Date Published: June 26, 2018
Publisher: Public Library of Science
Author(s): Aleksandra Jakubowski, Katherine Snyman, Dalsone Kwarisiima, Norton Sang, Rachel Burger, Laura Balzer, Tamara Clark, Gabriel Chamie, Starley Shade, Craig Cohen, Elizabeth Bukusi, Edwin Charlebois, Moses Kamya, Maya Petersen, Diane Havlir, Harsha Thirumurthy, Jacob Bor.
Country decisions to scale-up “test and treat” approaches for HIV depend on consideration of both the health and economic consequences of such investments. Evidence about economic impacts of expanded antiretroviral therapy (ART) provision is particularly relevant for decisions regarding foreign assistance levels for HIV/AIDS programs. We used baseline data from the Sustainable East Africa Research in Community Health (SEARCH) cluster randomized controlled trial in Kenya and Uganda to examine the association between HIV status, CD4+ T-cell counts, viral suppression, and multiple indicators of economic well-being.
Socio-economic surveys were conducted in households with HIV-positive and HIV-negative adults sampled after a census of 32 communities participating in the SEARCH trial (NCT01864603). Data were obtained for 11,500 individuals from 5,884 households in study communities. Participants were stratified based on their own HIV status as well as CD4 counts and viral suppression status if they were HIV-positive. HIV-negative participants residing in households with no HIV-positive adults were considered separately from HIV-negative participants residing in households with ≥1 HIV-positive adult. Generalized estimating equation models were used to examine the relationship between HIV status, CD4 counts, ART, viral suppression, and outcomes of employment, self-reported illness, lost time from usual activities due to illness, healthcare utilization, health expenditures, and hospitalizations. In all models, HIV-negative participants in households with no HIV-positive persons were the reference group.
Data from a large population-representative sample of households in east Africa showed a strong association between the health of HIV-positive persons and economic outcomes. The findings suggest there may be economic benefits associated with maintaining high CD4 counts, both for HIV-positive persons and their HIV-negative household members. The association of high CD4 counts with improved outcomes is consistent with the hypothesis that early ART initiation can avert declines in employment and other economic outcomes. Prospective longitudinal evaluation is needed to assess the causal impact of early ART initiation on economic functioning of households.
Compelling evidence on the public health benefits of antiretroviral (ART) treatment as prevention and the individual-level benefits of early ART initiation [1, 2] was the foundation for the 2015 WHO guidelines that recommend treatment for all persons living with HIV. Given the promise ART now holds for HIV-positive people and the broader population, the UNAIDS established the ‘90-90-90 targets’ that call for 90% coverage of HIV testing, ART initiation, and treatment adherence among HIV-positive persons [3, 4]. Despite these data and recommendations, less than half of countries have adopted the WHO guidelines and pace of adaptation is threatened even among countries moving forward to “HIV test and treat” . Despite the strong public health case and economic rationale, a number of factors including resource constraints have contributed to these delays [3, 6–8]. Uncertainty about levels of support from the US government for HIV/AIDS programs through the President’s Emergency Plan For AIDS Relief (PEPFAR) and other initiatives  could put an even greater financial burden on low-income countries that depend on this financing. Policymakers could therefore benefit from assessments of the potential economic gains of finding and keeping HIV-positive persons in the high CD4 range through early ART initiation—gains that may be realized by the affected HIV-positive individual and their household members.
In this large, population-representative study from 32 communities participating in the SEARCH trial in Kenya and Uganda, economic outcomes for HIV-positive adults with CD4 counts above 500 were significantly better than those for HIV-positive adults with CD4 counts below 500, and also statistically equivalent to outcomes for HIV-negative adults. For HIV-negative household members of HIV-positive persons, higher CD4 count of an HIV-positive household member was similarly protective of employment outcomes. Patterns in healthcare utilization and healthcare costs incurred by HIV-positive individuals also indicated a benefit to having higher CD4 counts, although the outcomes of those with CD4>500 remained worse than those for HIV-negative persons in households not directly affected by HIV. Importantly, even among HIV-positive participants who had not initiated ART or were not virally suppressed, those with CD4>500 had better economic outcomes than those with lower CD4 counts, including in the mid-range of 351–500 cells/μL. These findings suggest that initiating ART before CD4 counts decline substantially could generate economic benefits, though the results need to be confirmed with longitudinal data to establish causality.
At a time when countries most affected by the HIV epidemic face increasing financial challenges to fund the HIV response, our study provides evidence about the potential economic benefits of earlier ART initiation. While we cannot draw causal conclusions, our findings provide important insights about the associations between the CD4 counts and ART use of HIV-positive persons and the economic outcomes they and their HIV-negative household members achieve. Future data from the SEARCH trial will enable us to test the hypothesis that early ART initiation has a causal effect on individual- and household-level economic outcomes.