Acknowledgements: Ellen McRobie

1. The epidemiological impact and cost-effectiveness of expanded eligibility for and access to adult antiretroviral therapy in South Africa, Zambia, India and Vietnam: a twelve model analysis JW Eaton, NA Menzies, J Stover, V Cambiano, L Chindelevitch, A Cori, JAC Hontelez, S Humair, CC Kerr, DJ Klein, S Mishra, KM Mitchell, BE Nichols, P Vickerman, T Bärnighausen, A Bershteyn, DE Bloom, M-C Boily, ST Chang, T Cohen, PJ Dodd, C Fraser, C Gopalappa, J Lundgren, NK Martin, E Mountain, QD Pham, M Pickles, A Phillips, L Platt, C Pretorius, HJ Prudden, JA Salomon, DAMC van de Vijver, BG Wagner, RG White, DP Wilson, L Zhang, J Blandford, G Meyer-Rath, M Remme, F Terris-Prestholt, P Revill, N Sangrujee, M Doherty, P Easterbrook, G Hirnschall, TB Hallett 7th IAS Conference on HIV Pathogenesis, Treatment and Prevention Kuala Lumpur Malaysia, 1 July 2013 Funding: Acknowledgements: Ellen McRobie

2. Questions for programmes • ART eligibility: • Given an HIV+ person in care, should they be initiated on ART if they have a CD4 > 350 cells/µL? • Program scale-up priorities: • Should programmes devote resources to (i) expanding access following current ART guidelines, or (ii) immediately adopt new ART eligibility guidelines? • Strategic prioritisation: • Are there certain populations that should be prioritised for expanded access and earlier ART?

3. Model analyses • Settings: • South Africa (7 models) • Zambia (4 models) • India (3 models) • Vietnam (1 model) • Eligibility x access strategies projected over 20 years (2014–2033) • US$/DALY averted compared to current access & eligibility

4. Mathematical models

5. Impact on HIV incidence South Africa Zambia

6. Impact on HIV incidence India – sexual tranmsission India – injecting Vietnam

7. Costing approach

8. Unit costs: predictions vs. data

9. Cost-effectiveness of earlier eligibility Cost per DALY averted over 20 years (3% discount per annum):

10. Costs of program expansion Incremental cost of expanded eligibility and access (South Africa; 20 years, undiscounted): Expanded Access vs. Status Quo Eligibility for All vs. Status Quo

11. Earlier eligibility or expanded access? Uniform expansion of testing and immediate treatment for all $795/ DALY averted Uniform expansion of testing and treat <500 Treat all HIV-infected persons that in care/will enter care $237/ DALY averted Treated persons with CD4<500 that are in care/will enter care. Uniform expansion of testing with no change in eligibility Current eligibility criteria and testing levels.

12. Earlier eligibility or expanded access?

13. Prioritised access in concentrated epidemics Vietnam: (GDP $1407 pppy) $24,610 / DALY $2043 / DALY $290 / DALY

14. Conclusions • Expanded ART eligibility appears ‘cost-effective’ (CD4 ≤500 or all HIV+). • Cost of initiating ART vs. waiting are small, given a patient in care. • Expanded testing and linkage appears ‘cost-effective’ in generalised epidemic settings. • In concentrated epidemic settings, immediate eligibility and expanded access to high-risk populations appears highly cost-effective. • Consensus conclusions across many models increases confidence in policy recommendations based on modelling. • Conclusions must be reevaluated when new data are available (esp. when-to-start trials, community combination prevention trials). • Other considerations for programmes, e.g. equity. http://www.hivmodelling.org