The Impact of Company-Level ART Provision to a Mining Workforce in South Africa: A Cost–Benefit Analysis
Identifieur interne : 003286 ( Ncbi/Merge ); précédent : 003285; suivant : 003287The Impact of Company-Level ART Provision to a Mining Workforce in South Africa: A Cost–Benefit Analysis
Auteurs : Gesine Meyer-Rath [Royaume-Uni, États-Unis, Afrique du Sud] ; Jan Pienaar [Afrique du Sud] ; Brian Brink [Afrique du Sud] ; Andrew Van Zyl [Afrique du Sud] ; Debbie Muirhead [Afrique du Sud] ; Alison Grant [Royaume-Uni] ; Gavin Churchyard [Afrique du Sud, Royaume-Uni] ; Charlotte Watts [Royaume-Uni] ; Peter Vickerman [Royaume-Uni]Source :
- PLoS Medicine [ 1549-1277 ] ; 2015.
Abstract
HIV impacts heavily on the operating costs of companies in sub-Saharan Africa, with many companies now providing antiretroviral therapy (ART) programmes in the workplace. A full cost–benefit analysis of workplace ART provision has not been conducted using primary data. We developed a dynamic health-state transition model to estimate the economic impact of HIV and the cost–benefit of ART provision in a mining company in South Africa between 2003 and 2022.
A dynamic health-state transition model, called the Workplace Impact Model (WIM), was parameterised with workplace data on workforce size, composition, turnover, HIV incidence, and CD4 cell count development. Bottom-up cost analyses from the employer perspective supplied data on inpatient and outpatient resource utilisation and the costs of absenteeism and replacement of sick workers. The model was fitted to workforce HIV prevalence and separation data while incorporating parameter uncertainty; univariate sensitivity analyses were used to assess the robustness of the model findings. As ART coverage increases from 10% to 97% of eligible employees, increases in survival and retention of HIV-positive employees and associated reductions in absenteeism and benefit payments lead to cost savings compared to a scenario of no treatment provision, with the annual cost of HIV to the company decreasing by 5% (90% credibility interval [CrI] 2%–8%) and the mean cost per HIV-positive employee decreasing by 14% (90% CrI 7%–19%) by 2022. This translates into an average saving of US$950,215 (90% CrI US$220,879–US$1.6 million) per year; 80% of these cost savings are due to reductions in benefit payments and inpatient care costs. Although findings are sensitive to assumptions regarding incidence and absenteeism, ART is cost-saving under considerable parameter uncertainty and in all tested scenarios, including when prevalence is reduced to 1%—except when no benefits were paid out to employees leaving the workforce and when absenteeism rates were half of what data suggested. Scaling up ART further through a universal test and treat strategy doubles savings; incorporating ART for family members reduces savings but is still marginally cost-saving compared to no treatment. Our analysis was limited to the direct cost of HIV to companies and did not examine the impact of HIV prevention policies on the miners or their families, and a few model inputs were based on limited data, though in sensitivity analysis our results were found to be robust to changes to these inputs along plausible ranges.
Workplace ART provision can be cost-saving for companies in high HIV prevalence settings due to reductions in healthcare costs, absenteeism, and staff turnover. Company-sponsored HIV counselling and voluntary testing with ensuing treatment of all HIV-positive employees and family members should be implemented universally at workplaces in countries with high HIV prevalence.
