Interventions to keep people in HIV care more cost-effective than a ‘treat all’ approach
Treatment scale-up has had major public health benefits. But where resources are scarce, interventions to keep people in care could be more cost-effective than moving to treat everybody living with HIV after diagnosis.
The benefits of a universal test-and-treat, or ‘treat all’ strategy can only be fully realised when improvements are made to ensure people are retained throughout the HIV treatment and care cascade.
In a study conducted in Kenya, researchers found that a combination of five interventions – including improved antiretroviral treatment (ART) linkages, point-of-care CD4 testing, voluntary counselling and testing with point-of-care CD4, and outreach to improve retention in pre-ART care and retention on-ART – would be more cost effective than scaling-up treatment access in a ‘treat all’ approach, where there were no improvements in care retention.
A mathematical model showed that among all people dying from an AIDS-related illness between 2010 and 2030, the majority – some 61% – will have already started treatment. Although 25% of people will never have been diagnosed, and 14% will have been diagnosed but will not have yet started treatment.
According to the model, an intervention approach could reduce the number of lives lost due to morbidity and mortality relating to HIV, by 1.1 million disability-adjusted life-years (DALYs), and avert 25% of projected new HIV infections.
In fact, any combination of interventions implemented at various stages of the HIV treatment cascade would have a positive effect on DALYs, including improvements to diagnosis, linkage to care, retention and adherence of ART, immediate ART eligibility, and a universal test-and-treat strategy.
The research found that the most cost-effective single intervention would be to find people who had disengaged from ART care (on-ART outreach). But combining interventions at different stages of the treatment cascade would have greater benefits over implementing just one intervention. The authors attribute this to weaknesses across the whole treatment cascade.
While a test-and-treat strategy would have better health benefits than a combination of interventions overall, it would not be cost-effective, costing $1760 per DALY averted, compared to just $571 per DALY averted through improving care.
A combination approach would still significantly improve health outcomes – 69% of the DALYs that a test-and-treat strategy would – and it would have the same impact on AIDS-deaths.
In light of the World Health Organization (WHO) guidelines that call for all people living with HIV to be put on treatment, strengthening antiretroviral treatment programmes has to be a priority for meeting the Fast-Track target of ending AIDS by 2030.
As lower- and middle-income countries move to adopt WHOs ‘treat all’ guidelines as a public health approach, ensuring that treatment investments are cost-effective is vital. The authors state that investing in interventions along the treatment cascade should be prioritised over a test-and-treat strategy where no improvements are made in retaining people in care.
They conclude: “Our results suggest that there is substantial scope for programmes to improve population health and that alternative sets of strategies are available that will be consistent with their particular aims and budget.”