MANZINI, 13 September 2010 (PlusNews) - Research by South Africa's University of the Witwatersrand and Boston University in the US, has found that starting HIV-positive people on antiretrovirals (ARVs) earlier, and at a higher CD4 count (a measure of immune system strength), may be cheaper than previously thought.

After years of debating the financial feasibility of starting those in need of ARVs at a CD4 count of 350 instead of the current threshold of 200, research has shown that it would only add 13 percent to the cost of South Africa's national ARV programme if improved drug purchasing systems and task-shifting strategies were implemented. 

Activists and government have duelled for years over whether the country could afford the new treatment guidelines, including better drugs and earlier treatment initiation, in keeping with the World Health Organization (WHO) recommendations.

South Africa issued its first revised HIV treatment guidelines in six years in April 2010. The new guidelines featured less toxic ARVs, but access to treatment at a CD4 count of 350 was only extended to a selected group of high-risk patients, such as pregnant women, infants and tuberculosis patients.

Starting patients on ARVs at lower CD4 counts has been linked to a greater likelihood of opportunistic infections and poorer patient outcomes, but government argued that it could not afford to extend earlier treatment more broadly. WHO recommends that all HIV-positive patients start treatment at a CD4 count of 350.

The findings were part of a study that estimated the costs of implementing South Africa's current guidelines as well as the full WHO HIV treatment recommendations between 2010 and 2017.

Researchers combined mathematical models with costings and patient data collected from two Johannesburg ARV clinics over several years to estimate treatment need, patients lost to follow up, and treatment costs associated with each set of guidelines.

Under the current guidelines, the government will have spent about US$9.8 billion on treatment by 2017. Implementing the WHO recommendations by starting people on treatment earlier would cost about $11 billion over the same period.

Both price tags include savings of around $5.6 billion from sourcing drugs at internationally competitive prices and implementing task-shifting strategies, specifically nurse-initiated and -managed ARV treatment, with ARV dispensing by pharmacy assistants.

Prevalence, not eligibility, drives up patient numbers

Researchers also estimated that by 2017 about 3.5 million people would have started taking ARVs under the current guidelines, but earlier treatment would increase that figure by 400,000 patients.

"The growth in numbers of patients on [ARVs] over time, as a result of prevalence and sheer need, is higher than the growth in the number of patients as a result of increases in eligibility," said researcher and Boston University assistant professor Gesine Meyer-Rath during her recorded presentation of the study at the 2010 International AIDS Conference in in Vienna, Austria.

"If the South African government keeps doing what it said it would do - that is, put everyone who needs it on treatment - that will already drive the cost of the programme much more than decisions about eligibility, which will only drive costs at the margins," she said.

Data to drive advocacy, shape health systems

While the study found that  implementing earlier treatment would cost government about 10 percent of the national health services budget by 2012; the current guidelines would work out to just slightly less at around 8 percent.

Dr Francois Venter, head of the Southern Africa HIV Clinicians Society, discussed the research at the recent annual meeting of the Rural Doctors Association of Southern Africa (RuDASA) and noted that, given the medical expenses averted with treatment, the cost was worth it.

"It seems to me that if 47 percent of your deaths are HIV-related, then 10 percent of our budget isn't a lot to pay," he told IRIN/PlusNews.

"We [Reproductive Health and HIV Research Unit at Witwatersrand University] have done some evaluations and found that if you put someone on ARVs you stop at least one hospitalization and several clinics visits," he said.

In the context of decreased international aid, cost-saving will become increasingly important, Venter added.

"We need to make resources go further - whether it's rich South Africa or poor Malawi - those countries really need to think about working smarter," Venter he told IRIN/PlusNews. "If you employ a little creativity, some good people, and a little research money, you could go a long way in telling us how to run our health care systems a whole lot better and smarter."

The South African government funds about 80 percent of its national ARV programme, making it an exception in a region where the health budgets of many countries - Mozambique, Madagascar - are heavily supported by international donors. With an HIV prevalence of about 18 percent, South Africa has the world's largest ARV programme: more than a million people on treatment.