In  session titled “Costs and Cost Effectiveness of the New WHO Guidelines for Treatment”  WEAE02, the authors presented cutting edge information and analysis on the cost and cost effectiveness implications of the new WHO guidelines for AIDS treatment.  The paper by Rath et al showed that under new South African guidelines, the numbers expected to go on ART over the next six years will rise from around 1 million to about 2.6 million, and application of the full WHO guidelines would raise the numbers to about 3 million.  ART costs can also be expected to rise rapidly.  If the government implements a series of efficiency measures (lower drug prices, lower test costs, and task shifting), this could bring down total costs by about a third.  Nevertheless, total costs will rise from about $1.1 billion a year now to around $2.2 billion in 2016.

The work of Bollinger et al estimated the cost impact of adopting the new guidelines for all low and middle income countries, using the 350 cutoff and either rapid or slow phase out of d4T in favor of Tenofivir.  Overall, the new guidelines will increase the need for treatment by about 50%, and ART spending (drugs, tests, service delivery costs) is expected to grow from around $3.3 billion today to $9.5 billion by 2015.

The paper by Chirwa et al contained the results of a rapid assessment of the impact of the new WHO guidelines on ART spending by Malawi, a resource poor country.  In short, the new CD threshold and switch from d4T to TDF would, as well as expanded coverage, would result in an increase from $30 million a year in 2009 to $100-180 million by 2014 – more than Malawi’s total domestic spending on health in those years.

To address the challenges of financing treatment under the new guidelines, the paper by Wolensky et al pointed to one approach to decision-making – estimating the incremental cost effectiveness of alternative combination of CD monitoring, CD4 cutoffs for initiation, and regime switch to AZT and TDF based regimens.  These choices were modeled for the South African population.  The authors identified four stepwise changes in ART policy that represented the best choices, i.e., a cost-effectiveness frontier.  All had ICERs of less than South Africa’s GDP, suggesting that they represented good value for money as long as the country is willing to budget and spend for these features of the ART program.

Finally, Auld et al presented an analysis of the cost-effectiveness of the new 2009 WHO guidelines for PMTCT, as applied to the 15 PEPFAR focus countries.  They compared the old 2006 WHO guidelines involving dual therapy with Options A and B under the 2009 guidelines, and found that both options are superior to the old guidelines, with Option A being the most cost-effective.  To implement the new options, total spending for the 15 countries will need to increase from around $64 million a year to $250-350 million using 2010 PMTCT epi data.  ICERs ranged from $81-107 per life year gained, all well below the GDP per capita of the 15 countries.  In some instances, countries actually achieved cost savings using the new guidelines, because reductions in spending for opportunistic infections exceeded the additional costs of the new drug regimens.