The cost and effectiveness of achieving universal HIV treatment coverage in Africa: a modeling analysis of scaling up “treat all” in Zambia
Background: To achieve “90-90-90” targets, many countries
have adopted “treat all” with no eligibility threshold for ART. We
modeled the impact of adopting treat all in Zambia on total cost and HIV
incidence and mortality, to inform policy choices and resource mobilization.
Methods: We used existing Zambian Spectrum AIM and GOALS
models and new data on HIV program coverage, ART effectiveness, and
current local unit costs to estimate the impact and costs of implementing treat
all under three scale-up scenarios: (1) “baseline” (500 CD4 threshold for
ART eligibility, treatment coverage of 70% by 2020 and 82% by 2030); (2)
“90-90-90” (treat all, reaching 81% in 2020 and 90% in 2030); (3) “Fast Track”
(treat all, reaching 90% in 2020 and 95% in 2030, with scaled-up prevention
interventions).
Results: Figure 1 presents resulting changes in (i) ART
patient numbers, (ii) costs, (iii) HIV-related deaths, and (iv) HIV infections. Adult patient numbers
increase by 45% and 60% by 2020 in scenarios 2 and 3, respectively. New infections
and deaths both decline under scenarios 2 and 3, averting 3,000-5,000 more
deaths per year and 20,000-30,000 more new infections per year than scenario 1
by 2030. Treatment costs rise from $261 million/year in 2015 to $398 million,
$411 million or $443 million by 2020 in the three scenarios, respectively.
Annual costs for scenarios 2 and 3 plateau around 2025 and then fall below
baseline due to reduced transmission. Compared to baseline, the incremental
cost per infection averted over the period was $281 for Fast Track and (-$466)
(cost saving) for 90-90-90.
[Zambian Cost & Effectiveness of Treat All scale-up]
Conclusions: Scaling up treat all in Zambia has the potential
to save thousands of lives and reduce new infections, but costs will increase
dramatically. Domestic and international financing initiatives will need to be
explored, with greater efforts to ensure sustainability.
T. Guthrie1, C. Moyo2, A. Kinghorn3, C. van Rensberg4, J. Kuenhle5, W. Kaonga2, L. Hehman Soares6, M. Kamanga7, G. Sinyangwe5, J. Stover8, L. Long4, S. Rosen9
1Health Economics and Epidemiology Research Office, WITS University, Johannesburg, South Africa, 2Ministry of Health, Zambia, Clinical Services, Lusaka, Zambia, 3WITS University, Perianatal HIV Research Unit, Johannesburg, South Africa, 4WITS University, Health Economics & Epidemiology Research Office, Johannesburg, South Africa, 5USAID, Lusaka, Zambia, 6CHAI, Lusaka, Zambia, 7EQUIP, Lusaka, Zambia, 8Avenir Health, Washington, United States, 9Boston University, Boston, United States