Url:
DOI: 10.1371/journal.pmed.1001869
PubMed: 26327271
PubMed Central: 4556678
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<front><div type="abstract" xml:lang="en"><sec id="sec001"><title>Background</title>
<p>HIV impacts heavily on the operating costs of companies in sub-Saharan Africa, with many companies now providing antiretroviral therapy (ART) programmes in the workplace. A full cost–benefit analysis of workplace ART provision has not been conducted using primary data. We developed a dynamic health-state transition model to estimate the economic impact of HIV and the cost–benefit of ART provision in a mining company in South Africa between 2003 and 2022.</p>
</sec>
<sec id="sec002"><title>Methods and Findings</title>
<p>A dynamic health-state transition model, called the Workplace Impact Model (WIM), was parameterised with workplace data on workforce size, composition, turnover, HIV incidence, and CD4 cell count development. Bottom-up cost analyses from the employer perspective supplied data on inpatient and outpatient resource utilisation and the costs of absenteeism and replacement of sick workers. The model was fitted to workforce HIV prevalence and separation data while incorporating parameter uncertainty; univariate sensitivity analyses were used to assess the robustness of the model findings. As ART coverage increases from 10% to 97% of eligible employees, increases in survival and retention of HIV-positive employees and associated reductions in absenteeism and benefit payments lead to cost savings compared to a scenario of no treatment provision, with the annual cost of HIV to the company decreasing by 5% (90% credibility interval [CrI] 2%–8%) and the mean cost per HIV-positive employee decreasing by 14% (90% CrI 7%–19%) by 2022. This translates into an average saving of US$950,215 (90% CrI US$220,879–US$1.6 million) per year; 80% of these cost savings are due to reductions in benefit payments and inpatient care costs. Although findings are sensitive to assumptions regarding incidence and absenteeism, ART is cost-saving under considerable parameter uncertainty and in all tested scenarios, including when prevalence is reduced to 1%—except when no benefits were paid out to employees leaving the workforce and when absenteeism rates were half of what data suggested. Scaling up ART further through a universal test and treat strategy doubles savings; incorporating ART for family members reduces savings but is still marginally cost-saving compared to no treatment. Our analysis was limited to the direct cost of HIV to companies and did not examine the impact of HIV prevention policies on the miners or their families, and a few model inputs were based on limited data, though in sensitivity analysis our results were found to be robust to changes to these inputs along plausible ranges.</p>
</sec>
<sec id="sec003"><title>Conclusions</title>
<p>Workplace ART provision can be cost-saving for companies in high HIV prevalence settings due to reductions in healthcare costs, absenteeism, and staff turnover. Company-sponsored HIV counselling and voluntary testing with ensuing treatment of all HIV-positive employees and family members should be implemented universally at workplaces in countries with high HIV prevalence.</p>
</sec>
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<author><name sortKey="Macleod, W" uniqKey="Macleod W">W MacLeod</name>
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<author><name sortKey="Fox, M" uniqKey="Fox M">M Fox</name>
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<author><name sortKey="Thea, Dm" uniqKey="Thea D">DM Thea</name>
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</author>
<author><name sortKey="Simon, J" uniqKey="Simon J">J Simon</name>
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</author>
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</author>
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</author>
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</author>
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</author>
<author><name sortKey="Bii, M" uniqKey="Bii M">M Bii</name>
</author>
<author><name sortKey="Foglia, G" uniqKey="Foglia G">G Foglia</name>
</author>
</analytic>
