to $241 per DALY averted, and in Vietnam extending eligibility to patients with CD4 counts of 500 cells per μL or less cost $290 per DALY averted. In concentrated epidemics, expanded access for key populations was also cost effective.

INTERPRETATION: Our estimates suggest that earlier eligibility for antiretroviral therapy is very cost effective in low-income and middle-income settings, although these estimates should be revisited when more data become available. Scaling up antiretroviral therapy through earlier eligibility and expanded coverage should be considered alongside other high-priority health interventions competing for health budgets.

FUNDING: Bill & Melinda Gates Foundation, WHO.

Originalsprog	Engelsk
Tidsskrift	The Lancet Global Health
Vol/bind	2
Udgave nummer	1
Sider (fra-til)	e23-34
Antal sider	12
ISSN	2214-109X
DOI	https://doi.org/10.1016/S2214-109X(13)70172-4
Status	Udgivet - jan. 2014

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10.1016/S2214-109X(13)70172-4

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Eaton, J. W., Menzies, N. A., Stover, J., Cambiano, V., Chindelevitch, L., Cori, A., Hontelez, J. A. C., Humair, S., Kerr, C. C., Klein, D. J., Mishra, S., Mitchell, K. M., Nichols, B. E., Vickerman, P., Bakker, R., Bärnighausen, T., Bershteyn, A., Bloom, D. E., Boily, M-C., ... Hallett, T. B. (2014). Health benefits, costs, and cost-effectiveness of earlier eligibility for adult antiretroviral therapy and expanded treatment coverage: a combined analysis of 12 mathematical models. The Lancet Global Health, 2(1), e23-34. https://doi.org/10.1016/S2214-109X(13)70172-4

Health benefits, costs, and cost-effectiveness of earlier eligibility for adult antiretroviral therapy and expanded treatment coverage : a combined analysis of 12 mathematical models. / Eaton, Jeffrey W; Menzies, Nicolas A; Stover, John et al.

I: The Lancet Global Health, Bind 2, Nr. 1, 01.2014, s. e23-34.

Publikation: Bidrag til tidsskrift › Tidsskriftartikel › Forskning › peer review

Eaton, JW, Menzies, NA, Stover, J, Cambiano, V, Chindelevitch, L, Cori, A, Hontelez, JAC, Humair, S, Kerr, CC, Klein, DJ, Mishra, S, Mitchell, KM, Nichols, BE, Vickerman, P, Bakker, R, Bärnighausen, T, Bershteyn, A, Bloom, DE, Boily, M-C, Chang, ST, Cohen, T, Dodd, PJ, Fraser, C, Gopalappa, C, Lundgren, J, Martin, NK, Mikkelsen, E, Mountain, E, Pham, QD, Pickles, M, Phillips, A, Platt, L, Pretorius, C, Prudden, HJ, Salomon, JA, van de Vijver, DAMC, de Vlas, SJ, Wagner, BG, White, RG, Wilson, DP, Zhang, L, Blandford, J, Meyer-Rath, G, Remme, M, Revill, P, Sangrujee, N, Terris-Prestholt, F, Doherty, M, Shaffer, N, Easterbrook, PJ, Hirnschall, G & Hallett, TB 2014, 'Health benefits, costs, and cost-effectiveness of earlier eligibility for adult antiretroviral therapy and expanded treatment coverage: a combined analysis of 12 mathematical models', The Lancet Global Health, bind 2, nr. 1, s. e23-34. https://doi.org/10.1016/S2214-109X(13)70172-4

