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The Anticipated Clinical and Economic Effects of 90–90–90 in South AfricaAnticipated Clinical and Economic Effects of 90–90–90 in South Africa

Rochelle P. Walensky, MD, MPH; Ethan D. Borre, BA; Linda-Gail Bekker, MD, PhD; Stephen C. Resch, PhD; Emily P. Hyle, MD, SM; Robin Wood, MMed, DSc (Med); Milton C. Weinstein, PhD; Andrea L. Ciaranello, MD, MPH; Kenneth A. Freedberg, MD, MSc; and A. David Paltiel, MBA, PhD
[+] Article, Author, and Disclosure Information

This article was published at www.annals.org on 31 May 2016.


From the Medical Practice Evaluation Center, Massachusetts General Hospital; Brigham and Women's Hospital; the Harvard University Center for AIDS Research, Harvard Medical School; Center for Health Decision Science, Harvard T.H. Chan School of Public Health; and Boston University School of Public Health, Boston, Massachusetts; Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Medicine, University of Cape Town, Cape Town, South Africa; and Yale School of Public Health, New Haven, Connecticut.

Disclaimer: The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Dr. Walensky had access to all of the data in the study and takes responsibility for the integrity of the data and accuracy of the data analysis.

Financial Support: By the National Institutes of Health (R01 AI058736, R37 AI093269, R01 HD079214, K01 HL123349, R01 MH105203, R01 DA015612) and by the Steve and Deborah Gorlin MGH Research Scholars Award (Executive Committee on Research to Dr. Walensky).

Disclosures: Dr. Walensky reports grants from the National Institutes of Health during the conduct of this study, is a member of the Scientific and Technical Advisory Committee of UNAIDS, is a member of the U.S. Department of Health and Human Services Panel on Antiretroviral Guidelines for Adults and Adolescents, and serves on the board of the HIV Medicine Association. Dr. Resch reports grants from the National Institutes of Health/National Institute of Allergy and Infectious Diseases during the conduct of this study, and personal fees from Results for Development Institute outside the submitted work. Dr. Hyle reports grants from the National Institutes of Health during the conduct of this study. Dr. Weinstein reports personal fees from OptumInsight outside the submitted work. Dr. Ciaranello is a member of the U.S. Department of Health and Human Services Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission and reports grants from the National Institutes of Health during the conduct of this study. Dr. Freedberg reports grants from the National Institutes of Health during the conduct of this study. Dr. Paltiel reports grants from the National Institutes of Health during the conduct of this study. Authors not named here have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-0799.

Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.

Reproducible Research Statement:Study protocol, statistical code, and data set: Not available.

Requests for Single Reprints: Rochelle P. Walensky, MD, MPH, Medical Practice Evaluation Center, Massachusetts General Hospital, 50 Staniford Street, 9th Floor, Boston, MA 02114; e-mail, rwalensky@partners.org.

Current Author Addresses: Drs. Walensky, Hyle, Ciaranello, and Freedberg and Mr. Borre: Medical Practice Evaluation Center, Massachusetts General Hospital, 50 Staniford Street, 9th Floor, Boston, MA 02114.

Drs. Bekker and Wood: Desmond Tutu HIV Foundation, PO Box 13801, Mowbray 7705, Cape Town, South Africa.

Drs. Resch and Weinstein: Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115.

Dr. Paltiel: Yale School of Public Health, 60 College Street, New Haven, CT 06510.

Author Contributions: Conception and design: R.P. Walensky, E.D. Borre, L.G. Bekker, S.C. Resch, R. Wood, M.C. Weinstein, A.L. Ciaranello, A.D. Paltiel.

Analysis and interpretation of the data: R.P. Walensky, E.D. Borre, L.G. Bekker, S.C. Resch, E.P. Hyle, R. Wood, M.C. Weinstein, A.L. Ciaranello, K.A. Freedberg, A.D. Paltiel.

Drafting of the article: R.P. Walensky, E.D. Borre, A.L. Ciaranello, A.D. Paltiel.

Critical revision for important intellectual content: R.P. Walensky, S.C. Resch, E.P. Hyle, M.C. Weinstein, A.L. Ciaranello, K.A. Freedberg, A.D. Paltiel.

Final approval of the article: R.P. Walensky, E.D. Borre, L.G. Bekker, S.C. Resch, E.P. Hyle, R. Wood, M.C. Weinstein, A.L. Ciaranello, K.A. Freedberg, A.D. Paltiel.

Statistical expertise: M.C. Weinstein.

Obtaining of funding: R.P. Walensky, K.A. Freedberg, A.D. Paltiel.

Administrative, technical, or logistic support: R.P. Walensky, E.D. Borre.

Collection and assembly of data: R.P. Walensky, E.D. Borre, R. Wood.


Ann Intern Med. 2016;165(5):325-333. doi:10.7326/M16-0799
© 2016 American College of Physicians
Text Size: A A A

Background: The Joint United Nations Programme on HIV/AIDS (UNAIDS) 90–90–90 global treatment target aims to achieve 73% virologic suppression among HIV-infected persons worldwide by 2020.

Objective: To estimate the clinical and economic value of reaching this ambitious goal in South Africa, by using a microsimulation model of HIV detection, disease, and treatment.

