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Combining evidence for access to and benefits from antiretroviral treatment to inform planning

Editorial Steering Committee

doi: 10.1097/
Section III: Antiretroviral Treatment

*Please see Editorial for members of the Editorial Steering Committee.

Correspondence to Richard Marlink, Harvard School of Public Health, Boston, MA, USA. Tel: +1 617 432 4114; fax: +1 617 432 4545; e-mail:

The era of economic evaluations focusing on antiretroviral treatment (ART) versus a status quo of no treatment for HIV/AIDS is passing. With access to treatment expanding across developing countries, there is a growing, albeit insufficient, amount of research on the benefits to individuals, communities, companies, the workforce and economies. These benefits are broad, ranging from impacts on numbers of new HIV infections, quality of life, individual and social functioning, human capital investment, labour productivity and micro and macroeconomic performance. Policymakers attending the HIV/AIDS Interventions in Resource-Scarce Settings Conference called for economic analyses that consider the full range of HIV/AIDS intervention inputs and impacts, rather than traditional cost-effectiveness ratios alone.

Until recent years, evidence on the possible benefits of ART in developing countries was restricted to generalizations from high-income settings, modelled with relatively weak bases for parameter assumptions. In some cases, reservations existed about the implementation of ART in low-income settings. Increasingly, we are moving to an era in which economic evidence from developing country izimes is becoming available, and early studies are showing promising results [1]. There is now increasing demand for information about the ultimate effects of treatment on performance in the micro and macro economies of affected countries. Data from a variety of settings investigating different dimensions of benefit, therefore, become increasingly important for planning within both the government and private sectors. The articles in this section provide evidence on different areas of benefit derived from HIV/AIDS treatment in low-income settings.

In cost-effectiveness analysis in developing countries, quality-adjusted life years (QALY) are often calculated from utility weights placed on health states from high-income countries. Locally derived QALY, however, will better guide local resource allocation decisions according to local preferences. The first paper in this section by Medina Lara et al. adds to a small pool of evidence showing this is possible in low-income settings using existing tools in health economics for determining individual preferences over different states of health or quality of life. Comparing visual analogue scale, time trade off, and standard gamble derived weightings over three HIV/AIDS-related health states, the authors found that individuals drawn from two HIV-related study populations in Uganda could discriminate between health states using all methods, although most easily using visual analogue scale and time trade off techniques. QALY are usually calculated against a standard of ‘full health’, but the weightings of Medina Lara et al. are calculated against ‘improved health’ and require rescaling to enable izimes to be compared on the resulting QALY.

Rosen et al. show differences in a range of individual short-term outcomes from treatment, including symptoms, human functioning and job performance. Fewer symptoms, better performance of normal activities, and lower absenteeism from work for those employed were all seen in a 3-month period after treatment, with functioning and absenteeism continuing to improve over the 3–6-month period on treatment. Absenteeism results are in line with cited studies showing a significant reduction in self-report days missed from work in the months after commencing ART. One of the studies used payroll data from a large South African firm and showed reductions in sick days over 4 years of follow-up of 55% over the first 6 months, 66% over 12 months on treatment, and stabilizing over the 3 years on treatment to 72% less than at the commencement of ART. Levels and rates of decline in that study vary most significantly with the starting and ongoing CD4 cell count category, labour intensity of job role and financial incentives to stay at work (P < 0.002, P < 0.004 and P < 0.008, respectively; n = 1349) [2].

The paper by Aracena-Genao et al. adds to the body of literature regarding the survival benefit of ART in resource-limited settings. Healthcare costs in this Mexico-based study were compared with 5-year periods of additional life extension. Most cost-effectiveness and cost-benefit analyses of this sort, however, do not include any data on the impact of ART on HIV transmission and are increasingly identified as a gap in the economic analysis of ART. Salomon and Hogan, however, show that impacts of treatment on new cases of HIV may be relatively low, particularly in many developing countries where treatment is typically accessed at more advanced stages of disease. The authors combine wide-ranging and recent evidence on survival and behavior patterns of patients on ART with transmissibility of the virus in a series of models to show that it is still unclear whether ART will ultimately increase or decrease the total number of secondary infections.

How best to ensure that patients initiate treatment before they are severely immunosuppressed and maintain adherence are key questions in debating how to increase the cost-effectiveness and efficiency of treatment izimes, especially during rapid scale-up. Although debate continues on the role of user fees in increasing utilization and the quality of healthcare in developing countries, Souteyrand et al. provide a review that strongly suggests that for HIV/AIDS treatment, free care is important in facilitating access to and utilization of services. The authors cite a number of examples of HIV izimes in which the abolition of fees has led to greater service utilization. The authors also note the inefficiency of fees scales and exemptions that attempt to protect the poor while still retaining user charges for the majority. When patient retention and adherence to treatment are key drivers of cost-effectiveness, as is the case with ART, evidence supports the argument for free treatment. Further work should be done on comparing costs to the health systems in developing countries of poor adherence and retention with the income expected to be gained from user fees and whether widespread fee removal is more or less likely to help sustain a health system.

The papers in this section demonstrate the benefits of ART in developing countries in a number of ways. Improved quality of life, job performance and functioning in activities of daily living all result from accessing treatment. Universal abolishment of user fees may achieve access to treatment in low-income settings that is both of higher quality and more cost-effective. Even if ART provision does not have a large impact on HIV incidence, a compelling case can be made to allocate resources in ways that achieve better access to treatment and assist in keeping people on treatment, both of which are investments that are likely to have high returns for the populations of many developing countries.

Conflicts of interest: None.

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1. Cleary S, McIntyre D, Boulle A. The cost-effectiveness of antiretroviral treatment in Khayelitsha, South Africa– a primary data analysis. Cost Eff Resour Alloc 2006; 4:20.
2. Muirhead D, Kumaranayake L, Rice N. Exploring the impact of HIV/AIDS and its treatment on individual, team and firm level productivity in South Africa. In: Presentation to the International Health Economics Association Conference. Copenhagen, Denmark. 8–11 July 2007.
© 2008 Lippincott Williams & Wilkins, Inc.