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<biblStruct></biblStruct>
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<author><name sortKey="Rehle, T" uniqKey="Rehle T">T Rehle</name>
</author>
<author><name sortKey="Simbayi, Lc" uniqKey="Simbayi L">LC Simbayi</name>
</author>
<author><name sortKey="Zuma, K" uniqKey="Zuma K">K Zuma</name>
</author>
<author><name sortKey="Jooste, S" uniqKey="Jooste S">S Jooste</name>
</author>
<author><name sortKey="Pillay Van Wyk, V" uniqKey="Pillay Van Wyk V">V Pillay-van-Wyk</name>
</author>
</analytic>
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</author>
<author><name sortKey="Rehle, T" uniqKey="Rehle T">T Rehle</name>
</author>
<author><name sortKey="Simbayi, Lc" uniqKey="Simbayi L">LC Simbayi</name>
</author>
<author><name sortKey="Zuma, K" uniqKey="Zuma K">K Zuma</name>
</author>
<author><name sortKey="Jooste, S" uniqKey="Jooste S">S Jooste</name>
</author>
<author><name sortKey="Zungu, N" uniqKey="Zungu N">N Zungu</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Evian, C" uniqKey="Evian C">C Evian</name>
</author>
<author><name sortKey="Fox, M" uniqKey="Fox M">M Fox</name>
</author>
<author><name sortKey="Macleod, B" uniqKey="Macleod B">B MacLeod</name>
</author>
<author><name sortKey="Slotow, S" uniqKey="Slotow S">S Slotow</name>
</author>
<author><name sortKey="Rosen, S" uniqKey="Rosen S">S Rosen</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Harling, G" uniqKey="Harling G">G Harling</name>
</author>
<author><name sortKey="Wood, R" uniqKey="Wood R">R Wood</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Rosen, S" uniqKey="Rosen S">S Rosen</name>
</author>
<author><name sortKey="Ketlhapile, M" uniqKey="Ketlhapile M">M Ketlhapile</name>
</author>
<author><name sortKey="Sanne, I" uniqKey="Sanne I">I Sanne</name>
</author>
<author><name sortKey="Bachman, Desilva M" uniqKey="Bachman D">DeSilva M Bachman</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Rosen, S" uniqKey="Rosen S">S Rosen</name>
</author>
<author><name sortKey="Long, L" uniqKey="Long L">L Long</name>
</author>
<author><name sortKey="Sanne, I" uniqKey="Sanne I">I Sanne</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Rosen, S" uniqKey="Rosen S">S Rosen</name>
</author>
<author><name sortKey="Long, L" uniqKey="Long L">L Long</name>
</author>
<author><name sortKey="Fox, M" uniqKey="Fox M">M Fox</name>
</author>
<author><name sortKey="Sanne, I" uniqKey="Sanne I">I Sanne</name>
</author>
</analytic>
</biblStruct>
<biblStruct></biblStruct>
<biblStruct><analytic><author><name sortKey="Leisegang, R" uniqKey="Leisegang R">R Leisegang</name>
</author>
<author><name sortKey="Cleary, S" uniqKey="Cleary S">S Cleary</name>
</author>
<author><name sortKey="Hislop, M" uniqKey="Hislop M">M Hislop</name>
</author>
<author><name sortKey="Davidse, A" uniqKey="Davidse A">A Davidse</name>
</author>
<author><name sortKey="Regensberg, L" uniqKey="Regensberg L">L Regensberg</name>
</author>
<author><name sortKey="Little, F" uniqKey="Little F">F Little</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Martinson, N" uniqKey="Martinson N">N Martinson</name>
</author>
<author><name sortKey="Mohapi, L" uniqKey="Mohapi L">L Mohapi</name>
</author>
<author><name sortKey="Bakos, D" uniqKey="Bakos D">D Bakos</name>
</author>
<author><name sortKey="Gray, Le" uniqKey="Gray L">LE Gray</name>
</author>
<author><name sortKey="Mcintyre, Ja" uniqKey="Mcintyre J">JA McIntyre</name>
</author>
<author><name sortKey="Holmes, Cb" uniqKey="Holmes C">CB Holmes</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Kevany, S" uniqKey="Kevany S">S Kevany</name>
</author>
<author><name sortKey="Meintjes, G" uniqKey="Meintjes G">G Meintjes</name>
</author>
<author><name sortKey="Rebe, K" uniqKey="Rebe K">K Rebe</name>
</author>
<author><name sortKey="Maartens, G" uniqKey="Maartens G">G Maartens</name>
</author>
<author><name sortKey="Cleary, S" uniqKey="Cleary S">S Cleary</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Long, L" uniqKey="Long L">L Long</name>
</author>
<author><name sortKey="Fox, M" uniqKey="Fox M">M Fox</name>
</author>
<author><name sortKey="Sanne, I" uniqKey="Sanne I">I Sanne</name>
</author>
<author><name sortKey="Rosen, S" uniqKey="Rosen S">S Rosen</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Long, L" uniqKey="Long L">L Long</name>
