Universal Test, Treat, and Keep: Improving ART Retention is Key in Cost-effective HIV Control in Uganda
BMC Infectious Diseases
Background: With ambitious new UNAIDS targets to end AIDS by 2030, and new WHO treatment guidelines, there is increased interest in the best way to scale-up ART coverage. We investigate the cost-effectiveness of various ART scale-up options in Uganda. Methods: Individual-based HIV/ART model of Uganda, calibrated using history matching. 22 ART scale-up strategies were simulated from 2016-2030, comprising different combinations of six single interventions (1. increased HIV testing rates, 2. no CD4 threshold for ART initiation, 3. improved ART retention, 4. increased ART restart rates, 5. improved linkage to care, 6. improved pre-ART care). The incremental net monetary benefit (NMB) of each intervention was calculated, for a wide range of different willingness/ability to pay (WTP) per DALY averted (health-service perspective, 3% discount rate). Results: For all WTP thresholds above $210, interventions including removing the CD4 threshold were likely to be most cost-effective. At a WTP of $715 (1 × per-capita-GDP) interventions to improve linkage to and retention/re-enrolment in HIV care were highly likely to be more cost-effective than interventions to increase rates of HIV testing. At higher WTP (>~$1690), the most cost-effective option was 'Universal Test, Treat, and Keep' (UTTK), which combines interventions 1-5 detailed above. Conclusions: Our results support new WHO guidelines to remove the CD4 threshold for ART initiation in Uganda. With additional resources, this could be supplemented with interventions aimed at improving linkage to and/or retention in HIV care. To achieve the greatest reductions in HIV incidence, a UTTK policy should be implemented.
This work was supported by a Medical Research Council (UK) grant on Model Calibration (MR/J005088/1). RGW is additionally funded by the Medical Research Council (UK) (G0802414), the Bill and Melinda Gates Foundation (TB Modelling and Analysis Consortium: Grants 21675/ OPP1084276 and Consortium to Respond Effectively to the AIDS/TB Epidemic 19790.01), and CDC/PEPFAR via the Aurum Institute (U2GPS0008111). TJM is supported by Biotechnology and Biological Sciences Research Council grant number BB/I012192/1. RH receives support from the Medical Research Council (K012126/1). MS is supported by a National Institute for Health Research Post Doctoral Research Fellowship (PDF-2012-05-258). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. This article presents independent research part funded by the National Institute for Health Research (NIHR). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. The authors declare no conflicts of interest.
This is the author accepted manuscript. The final version is available from BioMed Central via the DOI in this record.
Vol. 17, 322