XIX International AIDS Conference

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MOAE0202 - Oral Abstract


Is treatment as prevention the new game-changer? Costs and effectiveness

Presented by Till Barnighausen (United States).

T. Bärnighausen1,2, D. Bloom1, S. Humair1,3


1Harvard School of Public Health, Boston, United States, 2bAfrica Centre for Health and Population Studies, University of KwaZulu-Natal, Mtubetuba, South Africa, 3School of Science and Engineering, Lahore University of Management Sciences, Lahore, Pakistan

Background: The results of the HPTN 052 study, which showed antiretroviral treatment (ART) is highly effective in reducing HIV transmission, have been hailed as a “game-changer” in the fight against HIV, leading to calls for significant scaling up of treatment-as-prevention (TasP). But it is unclear how TasP could be financed, given flat-lining support for global HIV programs. We assess if TasP is indeed a game-changer against HIV, or if comparable benefits can be obtained at a lower cost by scaling up existing interventions such medical male circumcision (MMC). We also assess the impact of TasP in combination with MMC. Since MMC is currently being scaled up in many countries in sub-Saharan Africa, the effectiveness of TasP in conjunction with MMC is a highly policy-relevant question.
Methods: We formulate a new mathematical model to overcome challenges in predicting the effectiveness of untried mass interventions (lack of a historical epidemic trajectory) and in predicting the combined effectiveness of different prevention interventions. Our model uses simple behavioral assumptions to estimate new HIV infections instead of estimating parameters by fitting a curve to a disease history.
Results: For South Africa, a combination of high ART coverage at CD4< 350/ml and circumcision coverage provides approximately the same HIV incidence reduction as TasP (defined as universal ART for all HIV-infected persons) at a cost ~ $5 billion less over 2009-2020. Circumcision outperforms high ART coverage at CD4< 350/ml (and TasP) significantly in cost per infection averted?$1096 compared to $6790 per infection averted. Further, circumcision increases in cost-effectiveness over time and becomes cost saving after 2040.
Conclusions: The preventive benefits of ART are largely reaped with high ART coverage at CD4< 350/ml. Expanding circumcision coverage first is most cost effective, and then scaling up ART under current guidelines is more cost-effective for preventing HIV infections than scaling up TasP.


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