</author>
<author><name sortKey="Brennan, A" uniqKey="Brennan A">A Brennan</name>
</author>
<author><name sortKey="Fox, Mp" uniqKey="Fox M">MP Fox</name>
</author>
<author><name sortKey="Ndibongo, B" uniqKey="Ndibongo B">B Ndibongo</name>
</author>
<author><name sortKey="Jaffray, I" uniqKey="Jaffray I">I Jaffray</name>
</author>
<author><name sortKey="Sanne, I" uniqKey="Sanne I">I Sanne</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Cleary, S" uniqKey="Cleary S">S Cleary</name>
</author>
<author><name sortKey="Blecher, M" uniqKey="Blecher M">M Blecher</name>
</author>
<author><name sortKey="Boulle, A" uniqKey="Boulle A">A Boulle</name>
</author>
<author><name sortKey="Dorrington, R" uniqKey="Dorrington R">R Dorrington</name>
</author>
<author><name sortKey="Darkoh, E" uniqKey="Darkoh E">E Darkoh</name>
</author>
<author><name sortKey="Bogopane Zulu, H" uniqKey="Bogopane Zulu H">H Bogopane-Zulu</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Meyer Rath, G" uniqKey="Meyer Rath G">G Meyer-Rath</name>
</author>
<author><name sortKey="Brennan, A" uniqKey="Brennan A">A Brennan</name>
</author>
<author><name sortKey="Long, L" uniqKey="Long L">L Long</name>
</author>
<author><name sortKey="Ndibongo, B" uniqKey="Ndibongo B">B Ndibongo</name>
</author>
<author><name sortKey="Technau, K" uniqKey="Technau K">K Technau</name>
</author>
<author><name sortKey="Moultrie, H" uniqKey="Moultrie H">H Moultrie</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Meyer Rath, G" uniqKey="Meyer Rath G">G Meyer-Rath</name>
</author>
<author><name sortKey="Miners, A" uniqKey="Miners A">A Miners</name>
</author>
<author><name sortKey="Santos, A" uniqKey="Santos A">A Santos</name>
</author>
<author><name sortKey="Variava, E" uniqKey="Variava E">E Variava</name>
</author>
<author><name sortKey="Venter, F" uniqKey="Venter F">F Venter</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Meyer Rath, G" uniqKey="Meyer Rath G">G Meyer-Rath</name>
</author>
<author><name sortKey="Brennan, A" uniqKey="Brennan A">A Brennan</name>
</author>
<author><name sortKey="Fox, Mp" uniqKey="Fox M">MP Fox</name>
</author>
<author><name sortKey="Modisenyane, T" uniqKey="Modisenyane T">T Modisenyane</name>
</author>
<author><name sortKey="Tshabangu, N" uniqKey="Tshabangu N">N Tshabangu</name>
</author>
<author><name sortKey="Mohapi, L" uniqKey="Mohapi L">L Mohapi</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Leisegang, R" uniqKey="Leisegang R">R Leisegang</name>
</author>
<author><name sortKey="Maartens, G" uniqKey="Maartens G">G Maartens</name>
</author>
<author><name sortKey="Hislop, M" uniqKey="Hislop M">M Hislop</name>
</author>
<author><name sortKey="Sargent, J" uniqKey="Sargent J">J Sargent</name>
</author>
<author><name sortKey="Darkoh, E" uniqKey="Darkoh E">E Darkoh</name>
</author>
<author><name sortKey="Cleary, S" uniqKey="Cleary S">S Cleary</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Cleary, S" uniqKey="Cleary S">S Cleary</name>
</author>
<author><name sortKey="Mcintyre, D" uniqKey="Mcintyre D">D McIntyre</name>
</author>
<author><name sortKey="Boulle, A" uniqKey="Boulle A">A Boulle</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Badri, M" uniqKey="Badri M">M Badri</name>
</author>
<author><name sortKey="Maartens, G" uniqKey="Maartens G">G Maartens</name>
</author>
<author><name sortKey="Mandalia, S" uniqKey="Mandalia S">S Mandalia</name>
</author>
<author><name sortKey="Bekker, L G" uniqKey="Bekker L">L-G Bekker</name>
</author>
<author><name sortKey="Penrod, Jr" uniqKey="Penrod J">JR Penrod</name>
</author>
<author><name sortKey="Platt, Rw" uniqKey="Platt R">RW Platt</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Bachmann, Mo" uniqKey="Bachmann M">MO Bachmann</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Holmes, Cb" uniqKey="Holmes C">CB Holmes</name>
</author>
<author><name sortKey="Zheng, H" uniqKey="Zheng H">H Zheng</name>
</author>
<author><name sortKey="Martinson, Na" uniqKey="Martinson N">NA Martinson</name>
</author>
<author><name sortKey="Freedberg, Ka" uniqKey="Freedberg K">KA Freedberg</name>
</author>
<author><name sortKey="Walensky, Rp" uniqKey="Walensky R">RP Walensky</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Granich, Rm" uniqKey="Granich R">RM Granich</name>
