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UNAIDS 90-90-90 Targets Could Prevent 2.5 Million HIV Deaths in South Africa

Achieving the UNAIDS 90-90-90 targets for getting more people with HIV tested and on effective treatment in South Africa would cost nearly 16 billion dollars over 10 years, but could avert more than 2 million new HIV infections and prevent 2.5 million deaths, according to a mathematical model analysis published in the May 31 online edition of Annals on Internal Medicine.

The UNAIDS 90-90-90 targets aim to have 90% of people with HIV aware of their status, 90% of those receiving antiretroviral therapy (ART), and 90% of people on treatment having undetectable viral load -- that is, 73% of people with HIV having viral suppression. UNAIDS recently announced that an estimated 17 million people living with HIV are now on ART, including 3.4 million in South Africa. ART can halt HIV disease progression, prolong survival, and prevent onward HIV transmission. But today around half of people with HIV are not yet on treatment and only about 30% are thought to have viral suppression.

Rochelle Walensky from Massachusetts General Hospital and colleagues estimated the clinical and economic value of reaching the 90-90-90 goals in South Africa, using a micro-simulation model of HIV detection, disease, and treatment.

The researchers used published estimates and South African survey data on HIV transmission rates (0.16 to 9.03 per 100 person-years), HIV-specific age-stratified fertility rates (1.0 to 9.1 per 100 person-years), and costs of care ($11 to $31 per month for ART and $20 to $157 per month for routine care).

They compared a "current pace" strategy assuming existing scale-up efforts and gradual increases in viral suppression from 24% to 36% in 5 years, versus the "90-90-90 strategy" assuming 73% viral suppression in 5 years. The latter strategy would involve aggressive HIV case detection, efficient linkage to care, rapid ART scale-up, and adherence and retention interventions. The model assumed that most people would respond well to treatment and stay on it.

Using these parameters, Walensky's team made projections for HIV transmissions, deaths, years of life saved, the number of children who would become orphans when their mothers died, costs (in 2014 U.S. dollars), and cost-effectiveness over 5- and 10-year time horizons.

Results

• Looking first at the 5-year horizon, the researchers calculated that the 90-90-90 strategy, compared to the current pace, would:

o   avert 873,000 HIV transmissions;

o   prevent 1,174,000 deaths;

o   keep 726,000 children from becoming maternal orphans;

o   save 3,002,000 life-years.

• Over 10 years the 90-90-90 strategy would:

o   avert 2,051,000 new HIV infections;

o   prevent 2,478,000 deaths;

o   keep 1,689,000 children from becoming orphans;

o   save 13,340,000 life-years.

• The estimated additional cost required for the 90-90-90 strategy would be $7.97 billion over 5 years and $15.98 billion over 10 years -- about a 40% increase over current funding levels.
• This would yield incremental cost-effectiveness ratios of $2720 per quality-adjusted year of life saved over 5 years, falling to $1260 over 10 years.

The researchers noted that outcomes generally varied by less than 20% from these base-case outcomes when key parameters were varied within "plausible ranges." They suggested that achieving the 90-90-90 levels would necessitate screening the entire South African population as often as every 2 years.

"Reaching the 90-90-90 HIV suppression target would be costly but very effective and cost-effective in South Africa," the study authors concluded. "Global health policymakers should mobilize the political and economic support to realize this target."

6/9/16

Reference

RP Walensky, ED Borre, L-G Bekker, et al. The Anticipated Clinical and Economic Effects of 90-90-90 in South Africa. Annals of Internal Medicine. May 31, 2016 (online ahead of print).

Other Source

FS Collins. Global Effort to End Aids Would Save Millions of Lives. Blog.AIDS.gov. June 8, 2016.