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title = "Health benefits, costs, and cost-effectiveness of earlier eligibility for adult antiretroviral therapy and expanded treatment coverage: a combined analysis of 12 mathematical models",

abstract = "BACKGROUND: New WHO guidelines recommend initiation of antiretroviral therapy for HIV-positive adults with CD4 counts of 500 cells per μL or less, a higher threshold than was previously recommended. Country decision makers have to decide whether to further expand eligibility for antiretroviral therapy accordingly. We aimed to assess the potential health benefits, costs, and cost-effectiveness of various eligibility criteria for adult antiretroviral therapy and expanded treatment coverage.METHODS: We used several independent mathematical models in four settings-South Africa (generalised epidemic, moderate antiretroviral therapy coverage), Zambia (generalised epidemic, high antiretroviral therapy coverage), India (concentrated epidemic, moderate antiretroviral therapy coverage), and Vietnam (concentrated epidemic, low antiretroviral therapy coverage)-to assess the potential health benefits, costs, and cost-effectiveness of various eligibility criteria for adult antiretroviral therapy under scenarios of existing and expanded treatment coverage, with results projected over 20 years. Analyses assessed the extension of eligibility to include individuals with CD4 counts of 500 cells per μL or less, or all HIV-positive adults, compared with the previous (2010) recommendation of initiation with CD4 counts of 350 cells per μL or less. We assessed costs from a health-system perspective, and calculated the incremental cost (in US$) per disability-adjusted life-year (DALY) averted to compare competing strategies. Strategies were regarded very cost effective if the cost per DALY averted was less than the country's 2012 per-head gross domestic product (GDP; South Africa: $8040; Zambia: $1425; India: $1489; Vietnam: $1407) and cost effective if the cost per DALY averted was less than three times the per-head GDP.FINDINGS: In South Africa, the cost per DALY averted of extending eligibility for antiretroviral therapy to adult patients with CD4 counts of 500 cells per μL or less ranged from $237 to $1691 per DALY averted compared with 2010 guidelines. In Zambia, expansion of eligibility to adults with a CD4 count threshold of 500 cells per μL ranged from improving health outcomes while reducing costs (ie, dominating the previous guidelines) to $749 per DALY averted. In both countries results were similar for expansion of eligibility to all HIV-positive adults, and when substantially expanded treatment coverage was assumed. Expansion of treatment coverage in the general population was also cost effective. In India, the cost for extending eligibility to all HIV-positive adults ranged from $131 to $241 per DALY averted, and in Vietnam extending eligibility to patients with CD4 counts of 500 cells per μL or less cost $290 per DALY averted. In concentrated epidemics, expanded access for key populations was also cost effective.INTERPRETATION: Our estimates suggest that earlier eligibility for antiretroviral therapy is very cost effective in low-income and middle-income settings, although these estimates should be revisited when more data become available. Scaling up antiretroviral therapy through earlier eligibility and expanded coverage should be considered alongside other high-priority health interventions competing for health budgets.FUNDING: Bill & Melinda Gates Foundation, WHO.",

author = "Eaton, {Jeffrey W} and Menzies, {Nicolas A} and John Stover and Valentina Cambiano and Leonid Chindelevitch and Anne Cori and Hontelez, {Jan A C} and Salal Humair and Kerr, {Cliff C} and Klein, {Daniel J} and Sharmistha Mishra and Mitchell, {Kate M} and Nichols, {Brooke E} and Peter Vickerman and Roel Bakker and Till B{\"a}rnighausen and Anna Bershteyn and Bloom, {David E} and Marie-Claude Boily and Chang, {Stewart T} and Ted Cohen and Dodd, {Peter J} and Christophe Fraser and Chaitra Gopalappa and Jens Lundgren and Martin, {Natasha K} and Evelinn Mikkelsen and Elisa Mountain and Pham, {Quang D} and Michael Pickles and Andrew Phillips and Lucy Platt and Carel Pretorius and Prudden, {Holly J} and Salomon, {Joshua A} and {van de Vijver}, {David A M C} and {de Vlas}, {Sake J} and Wagner, {Bradley G} and White, {Richard G} and Wilson, {David P} and Lei Zhang and John Blandford and Gesine Meyer-Rath and Michelle Remme and Paul Revill and Nalinee Sangrujee and Fern Terris-Prestholt and Meg Doherty and Nathan Shaffer and Easterbrook, {Philippa J} and Gottfried Hirnschall and Hallett, {Timothy B}",

year = "2014",

month = jan,

doi = "10.1016/S2214-109X(13)70172-4",

language = "English",

volume = "2",

pages = "e23--34",

journal = "The Lancet Global Health",

issn = "2572-116X",

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TY - JOUR

T1 - Health benefits, costs, and cost-effectiveness of earlier eligibility for adult antiretroviral therapy and expanded treatment coverage

