title: Expanding ART for treatment and prevention of HIV in South Africa: estimated cost and cost-effectiveness 2011-2050.
abstract: BACKGROUND
  Antiretroviral Treatment (ART) significantly reduces HIV transmission. We conducted a cost-effectiveness analysis of the impact of expanded ART in South Africa.
  
  
  METHODS
  We model a best case scenario of 90% annual HIV testing coverage in adults 15-49 years old and four ART eligibility scenarios: CD4 count <200 cells/mm(3) (current practice), CD4 count <350, CD4 count <500, all CD4 levels. 2011-2050 outcomes include deaths, disability adjusted life years (DALYs), HIV infections, cost, and cost per DALY averted. Service and ART costs reflect South African data and international generic prices. ART reduces transmission by 92%. We conducted sensitivity analyses.
  
  
  RESULTS
  Expanding ART to CD4 count <350 cells/mm(3) prevents an estimated 265,000 (17%) and 1.3 million (15%) new HIV infections over 5 and 40 years, respectively. Cumulative deaths decline 15%, from 12.5 to 10.6 million; DALYs by 14% from 109 to 93 million over 40 years. Costs drop $504 million over 5 years and $3.9 billion over 40 years with breakeven by 2013. Compared with the current scenario, expanding to <500 prevents an additional 585,000 and 3 million new HIV infections over 5 and 40 years, respectively. Expanding to all CD4 levels decreases HIV infections by 3.3 million (45%) and costs by $10 billion over 40 years, with breakeven by 2023. By 2050, using higher ART and monitoring costs, all CD4 levels saves $0.6 billion versus current; other ART scenarios cost $9-194 per DALY averted. If ART reduces transmission by 99%, savings from all CD4 levels reach $17.5 billion. Sensitivity analyses suggest that poor retention and predominant acute phase transmission reduce DALYs averted by 26% and savings by 7%.
  
  
  CONCLUSIONS
  Increasing the provision of ART to <350 cells/mm3 may significantly reduce costs while reducing the HIV burden. Feasibility including HIV testing and ART uptake, retention, and adherence should be evaluated.
authors.affiliation: HIV/AIDS Department, World Health Organization, Geneva, Switzerland. granichr@who.int
authors.forename: Reuben
authors.initials: R
authors.lastname: Granich
authors.forename: James G
authors.initials: JG
authors.lastname: Kahn
authors.forename: Rod
authors.initials: R
authors.lastname: Bennett
authors.forename: Charles B
authors.initials: CB
authors.lastname: Holmes
authors.forename: Navneet
authors.initials: N
authors.lastname: Garg
authors.forename: Celicia
authors.initials: C
authors.lastname: Serenata
authors.forename: Miriam Lewis
authors.initials: ML
authors.lastname: Sabin
authors.forename: Carla
authors.initials: C
authors.lastname: Makhlouf-Obermeyer
authors.forename: Christina
authors.initials: C
authors.lastname: De Filippo Mack
authors.forename: Phoebe
authors.initials: P
authors.lastname: Williams
authors.forename: Louisa
authors.initials: L
authors.lastname: Jones
authors.forename: Caoimhe
authors.initials: C
authors.lastname: Smyth
authors.forename: Kerry A
authors.initials: KA
authors.lastname: Kutch
authors.forename: Lo
authors.initials: L
authors.lastname: Ying-Ru
authors.forename: Marco
authors.initials: M
authors.lastname: Vitoria
authors.forename: Yves
authors.initials: Y
authors.lastname: Souteyrand
authors.forename: Siobhan
authors.initials: S
authors.lastname: Crowley
authors.forename: Eline L
authors.initials: EL
authors.lastname: Korenromp
authors.forename: Brian G
authors.initials: BG
authors.lastname: Williams
mesh_terms: D019380:Anti-HIV Agents / Q000191:economics* / Q000627:therapeutic use; D018791:CD4 Lymphocyte Count; D003362:Cost-Benefit Analysis / Q000639:trends; D003365:Costs and Cost Analysis / Q000639:trends; D005544:Forecasting; D015658:HIV Infections / Q000188:drug therapy / Q000191:economics / Q000517:prevention & control*; D006801:Humans; D013019:South Africa
chemical_list: D019380:Anti-HIV Agents