</author>
<author><name sortKey="Gilks, Cf" uniqKey="Gilks C">CF Gilks</name>
</author>
<author><name sortKey="Dye, C" uniqKey="Dye C">C Dye</name>
</author>
<author><name sortKey="De Cock, Km" uniqKey="De Cock K">KM De Cock</name>
</author>
<author><name sortKey="Williams, Bg" uniqKey="Williams B">BG Williams</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Cleary, S" uniqKey="Cleary S">S Cleary</name>
</author>
<author><name sortKey="Mooney, G" uniqKey="Mooney G">G Mooney</name>
</author>
<author><name sortKey="Mcintyre, D" uniqKey="Mcintyre D">D McIntyre</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Cleary, S" uniqKey="Cleary S">S Cleary</name>
</author>
<author><name sortKey="Mcintyre, D" uniqKey="Mcintyre D">D McIntyre</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Walensky, Rp" uniqKey="Walensky R">RP Walensky</name>
</author>
<author><name sortKey="Wolf, Ll" uniqKey="Wolf L">LL Wolf</name>
</author>
<author><name sortKey="Wood, R" uniqKey="Wood R">R Wood</name>
</author>
<author><name sortKey="Fofana, Mo" uniqKey="Fofana M">MO Fofana</name>
</author>
<author><name sortKey="Freedberg, Ka" uniqKey="Freedberg K">KA Freedberg</name>
</author>
<author><name sortKey="Martinson, Na" uniqKey="Martinson N">NA Martinson</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Walensky, Rp" uniqKey="Walensky R">RP Walensky</name>
</author>
<author><name sortKey="Wood, R" uniqKey="Wood R">R Wood</name>
</author>
<author><name sortKey="Ciaranello, Al" uniqKey="Ciaranello A">AL Ciaranello</name>
</author>
<author><name sortKey="Paltiel, Ad" uniqKey="Paltiel A">AD Paltiel</name>
</author>
<author><name sortKey="Lorenzana, Sb" uniqKey="Lorenzana S">SB Lorenzana</name>
</author>
<author><name sortKey="Anglaret, X" uniqKey="Anglaret X">X Anglaret</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Wagner, B" uniqKey="Wagner B">B Wagner</name>
</author>
<author><name sortKey="Blower, S" uniqKey="Blower S">S Blower</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Hontelez, Jac" uniqKey="Hontelez J">JAC Hontelez</name>
</author>
<author><name sortKey="De Vlas, Sj" uniqKey="De Vlas S">SJ de Vlas</name>
</author>
<author><name sortKey="Tanser, F" uniqKey="Tanser F">F Tanser</name>
</author>
<author><name sortKey="Bakker, R" uniqKey="Bakker R">R Bakker</name>
</author>
<author><name sortKey="B Rnighausen, T" uniqKey="B Rnighausen T">T Bärnighausen</name>
</author>
<author><name sortKey="Newell, Ml" uniqKey="Newell M">ML Newell</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Bendavid, E" uniqKey="Bendavid E">E Bendavid</name>
</author>
<author><name sortKey="Grant, P" uniqKey="Grant P">P Grant</name>
</author>
<author><name sortKey="Talbot, A" uniqKey="Talbot A">A Talbot</name>
</author>
<author><name sortKey="Owens, Dk" uniqKey="Owens D">DK Owens</name>
</author>
<author><name sortKey="Zolopa, A" uniqKey="Zolopa A">A Zolopa</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Ciaranello, Al" uniqKey="Ciaranello A">AL Ciaranello</name>
</author>
<author><name sortKey="Lockman, S" uniqKey="Lockman S">S Lockman</name>
</author>
<author><name sortKey="Freedberg, Ka" uniqKey="Freedberg K">KA Freedberg</name>
</author>
<author><name sortKey="Hughes, M" uniqKey="Hughes M">M Hughes</name>
</author>
<author><name sortKey="Chu, J" uniqKey="Chu J">J Chu</name>
</author>
<author><name sortKey="Currier, J" uniqKey="Currier J">J Currier</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Hallett, Tb" uniqKey="Hallett T">TB Hallett</name>
</author>
<author><name sortKey="Baeten, Jm" uniqKey="Baeten J">JM Baeten</name>
</author>
<author><name sortKey="Heffron, R" uniqKey="Heffron R">R Heffron</name>
</author>
<author><name sortKey="Barnabas, R" uniqKey="Barnabas R">R Barnabas</name>
</author>
<author><name sortKey="De Bruyn, G" uniqKey="De Bruyn G">G de Bruyn</name>
</author>
<author><name sortKey="Cremin, I" uniqKey="Cremin I">Í Cremin</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Eaton, Jw" uniqKey="Eaton J">JW Eaton</name>
</author>
<author><name sortKey="Menzies, Na" uniqKey="Menzies N">NA Menzies</name>
</author>
<author><name sortKey="Stover, J" uniqKey="Stover J">J Stover</name>
</author>
<author><name sortKey="Cambiano, V" uniqKey="Cambiano V">V Cambiano</name>