T2 - a combined analysis of 12 mathematical models

AU - Eaton, Jeffrey W

AU - Menzies, Nicolas A

AU - Stover, John

AU - Cambiano, Valentina

AU - Chindelevitch, Leonid

AU - Cori, Anne

AU - Hontelez, Jan A C

AU - Humair, Salal

AU - Kerr, Cliff C

AU - Klein, Daniel J

AU - Mishra, Sharmistha

AU - Mitchell, Kate M

AU - Nichols, Brooke E

AU - Vickerman, Peter

AU - Bakker, Roel

AU - Bärnighausen, Till

AU - Bershteyn, Anna

AU - Bloom, David E

AU - Boily, Marie-Claude

AU - Chang, Stewart T

AU - Cohen, Ted

AU - Dodd, Peter J

AU - Fraser, Christophe

AU - Gopalappa, Chaitra

AU - Lundgren, Jens

AU - Martin, Natasha K

AU - Mikkelsen, Evelinn

AU - Mountain, Elisa

AU - Pham, Quang D

AU - Pickles, Michael

AU - Phillips, Andrew

AU - Platt, Lucy

AU - Pretorius, Carel

AU - Prudden, Holly J

AU - Salomon, Joshua A

AU - van de Vijver, David A M C

AU - de Vlas, Sake J

AU - Wagner, Bradley G

AU - White, Richard G

AU - Wilson, David P

AU - Zhang, Lei

AU - Blandford, John

AU - Meyer-Rath, Gesine

AU - Remme, Michelle

AU - Revill, Paul

AU - Sangrujee, Nalinee

AU - Terris-Prestholt, Fern

AU - Doherty, Meg

AU - Shaffer, Nathan

AU - Easterbrook, Philippa J

AU - Hirnschall, Gottfried

AU - Hallett, Timothy B

PY - 2014/1

Y1 - 2014/1

N2 - BACKGROUND: New WHO guidelines recommend initiation of antiretroviral therapy for HIV-positive adults with CD4 counts of 500 cells per μL or less, a higher threshold than was previously recommended. Country decision makers have to decide whether to further expand eligibility for antiretroviral therapy accordingly. We aimed to assess the potential health benefits, costs, and cost-effectiveness of various eligibility criteria for adult antiretroviral therapy and expanded treatment coverage.METHODS: We used several independent mathematical models in four settings-South Africa (generalised epidemic, moderate antiretroviral therapy coverage), Zambia (generalised epidemic, high antiretroviral therapy coverage), India (concentrated epidemic, moderate antiretroviral therapy coverage), and Vietnam (concentrated epidemic, low antiretroviral therapy coverage)-to assess the potential health benefits, costs, and cost-effectiveness of various eligibility criteria for adult antiretroviral therapy under scenarios of existing and expanded treatment coverage, with results projected over 20 years. Analyses assessed the extension of eligibility to include individuals with CD4 counts of 500 cells per μL or less, or all HIV-positive adults, compared with the previous (2010) recommendation of initiation with CD4 counts of 350 cells per μL or less. We assessed costs from a health-system perspective, and calculated the incremental cost (in US$) per disability-adjusted life-year (DALY) averted to compare competing strategies. Strategies were regarded very cost effective if the cost per DALY averted was less than the country's 2012 per-head gross domestic product (GDP; South Africa: $8040; Zambia: $1425; India: $1489; Vietnam: $1407) and cost effective if the cost per DALY averted was less than three times the per-head GDP.FINDINGS: In South Africa, the cost per DALY averted of extending eligibility for antiretroviral therapy to adult patients with CD4 counts of 500 cells per μL or less ranged from $237 to $1691 per DALY averted compared with 2010 guidelines. In Zambia, expansion of eligibility to adults with a CD4 count threshold of 500 cells per μL ranged from improving health outcomes while reducing costs (ie, dominating the previous guidelines) to $749 per DALY averted. In both countries results were similar for expansion of eligibility to all HIV-positive adults, and when substantially expanded treatment coverage was assumed. Expansion of treatment coverage in the general population was also cost effective. In India, the cost for extending eligibility to all HIV-positive adults ranged from $131 to $241 per DALY averted, and in Vietnam extending eligibility to patients with CD4 counts of 500 cells per μL or less cost $290 per DALY averted. In concentrated epidemics, expanded access for key populations was also cost effective.INTERPRETATION: Our estimates suggest that earlier eligibility for antiretroviral therapy is very cost effective in low-income and middle-income settings, although these estimates should be revisited when more data become available. Scaling up antiretroviral therapy through earlier eligibility and expanded coverage should be considered alongside other high-priority health interventions competing for health budgets.FUNDING: Bill & Melinda Gates Foundation, WHO.

