HIV This Week

Walensky RP, Wood R, Weinstein MC, Martinson NA, Losina E, Fofana MO, Goldie SJ, Divi N, Yazdanpanah Y, Wang B, Paltiel AD, Freedberg KA; CEPAC International Investigators. Scaling Up Antiretroviral Therapy in South Africa: The Impact of Speed on Survival. J Infect Dis. 2008 May 1;197(9):1324-1332.

Only 33% of eligible human immunodeficiency virus (HIV)-infected patients in South Africa receive antiretroviral therapy. Walensky and co-authors sought to estimate the impact of alternative antiretroviral therapy scale-up scenarios on patient outcomes from 2007-2012. Using a simulation model of HIV infection with South African data, they projected HIV-associated mortality with and without effective antiretroviral therapy for an adult cohort in need of therapy (2007) and for adults who became eligible for treatment (2008-2012). The authors compared 5 scale-up scenarios: (1) zero growth, with a total of 100,000 new treatment slots; (2) constant growth, with 600,000; (3) moderate growth, with 2.1 million; (4) rapid growth, with 2.4 million); and (5) full capacity, with 3.2 million. The projections showed that by 2011, the rapid growth scenario fully met the South African need for antiretroviral therapy; by 2012, the moderate scenario met 97% of the need, but the zero and constant growth scenarios met only 28% and 52% of the need, respectively. The latter scenarios resulted in 364,000 and 831,000 people alive and on antiretroviral therapy in 2012. From 2007 to 2012, cumulative deaths in South Africa ranged from 2.5 million under the zero growth scenario to 1.2 million under the rapid growth scenario. Alternative antiretroviral therapy scale-up scenarios in South Africa will lead to differences in the death rate that amount to more than 1.2 million deaths by 2012. More rapid scale-up remains critically important.

Editors’ note: Decision-makers can be influenced by modelling which demonstrates the differential impact of choosing various scale-up strategies for programmes. In this case, the speed of treatment scale-up has a large effect on the number of citizens alive in 2012. Although South Africa now has the highest number of people on antiretroviral treatment, two-thirds of eligible people are awaiting the expedient scale-up of services that will make a striking difference to their lives.