Antiretroviral Therapy: Survival Benefits in South Africa Interview with:
Michael D. April, MD, DPhil
San Antonio Uniformed Services Health Education Consortium.Department
Harvard Medical School
The Medical Practice Evaluation Center What are the main findings of this study?

Dr. April: Using a mathematical model, this study quantified the survival benefits associated with antiretroviral therapy to HIV-infected people in South Africa since 2004.  Our results highlight the astounding benefits of treatment.  In short, antiretroviral therapy has saved 2.8 million years of life in South Africa to date and is projected to save an additional 15.1 million years of life by 2030. What are the most important points or takeaway messages from these findings?

Dr. April: The return on global investment in antiretroviral therapy has been impressive, but gains already achieved are merely the tip of the iceberg.  Using very conservative estimates, our study projects that gains as of December 2011 comprise only 15.6% of the 17.9 million years of life to be saved by 2030 or 12.7% of the 21.7 million years of life projected to be saved over the lifetime of those patients currently receiving ART.  What these estimates exclude is those who might benefit from ART in the future.  As such, policy-makers have the power to magnify the future trajectory of survival gains further still by pursuing more aggressive HIV testing and treatment strategies.  Increased case identification, early ART initiation and expanded treatment options might catapult our conservative survival projections even further.

It is our hope that this study reminds stake-holders of the astounding efficacy of the global ART rollout while simultaneously invigorating efforts to redouble commitments toward expanding the availability of ART. What should clinicians, patients, and decision makers take away from your report?

Dr. April: Significant capital and manpower have already been invested into the impressive ART rollout in South Africa and throughout the globe spanning from early 2004 to the present day.  Our results are a testament to the return already realized on that investment.  However, the real story here is less the years of life already saved but rather the hard-won establishment of an effective ART delivery system responsible for treatment of 1.4 million HIV-infected persons according to recent WHO estimates.  Having already expended significant resources to meet the start-up costs to establish this system, these results highlight the devastating opportunity cost of cutting international commitments to ART in the name of fiscal austerity to avoid current upkeep costs.  What recommendations do you have for future research as a result of this study?

Dr. April: Our results suggest that rather than a debate over continuation of current funding commitments, policy-makers and resources should be examining strategies to expand testing and treatment efforts, so increasing future potential survival gains.  We are not advocating a blanket approach as we realize these investments need to be made efficiently.  Future studies need to best understand where these investments can  produce the largest survival yield. Moreover, future survival gains will rise significantly if increasing numbers of patients continue to initiate ART each year, leading to further financing needs.  Approaches to reduce these cost may include expansion of access to second-line ART through, negotiations with pharmaceutical companies, competitive price reductions, infrastructure improvement, and examining alternatives to promote economies scale.

Our study also highlights where current defaults in the system might have attenuated survival to date and where more work needs to be done.  Patients are often limited in their benefits realized because they are diagnosed too late; expanding case detection through more aggressive HIV testing by using rapid tests, mobile testing centers, or home-based testing models are areas meriting further research.  Furthermore, mechanisms for effectively tracking monitoring HIV-infected patients not yet eligible for ART must be improved to minimize loss-to-follow-up of potential future ART recipients.  Finally, research should continue to examine clinical utility and cost-effectiveness of liberalizing ART eligibility criteria to maximize the number of HIV-infected persons benefiting from ART.


The Survival Benefits of Antiretroviral Therapy in South Africa
Michael D. April, Robin Wood, Bethany K. Berkowitz, A. David Paltiel, Xavier Anglaret, Elena Losina, Kenneth A. Freedberg, and Rochelle P. Walensky

J Infect Dis. first published online December 3, 2013 doi:10.1093/infdis/jit584

Last Updated on December 5, 2013 by Marie Benz MD FAAD