XIX International AIDS Conference


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FRLBC01 - Oral Abstract

The cost-effectiveness of treatment as prevention: analysis of the HPTN 052 trial

Presented by Kenneth A. Freedberg (United States).

R.P. Walensky1,2,3, E.L. Ross1, N. Kumarasamy4, R. Wood5, F. Noubary1, A.D. Paltiel6, Y.M. Nakamura1, S. Godbole7, M. Hosseinipour8, J.G. Hakim9, J. Kumwenda10, J. Makhema11, V. Akelo12, R. Panchia13, I. Sanne14, M.C. Weinstein15, E. Losina3,16,17, K.H. Mayer18, B. Grinsztejn19, J. Pilotto20, S. Chariyalertsak21, B. Santos22, Y.Q. Chen23, L. Wang23, X. Li23, M. McCauley24, T. Gamble25, E. Piwowar-Manning26, L. Cottle27, I. Hoffman28, J. Eron28, J. Gallant26, S. Swindells29, T. Taha30, K. Nielsen-Saines31, D. Celentano30, M. Essex15, V. Elharrar32, D. Burns32, G.R. Seage15, M.S. Cohen28, K.A. Freedberg1,2,16

1Massachusetts General Hospital, Boston, United States, 2Harvard Medical School, Boston, United States, 3Brigham & Women's Hospital, Boston, United States, 4Y. R. Gaitonade Center for AIDS Research and Education, Chennai, India, 5University of Cape Town and Desmond Tutu HIV centre, Cape Town, South Africa, 6Yale University School of Medicine, New Haven, United States, 7National AIDS Research Institute (NARI), Pune, India, 8UNC Project Malawi and University of North Carolina at Chapel Hill, Lilongwe, Malawi, 9University of Zimbabwe, Department of Medicine, Harare, Zimbabwe, 10College of Medicine Johns Hopkins Project, Blantyre, Malawi, 11Botswana Harvard AIDS Institute, Gaborone, Botswana, 12KEMRI-CDC Research and Public Health Collaboration, Kisumu, Kenya, 13Perinatal HIV Research Unit (PHRU), University of the Witwatersrand, Johannesburg, South Africa, 14University of Witswatersrand, Department of Medicine, Johannesburg, South Africa, 15Harvard School of Public Health, Boston, United States, 16Boston University School of Public Health, Boston, United States, 17Harvard Center for AIDS Research, Boston, United States, 18Fenway Institute, Boston, United States, 19Instituto de Pesquisa Clinica Evandro Chagas, Fiocruz, Rio de Janeiro, Brazil, 20Hospital Geral de Nova Iguacu and Laboratorio de AIDS e Imunologia Molecular-IOC/Fiocruz, Rio de Janeiro, Brazil, 21Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand, 22Hospital Nossa Senhora da Conceição, Porto Alegre, Brazil, 23Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, United States, 24FHI 360, Washington, United States, 25FHI 360, Durham, United States, 26Joh

Background: HPTN 052, a multi-country randomized trial, showed that early ART initiation produced a 96% reduction in HIV transmission among serodiscordant couples. Using an HIV microsimulation model (CEPAC-International), we project the clinical impact, costs, and cost-effectiveness of early ART.
Methods: Per the 052 protocol, we compare two ART initiation strategies: early (at presentation-to-care) vs. delayed (CD4< 250/µl). Each strategy is modeled in South Africa (RSA) and India using trial-derived data: mean age 33.8y, mean CD4 449/µl (±120/µL), 42% (RSA) and 67% (India) male, 0.103/1.483 transmissions/100PY while virologically suppressed/unsuppressed. ART strategies are applied consistently to transmitted and index cases. Outcomes include: first-order HIV transmissions, survival, costs, and cost-effectiveness. We designate early ART very cost-effective or cost-effective if its cost-effectiveness ratio is < 1x or < 3x per capita GDP (GDPs: $8,100 [RSA]; $1,400 [India]).
Results: In RSA, early ART increases survival, prevents costly OIs (partially offsetting ART costs), averts early transmissions, and is very cost-effective over both 5-year ($700/YLS, Table) and lifetime horizons ($1,200/YLS, Table). In India over a 5-year horizon, early ART increases survival and averts transmissions. Because ART is expensive relative to other medical treatment in India (Figure), OI prevention offsets fewer ART costs. Early ART, however, is cost-effective ($2,900/YLS, Table); over a lifetime horizon, it becomes very cost-effective ($1,300/YLS, Table). In sensitivity analyses in both countries, early ART remains very cost-effective over a lifetime horizon under a wide range of assumptions regarding the clinical and preventive efficacy of ART. Consideration of second-order transmissions increases the clinical and cost benefits of early ART.
Conclusions: Early ART averts HIV transmissions over shorter horizons, but increased survival attenuates this affect over time. Over 5 years, early ART is cost-effective in India and very cost-effective in RSA; in both countries, early ART is very cost-effective over a lifetime horizon.

Table: Cost-effectiveness of early vs. delayed ART
[Table: Cost-effectiveness of early vs. delayed ART]

Figure: Cost components in RSA and India
[Figure: Cost components in RSA and India]

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