A new study finds that implementing the United Nations targets for HIV testing and treatment would be an expensive but ultimately very cost-effective way to increase survival, reduce the number of children orphaned by HIV, and contain the global AIDS epidemic. That is the conclusion of researchers at the Massachusetts General Hospital (MGH), the University of Cape Town and the Yale School of Public Health, who estimated the likely impact of the so-called "90-90-90" program.
"Based on our findings, there is nothing overstated about the suggestion that 90-90-90 could lay the foundation for a healthier, more just and equitable world for future generations," says Rochelle P. Walensky, MD, MPH, of the MGH Division of Infectious Disease, who led the study that will appear in the May 31 online edition of Annals of Internal Medicine. "Yes it would be very expensive, but it would be worth every penny."
Launched in September 2014 by the Joint United Nations Programme on HIV/AIDS (UNAIDS), the 90-90-90 program has three key objectives - diagnosing 90 percent of HIV-infected persons worldwide; linking 90 percent of identified cases to antiretroviral therapy (ART); and achieving virologic suppression among 90 percent of ART recipients. The program's overall goal is achieving viral suppression - reducing the viral load to an undetectable level - among 73 percent of HIV-infected persons worldwide by 2020, a marked improvement from current estimates of 24 percent.
Critics have expressed concern that successful implementation of 90-90-90 would require unprecedented cash infusions from donor organizations such as the President's Emergency Plan for AIDS Relief, the Global Fund, and the World Bank. Study co-author Linda-Gail Bekker, MD, PhD, of the Desmond Tutu HIV Centre and University of Cape Town in South Africa, notes, "Recent funding from these sources has been flat. Our goal for this study was to provide donors and partner countries with pragmatic estimates of what it will cost and what return they can expect by investing in 90-90-90."
The study used South African epidemiologic data and results from HIV screening and treatment programs to give a realistic picture of the likely impact of 90-90-90 in South Africa and compared it with the current pace of HIV detection and treatment over the next 5 and 10 years. Using a well-published computer simulation model developed by the research team, their analysis revealed that, over the next decade, the 90-90-90 strategy would avert more than 2 million new HIV infections, more than 2.4 million deaths and over 1.6 million orphans - saving an additional 13 million patient-years of life compared with the current strategy.
Over the same period, the cost of the 90-90-90 effort would be $54 billion, a 42 percent increase over the costs of current scale-up activities that still suffer from challenges related to both linkage to care and treatment retention. But taken as a whole, the study found that investment in 90-90-90 would yield a cost-effectiveness ratio of $1,260 per year of life saved, well within what would be considered very cost effective for South Africa and a ratio similar to that of HIV treatment itself.
A. David Paltiel, MBA, PhD, professor of Public Health (Health Policy) at the Yale School of Public Health and senior author of the study, says, "We're convinced, based on the results of our analysis, that successful implementation of the 90-90-90 targets would effectively put an end to the AIDS epidemic worldwide,"
Publication of the study coincides with a June 8-10 United Nations meeting of world leaders, HIV program implementers, government representatives and other key stakeholders to solidify a plan to put an end to the global AIDS epidemic by 2030. "Implementation of 90-90-90 would represent a 'virtuous circle' of care - leading to earlier HIV diagnosis, more rapid treatment initiation, longer survival for HIV-infected persons, and fewer new cases of HIV transmission," says Walensky, a professor of Medicine at Harvard Medical School. "The time to jump-start this worthy global undertaking is now."
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Additional co-authors of the Annals of Internal Medicine report are Emily Hyle, MD, SM, Andrea Ciaranello, MD, MPH, and Kenneth Freedberg, MD, MSc, MGH Division of Infectious Disease; Ethan Borre, MGH Medical Practice Evaluation Center; Robin Wood, FCP, MMed, DSc, University of Cape Town; and Stephen Resch, PhD, and Milton Weinstein, PhD, Harvard T.H. Chan School of Public Health. The study was supported by grants from the National Institutes of Health and the Steve and Deborah Gorlin MGH Research Scholars Award.
The Yale School of Public Health was founded in 1915 and is one of the oldest accredited schools of its kind in the United States. Today the school has nearly 250 full- and part-time faculty who conduct a wide range of research around the world to addresses current health problems as well as emerging diseases. The school also has some 4,500 alumni who work in 70 countries and in virtually every field of public health. Through its collaborative approach to research, education and training, the Yale School of Public Health has fostered meaningful innovations that have improved the health and well-being of communities throughout the world.
Massachusetts General Hospital, founded in 1811, is the original and largest teaching hospital of Harvard Medical School. The MGH Research Institute conducts the largest hospital-based research program in the nation, with an annual research budget of more than $800 million and major research centers in HIV/AIDS, cardiovascular research, cancer, computational and integrative biology, cutaneous biology, human genetics, medical imaging, neurodegenerative disorders, regenerative medicine, reproductive biology, systems biology, photomedicine and transplantation biology. The MGH topped the 2015 Nature Index list of health care organizations publishing in leading scientific journals, earned the prestigious 2015 Foster G. McGaw Prize for Excellence in Community Service and returned to the number one spot on the 2015-16 U.S. News & World Report list of "America's Best Hospitals."
Journal
Annals of Internal Medicine