Post-2015 Consensus: Health Perspective - HIV/AIDS, Geldsetzer et al

Perspective Paper

Summary 

Thirty years after the human immunodeficiency virus (HIV) was first identified, the HIV epidemic continues to cause large-scale human suffering and economic losses. Since featuring prominently in the Millennium Development Goals (MDGs), HIV has received an unprecedented global political and financial commitment, being allocated 25% of all international development assistance for health in 2011. But, despite significant successes, the HIV epidemic is still one of the most important causes of loss of life and health in sub-Saharan Africa. The global HIV response will thus have to be a major continued focus of national and international development strategies after 2015.

Sub-Saharan Africa is home to 70% of people living with HIV globally. Within this region, Southern Africa has been hit hardest by the epidemic – all of the world’s so-called HIV hyperendemic countries (i.e., countries with an adult HIV prevalence >15%) are located here: Botswana, Lesotho, South Africa, Swaziland and Zimbabwe. We recommend two goals to address the HIV epidemic in these hyperendemic countries over the next 15 years:

• Target 1: Achieve anti-retroviral treatment (ART) coverage of at least 90% of HIV-infected adults with a CD4 cell count <350 cells/μL before expanding the HIV treatment scale-up to people with higher CD4 cell counts.
• Target 2: Attain circumcision coverage of at least 90% amongst HIV-uninfected adult men.

The CD4 cell count decreases in concentration with deteriorating immune system function. The rationale for target 1 is based on two main lines of reasoning. Firstly, providing ART to an individual with a CD4 cell count <350 cells/μL is, on average, more cost-effective than offering it to a patient with a higher CD4 cell count: at the lower CD4 cell count both the survival-increasing and HIV transmission-reducing effects of ART are larger. Secondly, the severe constraints in financial, human and physical resources in hyperendemic countries will likely mean that ART cannot be provided to all HIV-infected individuals immediately. As long as resources are insufficient for universal ART coverage of all HIV-infected people, a scenario may arise whereby a healthier patient receiving ART implies that a less healthy patient cannot gain access to the life-saving treatment (a “crowding-out” effect).

The rationale for suggesting male medical circumcision as another target is that circumcision has an efficacy of around 60% in reducing HIV acquisition by men through heterosexual intercourse, and that in the longer term infection rates in women are also substantially reduced due to circumcision as less of their sexual partners become infected. In addition, circumcision is a comparatively cheap one-off intervention that lasts for life. Although current levels of circumcision are still relatively low, the level of acceptability of circumcision is encouraging with a review finding that a median of 65% of uncircumcised men in sub-Saharan Africa are willing to be circumcised.

Using a mathematical model, we find that, for discount rates of 3% and 5%, the life years gained are more than ten times higher for ART as compared to circumcision. However, compared to maintaining current coverage levels, the additional cost of scaling up circumcision in hyperendemic countries is only 500 million dollars while the additional cost of scaling up ART is 16.5 to 19.3 billion dollars. In fact, scaling up of ART as proposed would require a doubling of the current investment. The main reason for this difference is that ART requires long-term use of expensive medication, while circumcision is a one-off procedure.

Although scaling up ART and circumcision are both cost-beneficial, the benefit-to-cost ratio (BCR) for circumcision is significantly higher, ranging from 7.4 ($1,000 per life year, 5% discount rate) to 56.4 ($5,000 per life year, 3% discount rate). However, especially when valuing a life year at $5,000, scaling up ART is also a highly cost-beneficial intervention (BCR between 3.0 and 16.6) and, in our view, an important goal for HIV and AIDS for the period 2015 to 2030.

Similar to any large-scale public health intervention, both increasing coverage of ART and circumcision are likely to face several implementation challenges. Increasing ART coverage hinges on the ability to identify HIV-infected individuals who are not yet aware of their positive status. However, current testing efforts have fallen far short of testing everyone, and many of those eligible for ART do not start or continue the treatment. Low demand is one of the main obstacles for scaling up circumcision, and thus implementing and evaluating demand creation approaches, such as financial incentives, should be an important component of future circumcision programs.