Is there a possibility that the AIDS epidemic can be eradicated by 2030?
Ending the AIDs epidemic by 2030 in South Africa is part of a Joint United Nations (UN) Programme on HIV and AIDS (UNAIDS). With one in five people in the world infected with HIV living in South Africa, the ending of AIDS relies heavily on intervention in South Africa. Also, the risk of developing tuberculosis (TB) is an estimated 26-31 times higher for people living with HIV due to their weakened immune system and worldwide it is one of the leading causes of death among people living with HIV. The uncertainty of the health system in South Africa and the scale of the problem presents as an opportunity to show what can be done in these challenging conditions to control and prevent HIV & TB.
In 2016, the South African Government agreed to provide antiretroviral treatment (ART) to people infected with HIV irrespective of their CD4 cell counts. The number of CD4 cells in a sample of blood is the most important laboratory indicator for people with HIV, as it indicates not only how well your immune systems is functioning but it is also the strongest predictor of HIV progression.
Previous studies on the effects of expanding treatment and prevention have shown conflicting projections in terms of associated costs and likely outcomes. Thus, Williams and colleagues took this opportune moment to attempt to find a consensus on the potential cost-effectiveness and efficacy of this new implemented policy in South Africa. Their findings were published in The Lancet Public Health.
Using data from UNAIDS between 1988 and 2013 along with data from the World Health Organisation (WHO) on TB from 1980 to 2013, a dynamic model was applied to analyse trends in HIV prevalence, ART coverage and TB notification rates. This model was then used to evaluate current trends and project future patterns in terms of HIV prevalence and incidence, AIDS-related mortality and TB notification rates.
Two treatment strategies were also considered, including the Constant Effort strategy, where people infected with HIV continue to start treatment at the rate in 2016, and the Expanded Treatment and Prevention (ETP) strategy. The ETP strategy involves increasing testing rates, immediately starting treatment after HIV detection, and expansion of prevention programs such as voluntary medical male circumcision, pre-exposure prophylaxis (PrEP – a pill taken daily to prevent HIV infection of people who do not have HIV but are at substantial risk of contracting it) and condom distribution. Data obtained from the South African National AIDS Council was used to assess the current and future costs associated with these treatment and prevention approaches.
The results of the model estimations showed that the incidence of HIV in adults 15 years and older was reduced by 72%, with 2.3% per year in 1996 to 0.65% in 2016, AIDS-related mortality showed a 74% reduction where it fell from 1.4% per year in 2006 to 0.37% in 2016. Also, both the incidence of HIV and AIDS-related mortality continue to decrease at a rate of 17% per year. It was estimated that by 2025, due to the acceleration of ETP combined with the substantial treatment already administered to prevent and control the epidemic, almost all people infected with HIV will be receiving treatment.
Furthermore, the model showed that maintenance of the Constant Effort strategy will have a significant impact on HIV but it is unlikely to end AIDS in comparison to the ETP strategy which could indeed end the AIDS epidemic by 2030. The results show that under the ETP strategy the incidence of HIV infection and AIDS-related mortality would be less than one event per 1000 adults per year.
So, what is the impact on the healthcare system under the ETP strategy? Initially, it is estimated that the annual cost will increase to US$2.9 billion in 2018 (from $2.3 billion in 2016). However, it would decrease to approximately $1.7 billion by 2030 and $0.9 billion by 2050. Whilst the initial costs are increasing, the long-term benefit is significant in terms of costs on the healthcare system and in turn would advert approximately 3.8 million new infections, save over 1.1 million lives and save $3.2 billion when comparing the outcomes and costs with the Constant Effort strategy.
It is important to note that the main limitation of this study and model was the scarcity of reliable trend data, particularly for HIV incidence and AIDS-related mortality. This type of data would have given a much more precise model prediction.
Therefore, the results of the modelling study suggested that reaching the visionary goal of ending the AIDS epidemic by 2030 may be possible, provided there is a commitment to getting as many people as possible onto ART. The performance of the ETP strategy and ending AIDS requires ensuring early diagnosis, sustained treatment and good surveillance to monitor progress. Furthermore, the increase of ART coverage has had a substantial impact on TB notification rates and thus continued increases will likely have a substantial effect on reducing TB, particularly in people living with HIV.
However, decreasing the number of infections of HIV & TB as a subsequent result, the end of AIDS in South Africa does not mean the end of HIV; people living with the infection will require continuing care and support for at least the next 50 years or until a cure is found.
Written By: Lacey Hizartzidis, PhD