Do HIV Treatment Eligibility Expansions Crowd out the Sickest? Evidence from Rural South Africa

In September 2015, the World Health Organization revised its antiretroviral therapy (ART) treatment guidelines for people living with HIV, calling for a “test-and-treat” strategy and extending treatment eligibility to all people diagnosed with HIV regardless of CD4 white blood cell count. This recommendation reversed earlier guidelines that limited treatment to patients with lower CD4 counts or severe illness. Although expanding eligibility aims to reduce morbidity, mortality and transmission among patients, it is possible that a large influx of newly eligible patients in a resource-limited health system could crowd out sicker patients and reduce quality of care for all.

South Africa has the largest HIV-infected population in the world, with 2015 estimates of 7 million people living with HIV and over 3.3 million receiving ART. In August 2011, South Africa’s National Department of Health extended ART eligibility to all adults with CD4 counts ≤350 cells/μl, as recommended by the WHO 2010 guidelines. The 2011 policy change was estimated to have increased the ART-eligible population in South Africa by 900,000 individuals or 51 percent.

In a new journal article published in Tropical Medicine & International Health, Jacob Bor and colleagues assess the potential for negative spillover effects from the 2015 ART eligibility expansion by evaluating whether the 2011 expansion in South Africa affected entry into care and ART uptake among the sickest patients.

Main findings:

• Expanding CD4 eligibility criteria at the Hlabisa HIV Treatment and Care Programme in rural South Africa resulted in an 85 percent increase in ART initiation among newly eligible patients and a 32 percent increase in the number of patients initiating ART overall.
• In spite of the large influx of healthier patients onto ART, there was no evidence of crowd-out among sicker patients who have the greatest need for ART. In fact, ART uptake increased modestly for the sickest patients and times to initiation fell. 

Increasing the number of patients on treatment without compromising timeliness of care is a noteworthy achievement and may bode well for the rising patient loads as South Africa implements test-and-treat. The Hlabisa program can serve as a model for scale-up in other rural, resource-limited settings and should be considered when evaluating the economic costs and implications of ART eligibility expansions.