Design: Modeling of the “current pace” strategy, which simulates existing scale-up efforts and gradual increases in overall virologic suppression from 24% to 36% in 5 years, and the UNAIDS target strategy, which simulates 73% virologic suppression in 5 years.

Data Sources: Published estimates and South African survey data on HIV transmission rates (0.16 to 9.03 per 100 person-years), HIV-specific age-stratified fertility rates (1.0 to 9.1 per 100 person-years), and costs of care ($11 to $31 per month for antiretroviral therapy and $20 to $157 per month for routine care).

Target Population: South African HIV-infected population, including incident infections over the next 10 years.

Perspective: Modified societal perspective, excluding time and productivity costs.

Time Horizon: 5 and 10 years.

Intervention: Aggressive HIV case detection, efficient linkage to care, rapid treatment scale-up, and adherence and retention interventions toward the UNAIDS target strategy.

Outcome Measures: HIV transmissions, deaths, years of life saved, maternal orphans, costs (2014 U.S. dollars), and cost-effectiveness.

Results of Base-Case Analysis: Compared with the current pace strategy, over 5 years the UNAIDS target strategy would avert 873 000 HIV transmissions, 1 174 000 deaths, and 726 000 maternal orphans while saving 3 002 000 life-years; over 10 years, it would avert 2 051 000 HIV transmissions, 2 478 000 deaths, and 1 689 000 maternal orphans while saving 13 340 000 life-years. The additional budget required for the UNAIDS target strategy would be $7.965 billion over 5 years and $15.979 billion over 10 years, yielding an incremental cost-effectiveness ratio of $2720 and $1260 per year of life saved, respectively.

Results of Sensitivity Analysis: Outcomes generally varied less than 20% from base-case outcomes when key input parameters were varied within plausible ranges.

Limitation: Several pathways may lead to 73% overall virologic suppression; these were examined in sensitivity analyses.

Conclusion: Reaching the 90–90–90 HIV suppression target would be costly but very effective and cost-effective in South Africa. Global health policymakers should mobilize the political and economic support to realize this target.

Primary Funding Source: National Institutes of Health and the Steve and Deborah Gorlin MGH Research Scholars Award.

Figures

Grahic Jump Location
Figure 1.

Results of the HIV treatment cascade over time, by cascade strategy.

For the current pace strategy, the literature-derived data and the model-projected effects on the current South African cascade after 1, 5, and 10 y of the current pace strategy are shown. At 10 y of the current pace strategy, 44% of living patients have virologic suppression. For the UNAIDS target strategy, model output demonstrates results that might be achieved in 5 and 10 y, compared with the 90–90–90 benchmark. When screening, linkage, and adherence and retention variables of the model were adjusted to force the 5-y values to reach 90–90–90 target values, 80% of patients who were alive and had virologic suppression in 10 y. The absolute number of patients alive in the 2 strategies over time differs owing to an increased number of transmissions and deaths in the current pace strategy. ART = antiretroviral therapy; UNAIDS = Joint United Nations Programme on HIV/AIDS.

Grahic Jump Location
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Figure 2.

Survival outcomes over time, by cascade strategy.

The difference in the height of the bars in each year indicates the cumulative number of additional transmissions in the current pace strategy compared with the UNAIDS target strategy. ART = antiretroviral therapy; UNAIDS = Joint United Nations Programme on HIV/AIDS.

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Appendix Figure 1.

Cumulative HIV transmissions over the 10-year model horizon.

By the end of 2025, the UNAIDS target strategy results in 2.051 million fewer transmission events. UNAIDS = Joint United Nations Programme on HIV/AIDS.

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Figure 3.

Outcomes related to maternal orphans, by cascade strategy.

“Maternal orphans” were defined as children younger than 18 years whose mother died of HIV/AIDS. Cumulative orphans are the cumulative number of children ever orphaned by HIV/AIDS during the time horizon of the analysis (see the Methods section). Current orphans are the projected number of orphans in a given year, accounting for both death among orphans after orphanhood and for aging out of being considered an orphan. The kinks in the solid lines around year 8 demonstrate the aging out of a large majority of prevalent orphans aged 9 to 14 y at model initiation. UNAIDS = Joint United Nations Programme on HIV/AIDS.

Grahic Jump Location
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Appendix Figure 2.

Results of the HIV treatment cascade over time, by cascade strategy; sensitivity analysis of an alternative way of reaching virologic suppression goals for the UNAIDS target strategy.

For the current pace strategy, the literature-derived data and the model-projected effects on the current South African cascade after 1, 5, and 10 y are shown. At 10 y of the current pace strategy, 44% of living patients have virologic suppression. For the UNAIDS target strategy, model output demonstrates results that might be achieved in 5 and 10 y, compared with the 90–90–90 benchmark. In the alternative UNAIDS target strategy, lower testing and linkage rates and higher rates of virologic suppression than in the UNAIDS target strategy base case were used to achieve viral suppression goals, but less than 81% of persons on ART. Although the UNAIDS target strategy and the alternative UNAIDS target strategy have similar viral suppression rates (approximately 73% at 5 y), they differ in the proportion of persons receiving ART (81% and 75%, respectively). The number of patients alive in the 3 strategies over time differs owing to an increased number of transmissions and deaths. ART = antiretroviral therapy; UNAIDS = Joint United Nations Programme on HIV/AIDS.

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