</author>
<author><name sortKey="Chindelevitch, L" uniqKey="Chindelevitch L">L Chindelevitch</name>
</author>
<author><name sortKey="Cori, A" uniqKey="Cori A">A Cori</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Granich, R" uniqKey="Granich R">R Granich</name>
</author>
<author><name sortKey="Kahn, Jg" uniqKey="Kahn J">JG Kahn</name>
</author>
<author><name sortKey="Bennett, R" uniqKey="Bennett R">R Bennett</name>
</author>
<author><name sortKey="Holmes, Cb" uniqKey="Holmes C">CB Holmes</name>
</author>
<author><name sortKey="Garg, N" uniqKey="Garg N">N Garg</name>
</author>
<author><name sortKey="Serenata, C" uniqKey="Serenata C">C Serenata</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Alistar, Ss" uniqKey="Alistar S">SS Alistar</name>
</author>
<author><name sortKey="Grant, Pm" uniqKey="Grant P">PM Grant</name>
</author>
<author><name sortKey="Bendavid, E" uniqKey="Bendavid E">E Bendavid</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Larson, Ba" uniqKey="Larson B">BA Larson</name>
</author>
<author><name sortKey="Fox, Mp" uniqKey="Fox M">MP Fox</name>
</author>
<author><name sortKey="Rosen, S" uniqKey="Rosen S">S Rosen</name>
</author>
<author><name sortKey="Bii, M" uniqKey="Bii M">M Bii</name>
</author>
<author><name sortKey="Sigei, C" uniqKey="Sigei C">C Sigei</name>
</author>
<author><name sortKey="Shaffer, D" uniqKey="Shaffer D">D Shaffer</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Larson, Ba" uniqKey="Larson B">BA Larson</name>
</author>
<author><name sortKey="Fox, Mp" uniqKey="Fox M">MP Fox</name>
</author>
<author><name sortKey="Rosen, S" uniqKey="Rosen S">S Rosen</name>
</author>
<author><name sortKey="Bii, M" uniqKey="Bii M">M Bii</name>
</author>
<author><name sortKey="Sigei, C" uniqKey="Sigei C">C Sigei</name>
</author>
<author><name sortKey="Shaffer, D" uniqKey="Shaffer D">D Shaffer</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Thirumurthy, H" uniqKey="Thirumurthy H">H Thirumurthy</name>
</author>
<author><name sortKey="Zivin, Jg" uniqKey="Zivin J">JG Zivin</name>
</author>
<author><name sortKey="Goldstein, M" uniqKey="Goldstein M">M Goldstein</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Fox, Mp" uniqKey="Fox M">MP Fox</name>
</author>
<author><name sortKey="Mccoy, K" uniqKey="Mccoy K">K McCoy</name>
</author>
<author><name sortKey="Larson, Ba" uniqKey="Larson B">BA Larson</name>
</author>
<author><name sortKey="Rosen, S" uniqKey="Rosen S">S Rosen</name>
</author>
<author><name sortKey="Bii, M" uniqKey="Bii M">M Bii</name>
</author>
<author><name sortKey="Sigei, C" uniqKey="Sigei C">C Sigei</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Habariyamana, J" uniqKey="Habariyamana J">J Habariyamana</name>
</author>
<author><name sortKey="Mbakile, B" uniqKey="Mbakile B">B Mbakile</name>
</author>
<author><name sortKey="Pop Eleches, C" uniqKey="Pop Eleches C">C Pop-Eleches</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Marseille, E" uniqKey="Marseille E">E Marseille</name>
</author>
<author><name sortKey="Saba, J" uniqKey="Saba J">J Saba</name>
</author>
<author><name sortKey="Muyingo, S" uniqKey="Muyingo S">S Muyingo</name>
</author>
<author><name sortKey="Kahn, Jg" uniqKey="Kahn J">JG Kahn</name>
</author>
</analytic>
</biblStruct>
<biblStruct></biblStruct>
<biblStruct></biblStruct>
<biblStruct></biblStruct>
<biblStruct><analytic><author><name sortKey="Charalambous, S" uniqKey="Charalambous S">S Charalambous</name>
</author>
<author><name sortKey="Innes, C" uniqKey="Innes C">C Innes</name>
</author>
<author><name sortKey="Muirhead, D" uniqKey="Muirhead D">D Muirhead</name>
</author>
<author><name sortKey="Kumaranayake, L" uniqKey="Kumaranayake L">L Kumaranayake</name>
</author>
<author><name sortKey="Fielding, K" uniqKey="Fielding K">K Fielding</name>
</author>
<author><name sortKey="Pemba, L" uniqKey="Pemba L">L Pemba</name>
</author>
</analytic>
</biblStruct>
<biblStruct></biblStruct>
<biblStruct><analytic><author><name sortKey="Briggs, Ah" uniqKey="Briggs A">AH Briggs</name>
</author>
<author><name sortKey="Sculpher, Mj" uniqKey="Sculpher M">MJ Sculpher</name>
</author>
<author><name sortKey="Claxton, K" uniqKey="Claxton K">K Claxton</name>
</author>
</analytic>
</biblStruct>
<biblStruct></biblStruct>
