title: The impact of the new WHO antiretroviral treatment guidelines on HIV epidemic dynamics and cost in South Africa.
abstract: BACKGROUND
  Since November 2009, WHO recommends that adults infected with HIV should initiate antiretroviral therapy (ART) at CD4+ cell counts of ≤350 cells/µl rather than ≤200 cells/µl. South Africa decided to adopt this strategy for pregnant and TB co-infected patients only. We estimated the impact of fully adopting the new WHO guidelines on HIV epidemic dynamics and associated costs.
  
  
  RESULTS
  We used an established model of the transmission and control of HIV in specified sexual networks and healthcare settings. We quantified the model to represent Hlabisa subdistrict, KwaZulu-Natal, South Africa. We predicted the HIV epidemic dynamics, number on ART and program costs under the new guidelines relative to treating patients at ≤200 cells/µl for the next 30 years. During the first five years, the new WHO treatment guidelines require about 7% extra annual investments, whereas 28% more patients receive treatment. Furthermore, there will be a more profound impact on HIV incidence, leading to relatively less annual costs after seven years. The resulting cumulative net costs reach a break-even point after on average 16 years.
  
  
  CONCLUSIONS
  Our study strengthens the WHO recommendation of starting ART at ≤350 cells/µl for all HIV-infected patients. Apart from the benefits associated with many life-years saved, a modest frontloading appears to lead to net savings within a limited time-horizon. This finding is robust to alternative assumptions and foreseeable changes in ART prices and effectiveness. Therefore, South Africa should aim at rapidly expanding its healthcare infrastructure to fully embrace the new WHO guidelines.
authors.affiliation: Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands. j.hontelez@erasmusmc.nl
authors.forename: Jan A C
authors.initials: JA
authors.lastname: Hontelez
authors.forename: Sake J
authors.initials: SJ
authors.lastname: de Vlas
authors.forename: Frank
authors.initials: F
authors.lastname: Tanser
authors.forename: Roel
authors.initials: R
authors.lastname: Bakker
authors.forename: Till
authors.initials: T
authors.lastname: Bärnighausen
authors.forename: Marie-Louise
authors.initials: ML
authors.lastname: Newell
authors.forename: Rob
authors.initials: R
authors.lastname: Baltussen
authors.forename: Mark N
authors.initials: MN
authors.lastname: Lurie
mesh_terms: D000293:Adolescent; D000328:Adult; D019380:Anti-HIV Agents / Q000191:economics / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D058872:Epidemics / Q000191:economics*; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000191:economics* / Q000276:immunology / Q000635:transmission; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008962:Models, Theoretical; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D013019:South Africa / Q000453:epidemiology; D013997:Time Factors; D014944:World Health Organization
chemical_list: D019380:Anti-HIV Agents