title: Changing HIV treatment eligibility under health system constraints in sub-Saharan Africa: investment needs, population health gains, and cost-effectiveness.
abstract: We estimated the investment needs, population health gains, and cost-effectiveness of different policy options for scaling-up prevention and treatment of HIV in the 10 countries that currently comprise 80% of all people living with HIV in sub-Saharan Africa (Ethiopia, Kenya, Malawi, Mozambique, Nigeria, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe).
  
  
  
  We adapted the established STDSIM model to capture the health system dynamics: demand-side and supply-side constraints in the delivery of antiretroviral treatment (ART).
  
  
  
  We compared different scenarios of supply-side (i.e. health system capacity) and demand-side (i.e. health seeking behavior) constraints, and determined the impact of changing guidelines to ART eligibility at any CD4 cell count within these constraints.
  
  
  
  Continuing current scale-up would require US$178 billion by 2050. Changing guidelines to ART at any CD4 cell count is cost-effective under all constraints tested in the model, especially in demand-side constrained health systems because earlier initiation prevents loss-to-follow-up of patients not yet eligible. Changing guidelines under current demand-side constraints would avert 1.8 million infections at US$208 per life-year saved.
  
  
  
  Treatment eligibility at any CD4 cell count would be cost-effective, even under health system constraints. Excessive loss-to-follow-up and mortality in patients not eligible for treatment can be avoided by changing guidelines in demand-side constrained systems. The financial obligation for sustaining the AIDS response in sub-Saharan Africa over the next 35 years is substantial and requires strong, long-term commitment of policy-makers and donors to continue to allocate substantial parts of their budgets.
authors.affiliation: aHarvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA bDepartment of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands cAfrica Centre for Population Health, University of KwaZulu-Natal, Mtubatuba, South Africa.
authors.forename: Jan A C
authors.initials: JA
authors.lastname: Hontelez
authors.forename: Angela Y
authors.initials: AY
authors.lastname: Chang
authors.forename: Osondu
authors.initials: O
authors.lastname: Ogbuoji
authors.forename: Sake J
authors.initials: SJ
authors.lastname: de Vlas
authors.forename: Till
authors.initials: T
authors.lastname: Bärnighausen
authors.forename: Rifat
authors.initials: R
authors.lastname: Atun
mesh_terms: D017954:Africa South of the Sahara; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D003362:Cost-Benefit Analysis; D015658:HIV Infections / Q000188:drug therapy* / Q000473:pathology*; D006291:Health Policy; D006801:Humans
chemical_list: D044966:Anti-Retroviral Agents