<biblStruct></biblStruct>
<biblStruct></biblStruct>
<biblStruct><analytic><author><name sortKey="Morris, C" uniqKey="Morris C">C Morris</name>
</author>
<author><name sortKey="Burdge, D" uniqKey="Burdge D">D Burdge</name>
</author>
<author><name sortKey="Cheevers, E" uniqKey="Cheevers E">E Cheevers</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Moore, D" uniqKey="Moore D">D Moore</name>
</author>
</analytic>
</biblStruct>
<biblStruct></biblStruct>
<biblStruct></biblStruct>
</listBibl>
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<pmc article-type="research-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">PLoS Med</journal-id>
<journal-id journal-id-type="iso-abbrev">PLoS Med</journal-id>
<journal-id journal-id-type="publisher-id">plos</journal-id>
<journal-id journal-id-type="pmc">plosmed</journal-id>
<journal-title-group><journal-title>PLoS Medicine</journal-title>
</journal-title-group>
<issn pub-type="ppub">1549-1277</issn>
<issn pub-type="epub">1549-1676</issn>
<publisher><publisher-name>Public Library of Science</publisher-name>
<publisher-loc>San Francisco, CA USA</publisher-loc>
</publisher>
</journal-meta>
<article-meta><article-id pub-id-type="pmid">26327271</article-id>
<article-id pub-id-type="pmc">4556678</article-id>
<article-id pub-id-type="doi">10.1371/journal.pmed.1001869</article-id>
<article-id pub-id-type="publisher-id">PMEDICINE-D-14-02595</article-id>
<article-categories><subj-group subj-group-type="heading"><subject>Research Article</subject>
</subj-group>
</article-categories>
<title-group><article-title>The Impact of Company-Level ART Provision to a Mining Workforce in South Africa: A Cost–Benefit Analysis</article-title>
<alt-title alt-title-type="running-head">Cost–Benefit Analysis of Workplace ART in South Africa</alt-title>
</title-group>
<contrib-group><contrib contrib-type="author"><name><surname>Meyer-Rath</surname>
<given-names>Gesine</given-names>
</name>
<xref ref-type="aff" rid="aff001"><sup>1</sup>
</xref>
<xref ref-type="aff" rid="aff002"><sup>2</sup>
</xref>
<xref ref-type="aff" rid="aff003"><sup>3</sup>
</xref>
<xref rid="cor001" ref-type="corresp">*</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Pienaar</surname>
<given-names>Jan</given-names>
</name>
<xref ref-type="aff" rid="aff004"><sup>4</sup>
</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Brink</surname>
<given-names>Brian</given-names>
</name>
<xref ref-type="aff" rid="aff005"><sup>5</sup>
</xref>
</contrib>
<contrib contrib-type="author"><name><surname>van Zyl</surname>
<given-names>Andrew</given-names>
</name>
<xref ref-type="aff" rid="aff006"><sup>6</sup>
</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Muirhead</surname>
<given-names>Debbie</given-names>
</name>
<xref ref-type="aff" rid="aff006"><sup>6</sup>
</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Grant</surname>
<given-names>Alison</given-names>
</name>
<xref ref-type="aff" rid="aff007"><sup>7</sup>
</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Churchyard</surname>
<given-names>Gavin</given-names>
</name>
<xref ref-type="aff" rid="aff006"><sup>6</sup>
</xref>
<xref ref-type="aff" rid="aff007"><sup>7</sup>
</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Watts</surname>
<given-names>Charlotte</given-names>
</name>
<xref ref-type="aff" rid="aff008"><sup>8</sup>
</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Vickerman</surname>
<given-names>Peter</given-names>
</name>
<xref ref-type="aff" rid="aff009"><sup>9</sup>
</xref>
</contrib>
</contrib-group>
<aff id="aff001"><label>1</label>
<addr-line>Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom</addr-line>
</aff>
<aff id="aff002"><label>2</label>
<addr-line>Center for Global Health and Development, Boston University, Boston, Massachusetts, United States of America</addr-line>
</aff>
<aff id="aff003"><label>3</label>
<addr-line>Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa</addr-line>
</aff>
<aff id="aff004"><label>4</label>
<addr-line>Highveld Hospital, Anglo American Coal, Emalahleni, South Africa</addr-line>
</aff>
<aff id="aff005"><label>5</label>
<addr-line>Anglo American, Johannesburg, South Africa</addr-line>
</aff>
<aff id="aff006"><label>6</label>
<addr-line>The Aurum Institute, Johannesburg, South Africa</addr-line>
