Open AccessEconomic and epidemiological impact of early antiretroviral therapy initiation in India
Author(s) -
Maddali Manoj V,
Dowdy David W,
Gupta Amita,
Shah Maunank
Publication year - 2015
Publication title -
journal of the international aids society
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 2.724
H-Index - 62
ISSN - 1758-2652
DOI - 10.7448/ias.18.1.20217
Subject(s) - medicine , antiretroviral therapy , epidemiology , human immunodeficiency virus (hiv) , health care , viral load , pediatrics , immunology , economics , economic growth
Recent WHO guidance advocates for early antiretroviral therapy (ART) initiation at higher CD4 counts to improve survival and reduce HIV transmission. We sought to quantify how the cost‐effectiveness and epidemiological impact of early ART strategies in India are affected by attrition throughout the HIV care continuum. Methods We constructed a dynamic compartmental model replicating HIV transmission, disease progression and health system engagement among Indian adults. Our model of the Indian HIV epidemic compared implementation of early ART initiation (i.e. initiation above CD4 ≥350 cells/mm 3 ) with delayed initiation at CD4 ≤350 cells/mm 3 ; primary outcomes were incident cases, deaths, quality‐adjusted‐life‐years (QALYs) and costs over 20 years. We assessed how costs and effects of early ART initiation were impacted by suboptimal engagement at each stage in the HIV care continuum. Results Assuming “idealistic” engagement in HIV care, early ART initiation is highly cost‐effective ($442/QALY‐gained) compared to delayed initiation at CD4 ≤350 cells/mm 3 and could reduce new HIV infections to <15,000 per year within 20 years. However, when accounting for realistic gaps in care, early ART initiation loses nearly half of potential epidemiological benefits and is less cost‐effective ($530/QALY‐gained). We project 1,285,000 new HIV infections and 973,000 AIDS‐related deaths with deferred ART initiation with current levels of care‐engagement in India. Early ART initiation in this continuum resulted in 1,050,000 new HIV infections and 883,000 AIDS‐related deaths, or 18% and 9% reductions (respectively), compared to current guidelines. Strengthening HIV screening increases benefits of earlier treatment modestly (1,001,000 new infections; 22% reduction), while improving retention in care has a larger modulatory impact (676,000 new infections; 47% reduction). Conclusions Early ART initiation is highly cost‐effective in India but only has modest epidemiological benefits at current levels of care‐engagement. Improved retention in care is needed to realize the full potential of earlier treatment.