AB - BACKGROUND: New WHO guidelines recommend initiation of antiretroviral therapy for HIV-positive adults with CD4 counts of 500 cells per μL or less, a higher threshold than was previously recommended. Country decision makers have to decide whether to further expand eligibility for antiretroviral therapy accordingly. We aimed to assess the potential health benefits, costs, and cost-effectiveness of various eligibility criteria for adult antiretroviral therapy and expanded treatment coverage.METHODS: We used several independent mathematical models in four settings-South Africa (generalised epidemic, moderate antiretroviral therapy coverage), Zambia (generalised epidemic, high antiretroviral therapy coverage), India (concentrated epidemic, moderate antiretroviral therapy coverage), and Vietnam (concentrated epidemic, low antiretroviral therapy coverage)-to assess the potential health benefits, costs, and cost-effectiveness of various eligibility criteria for adult antiretroviral therapy under scenarios of existing and expanded treatment coverage, with results projected over 20 years. Analyses assessed the extension of eligibility to include individuals with CD4 counts of 500 cells per μL or less, or all HIV-positive adults, compared with the previous (2010) recommendation of initiation with CD4 counts of 350 cells per μL or less. We assessed costs from a health-system perspective, and calculated the incremental cost (in US$) per disability-adjusted life-year (DALY) averted to compare competing strategies. Strategies were regarded very cost effective if the cost per DALY averted was less than the country's 2012 per-head gross domestic product (GDP; South Africa: $8040; Zambia: $1425; India: $1489; Vietnam: $1407) and cost effective if the cost per DALY averted was less than three times the per-head GDP.FINDINGS: In South Africa, the cost per DALY averted of extending eligibility for antiretroviral therapy to adult patients with CD4 counts of 500 cells per μL or less ranged from $237 to $1691 per DALY averted compared with 2010 guidelines. In Zambia, expansion of eligibility to adults with a CD4 count threshold of 500 cells per μL ranged from improving health outcomes while reducing costs (ie, dominating the previous guidelines) to $749 per DALY averted. In both countries results were similar for expansion of eligibility to all HIV-positive adults, and when substantially expanded treatment coverage was assumed. Expansion of treatment coverage in the general population was also cost effective. In India, the cost for extending eligibility to all HIV-positive adults ranged from $131 to $241 per DALY averted, and in Vietnam extending eligibility to patients with CD4 counts of 500 cells per μL or less cost $290 per DALY averted. In concentrated epidemics, expanded access for key populations was also cost effective.INTERPRETATION: Our estimates suggest that earlier eligibility for antiretroviral therapy is very cost effective in low-income and middle-income settings, although these estimates should be revisited when more data become available. Scaling up antiretroviral therapy through earlier eligibility and expanded coverage should be considered alongside other high-priority health interventions competing for health budgets.FUNDING: Bill & Melinda Gates Foundation, WHO.

U2 - 10.1016/S2214-109X(13)70172-4

DO - 10.1016/S2214-109X(13)70172-4

M3 - Journal article

C2 - 25104632

SN - 2572-116X

VL - 2

SP - e23-34

JO - The Lancet Global Health

JF - The Lancet Global Health

IS - 1

ER -

Health benefits, costs, and cost-effectiveness of earlier eligibility for adult antiretroviral therapy and expanded treatment coverage: a combined analysis of 12 mathematical models

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