CROI 2015 Program and Abstracts

Abstract Listing

Poster Abstracts

Conclusions: In a real-world setting, referral of patients to pre-ART care (vs. immediate ART eligibility) led to large losses of life and health. These losses could have been avoided with immediate ART, which was found to be “very cost effective” at conventional benchmarks. 1111 Community-Based Strategies to Strengthen the Continuum of HIV Care Are Cost-Effective

Jennifer A. Smith 1 ; Monisha Sharma 2 ; Carol Levin 2 ; Jared Baeten 2 ; Heidi van Rooyen 3 ; Connie Celum 2 ;Timothy Hallett 1 ; RuanneV. Barnabas 2 1 Imperial College London, London, United Kingdom; 2 University of Washington, Seattle, WA, US; 3 Human Sciences Research Council, Sweetwaters, South Africa

Background: Closing gaps in the continuum of HIV care is a priority for public health strategies that aim to reduce HIV-associated morbidity, mortality and HIV incidence. Facility-based HIV counselling and testing (HTC) has achieved limited testing coverage and linkage to care, particularly among asymptomatic persons. Home HTC and linkage to care achieved high testing coverage and linkage to care in KwaZulu-Natal, South Africa, but its impact on population-level health and cost-effectiveness compared to existing facility-based testing has not been evaluated. Methods: We developed an individual-based HIV transmission model parameterized with epidemiologic and cost data from home HTC and linkage studies in rural KwaZulu-Natal, South Africa. The HTC and linkage studies measured the change in the proportion of all HIV-positive persons with suppressed viral load between study enrolment and 12 months. The model simulated the intervention impact and projected the effect on health outcomes over 10 years. The incremental cost-effectiveness ratios (ICERs) were calculated for the intervention relative to existing facility-based testing per HIV incident infection and disability adjusted life year (DALY) averted. Results: With the high coverage (91%) and linkage to ART (80%) observed in the home HTC studies, HIV-associated disability and incident infections were reduced compared to current testing modalities, especially at higher ART initiation criteria: as the ART initiation threshold increased from ≤ 200 cells/mm 3 to universal eligibility, 10-22% of DALYs and 11-48% of HIV infections were averted over ten years. Home HTC is “very cost effective” by WHO standards across all ART initiation thresholds: US$1,080, $925, $985 and $1,150 per DALY averted and $7,000, $7,580, $7,100 and $6,560 per infection averted with ART initiation at ≤ 200 cells/mm 3 , ≤ 350 cells/mm 3 , ≤ 500 cells/mm 3 and universal eligibility, respectively. ART costs exceeded all other costs, accounting for 48-85% of total programme costs; with universal eligibility and a reduced ART cost, the ICER per DALY averted is reduced four-fold. Conclusions: Home HTC can strengthen linkage to care and enhance the increases in ART uptake that will result from South Africa’s expanding ART eligibility criteria. As treatment programs move forward to implement ‘90% of HIV-infected persons tested, 90% treated, 90% achieving viral load suppression’, insights from this analysis find that community- based HTC and linkage is a cost-effective strategy for HIV prevention. 1112 The Cost-Effectiveness of CD4 Cell Count Versus HIV RNA Viral Load for ART Initiation Roger Ying 1 ; BrianWilliams 3 ; RuanneV. Barnabas 1 ; Reuben Granich 2 1 University of Washington, Bellevue, WA, US; 2 Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland; 3 Stellenbosch University, Stellenbosch, South Africa Background: The UNAIDS has proposed achieving 90% diagnosis of HIV-positive persons, 90% antiretroviral therapy (ART) coverage among those diagnosed, and 90% viral suppression among those on ART. ART initiation guidelines have primarily depended on CD4 cell count, with the World Health Organization (WHO) currently recommending ART initiation for persons with CD4 ≤ 500 cells/ m L. However, HIV transmission, morbidity, and mortality are more closely linked with the level of virus—viral load (VL)—than CD4 count. The impact of CD4- versus VL-based ART criteria on HIV-associated outcomes has not previously been studied. Methods: We reviewed the literature for studies assessing the association between clinical outcomes—HIV transmission, time to AIDS, HIV-associated mortality, and ART initiation—and CD4 count and VL. These measures were used to parameterize a compartmental mathematical model of HIV transmission in KwaZulu-Natal, South Africa, that was stratified by gender, CD4 count, VL, and ART status. The model was used to estimate the proportion of ART-ineligible persons with high viral load, and the proportion of HIV infections, deaths, and quality-adjusted life-years (QALYs) that could have been saved if ART had been initiated for those with high VL. These values were estimated from 2004 to 2014 and from 2015 to 2025. From 2015 to 2025, we also estimated the incremental cost-effectiveness ratio (ICER) of ART initiation at VL>10,000 copies/mL to CD4 ≤ 500 cells/ m L. Results: We estimate that in KwaZulu-Natal from 2004 to 2014, 35% of ART-ineligible patients by CD4 count had VL >10,000 copies/mL, and 12% had VL>50,000 copies/mL. With 30% of ART-ineligible persons with VL>10,000 copies/mL initiating ART, an additional 72% of HIV infections and 46% of HIV-associated deaths could have been averted, and 44% of QALYs gained. From 2015 to 2025, ART initiation at CD4 ≤ 500 cells/ m L provides 5%more individuals with ART than VL>10,000 copies/mL. Using the VL criterion results in an ICER of $5,709 per HIV infection averted and $537 per QALY gained, whereas using the CD4 criterion results in an ICER of $7,851 per HIV infection averted and $612 per QALY gained.

Poster Abstracts

645

CROI 2015