The results of international clinical trials that are assessing when to initiate antiretroviral therapy (ART) will not be available for several years. To inform HIV treatment decisions about the optimal CD4 threshold at which to initiate ART in South Africa while awaiting the results of these trials. Cost-effectiveness analysis by using a computer simulation model of HIV disease. Published data from randomized trials and observational cohorts in South Africa. HIV-infected patients in South Africa. 5-year and lifetime. Modified societal. No treatment, ART initiated at a CD4 count less than 0.250 × 10⁹ cells/L, and ART initiated at a CD4 count less than 0.350 × 10⁹ cells/L. Morbidity, mortality, life expectancy, medical costs, and cost-effectiveness. If 10% to 100% of HIV-infected patients are identified and linked to care, a CD4 count threshold for ART initiation of 0.350 × 10⁹ cells/L would reduce severe opportunistic diseases by 22 000 to 221 000 and deaths by 25 000 to 253 000 during the next 5 years compared with ART initiation at 0.250 × 10⁹ cells/L; cost increases would range from $142 million (10%) to $1.4 billion (100%). Either ART initiation strategy would increase long-term survival by at least 7.9 years, with a mean per-person life expectancy of 3.8 years with no ART and 12.5 years with an initiation threshold of 0.350 × 10⁹ cells/L. Compared with an initiation threshold of 0.250 × 10⁹ cells/L, a threshold of 0.350 × 10⁹ cells/L has an incremental cost-effectiveness ratio of $1200 per year of life saved. Initiating ART at a CD4 count less than 0.350 × 10⁹ cells/L would remain cost-effective over the next 5 years even if the probability that the trial would demonstrate the superiority of earlier therapy is as low as 17%. This model does not consider the possible benefits of initiating ART at a CD4 count greater than 0.350 × 10⁹ cells/L or of reduced HIV transmission. Earlier initiation of ART in South Africa will probably reduce morbidity and mortality, improve long-term survival, and be cost-effective. While awaiting trial results, treatment guidelines should be liberalized to allow initiation at CD4 counts less than 0.350 × 10⁹ cells/L, earlier than is currently recommended. National Institute of Allergy and Infectious Diseases and the Doris Duke Charitable Foundation.

The persistent influence of coloniality both from external actors and from within threatens the response to COVID-19 in Africa. This essay presents historical context for the colonial inheritance of modern global health and analyses two controversies related to COVID-19 that illustrate facets of coloniality: comments made by French researchers regarding the testing of BCG vaccine in Africa, and the claims by Madagascar’s president Andry Rajoelina that the country had developed an effective traditional remedy named Covid-Organics. Leveraging both historical sources and contemporary documentary sources, I demonstrate how the currents of exploitation, marginalisation, pathologisation and saviourism rooted in coloniality are manifested via these events. I also discuss responses to coloniality, focussing on the misuse and co-optation of pan-Africanist rhetoric. In particular, I argue that the scandal surrounding Covid-Organics is a reflection of endogenised coloniality, whereby local elites entrench and benefit from inequitable power structures at the intersubjective (rather than trans-national) scale. I conclude with a reflection on the need for equity as a guiding principle to dismantle global health colonialism.

BackgroundOnly 33% of eligible human immunodeficiency virus (HIV)–infected patients in South Africa receive antiretroviral therapy (ART). We sought to

Background: Although 900,000 HIV-infected South Africans receive antiretroviral therapy, the majority of South Africans with HIV remain undiagnosed. Methods: We use a published simulation model of HIV case detection and treatment to examine 3 HIV screening scenarios, in addition to current practice as follows: (1) one-time; (2) every 5 years; and (3) annually. South African model input data include the following: 16.9% HIV prevalence, 1.3% annual incidence, 49% test acceptance rate, HIV testing costs of $6.49/patient, and a 47% linkage-to-care rate (including 2 sequential antiretroviral therapy regimens) for identified cases. Outcomes include life expectancy, direct medical costs, and incremental cost-effectiveness. Results: HIV screening one-time, every 5 years, and annually increase HIV-infected quality-adjusted life expectancy (mean age 33 years) from 180.6 months (current practice) to 184.9, 187.6, and 197.2 months. The incremental cost-effectiveness of one-time screening is dominated by screening every 5 years. Screening every 5 years and annually each have incremental cost-effectiveness ratios of $1570/quality-adjusted life year and $1720/quality-adjusted life year. Screening annually is very cost-effective even in settings with the lowest incidence/prevalence, with test acceptance and linkage rates both as low as 20%, or when accounting for a stigma impact at least four-fold that of the base case. Conclusions: In South Africa, annual voluntary HIV screening offers substantial clinical benefit and is very cost-effective, even with highly constrained access to care and treatment.

Background. Drug resistance poses a serious challenge for the control of tuberculosis in many settings. It is well established that the expected future trend in resistance depends on the reproductive fitness of drug-resistant Mycobacterium tuberculosis. However, the variability in fitness between strains with different resistance-conferring mutations has been largely ignored when making these predictions. Methods. We developed a novel approach for incorporating the variable fitness costs of drug resistance-conferring mutations and for tracking this distribution of fitness costs over time within a transmission model. We used this approach to describe the effects of realistic fitness cost distributions on the future prevalence of drug-resistant tuberculosis. Results. The shape of the distribution of fitness costs was a strong predictor of the long-term prevalence of resistance. While, as expected, lower average fitness costs of drug resistance–conferring mutations were associated with more severe epidemics of drug-resistant tuberculosis, fitness distributions with greater variance also led to higher levels of drug resistance. For example, compared to simulations in which the fitness cost of resistance was fixed, introducing a realistic amount of variance resulted in a 40% increase in prevalence of drug-resistant tuberculosis after 20 years. Conclusions. The differences in the fitness costs associated with drug resistance–conferring mutations are a key determinant of the future burden of drug-resistant tuberculosis. Future studies that can better establish the range of fitness costs associated with drug resistance–conferring mutations will improve projections and thus facilitate better public health planning efforts.