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Open Forum Infect Dis. 2017 Apr 22;4(2):ofx081. doi: 10.1093/ofid/ofx081. eCollection 2017 Spring.

Setting Performance Standards for a Cost-Effective Human Immunodeficiency Virus Cure Strategy in South Africa.

Paltiel AD1, Zheng A2,3, Weinstein MC4,5, Gaynes MR2,3, Wood R6, Freedberg KA2,3,7,4,8,9, Sax PE8,10, Walensky RP2,3,7,8,10.

Author information

1
Yale School of Public Health, New Haven, Connecticut.
2
Medical Practice Evaluation Center and Divisions of.
3
General Internal Medicine and.
4
Health Policy and Management and.
5
Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.
6
The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Medicine, University of Cape Town, South Africa.
7
Infectious Diseases, Massachusetts General Hospital, Boston; Departments of.
8
Harvard Medical School, Boston, Massachusetts.
9
Department of Epidemiology, Boston University School of Public Health, Massachusetts.
10
Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts.

Abstract

BACKGROUND:

Reports of a single case of human immunodeficiency virus (HIV) eradication suggest that elimination of HIV from individuals is possible. Anticipating both increased research funding and the development of effective, durable cure technologies, we describe the circumstances under which a cure might improve survival and be cost-effective in South Africa.

METHODS:

We adapted a simulation model comparing a hypothetical cure strategy ("Cure") to the standard of care, lifetime antiretroviral therapy ("LifetimeART") among adherent South Africans (58% female; mean age 33.8 years; mean CD4 257/µL; virologic suppression ≥1 year). We portrayed cure as a single intervention, producing sustained viral eradication without ART. We considered both a plausible, more imminently achievable "Baseline Scenario" and a more aspirational "Optimistic Scenario". Inputs (Baseline/Optimistic) included the following: 50%/75% efficacy; 0.6%/0.0% fatal toxicity; 0.37%/0.085% monthly relapse over 5 years (0.185%/0.0425% per month thereafter); and $2000/$500 cost. These inputs were varied extensively in sensitivity analysis.

RESULTS:

At baseline, Cure was "dominated," yielding lower discounted life expectancy (19.31 life-years [LY] vs 19.37 LY) and greater discounted lifetime costs ($13 800 vs $13 700) than LifetimeART. Under optimistic assumptions, Cure was "cost-saving," producing greater survival (19.91 LY) and lower lifetime costs ($11 000) than LifetimeART. Findings were highly sensitive to data assumptions, leaving little middle ground where a tradeoff existed between improved survival and higher costs.

CONCLUSIONS:

Only under the most favorable performance assumptions will an HIV cure strategy prove clinically and economically justifiable in South Africa. The scientific pursuit of a cure should not undermine continued expansions of access to proven, effective, and cost-effective ART.

KEYWORDS:

HIV; South Africa.; cost-effectiveness; cure; modeling

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