</aff>
<aff id="aff007"><label>7</label>
<addr-line>Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom</addr-line>
</aff>
<aff id="aff008"><label>8</label>
<addr-line>Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom</addr-line>
</aff>
<aff id="aff009"><label>9</label>
<addr-line>School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom</addr-line>
</aff>
<contrib-group><contrib contrib-type="editor"><name><surname>Salomon</surname>
<given-names>Joshua A.</given-names>
</name>
<role>Academic Editor</role>
<xref ref-type="aff" rid="edit1"></xref>
</contrib>
</contrib-group>
<aff id="edit1"><addr-line>Harvard School of Public Health, UNITED STATES</addr-line>
</aff>
<author-notes><fn fn-type="COI-statement" id="coi001"><p>GC is employed by the Aurum Institute, which received a small donation over the past few years from the Anglo American Chairman’s fund. At the time of conception and design, acquisition of data, analysis and interpretation of data as well as at the time of the drafting of the article and revising it critically for important intellectual content, BB was employed by Anglo American as their Chief Medical Officer (previously designated Senior Vice President: Medical and/or Group Medical Consultant). He retired from Anglo American on 31st December 2014, but continued to have a part-time consultancy contract with the Company. The research work was carried out through the health services of Anglo American Coal mines in South Africa, for which BB was responsible for overarching professional oversight as Chief Medical Officer of Anglo American plc. The research work was partly funded by Anglo American Operations Limited, through a budget for which he was responsible. BB is an independent non-executive director of Right to Care (nonprofit company), which has a close working relationship with GMR's Health Economics and Epidemiology Research Office through shared directors.</p>
</fn>
<fn fn-type="con" id="contrib001"><p>Conceived and designed the experiments: GMR BB DM CW PV. Performed the experiments: GMR AvZ DM PV. Analyzed the data: GMR JP DM AvZ. Contributed reagents/materials/analysis tools: GMR JP GC AG PV. Wrote the first draft of the manuscript: GMR. Contributed to the writing of the manuscript: GMR JP BB DM AvZ AG GC CW PV. Agree with the manuscript’s results and conclusions: GMR JP BB DM AvZ AG GC CW PV. Built the model: GMR PV AvZ. All authors have read, and confirm that they meet, ICMJE criteria for authorship.</p>
</fn>
<corresp id="cor001">* E-mail: <email>gesine@bu.edu</email>
</corresp>
</author-notes>
<pub-date pub-type="epub"><day>1</day>
<month>9</month>
<year>2015</year>
</pub-date>
<pub-date pub-type="collection"><month>9</month>
<year>2015</year>
</pub-date>
<volume>12</volume>
<issue>9</issue>
<elocation-id>e1001869</elocation-id>
<history><date date-type="received"><day>15</day>
<month>8</month>
<year>2014</year>
</date>
<date date-type="accepted"><day>17</day>
<month>7</month>
<year>2015</year>
</date>
</history>
<permissions><copyright-statement>© 2015 Meyer-Rath et al</copyright-statement>
<copyright-year>2015</copyright-year>
<copyright-holder>Meyer-Rath et al</copyright-holder>
<license xlink:href="http://creativecommons.org/licenses/by/4.0/"><license-p>This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly credited.</license-p>
</license>
</permissions>
<self-uri content-type="pdf" xlink:type="simple" xlink:href="pmed.1001869.pdf"></self-uri>
<abstract><sec id="sec001"><title>Background</title>
<p>HIV impacts heavily on the operating costs of companies in sub-Saharan Africa, with many companies now providing antiretroviral therapy (ART) programmes in the workplace. A full cost–benefit analysis of workplace ART provision has not been conducted using primary data. We developed a dynamic health-state transition model to estimate the economic impact of HIV and the cost–benefit of ART provision in a mining company in South Africa between 2003 and 2022.</p>
</sec>
<sec id="sec002"><title>Methods and Findings</title>
<p>A dynamic health-state transition model, called the Workplace Impact Model (WIM), was parameterised with workplace data on workforce size, composition, turnover, HIV incidence, and CD4 cell count development. Bottom-up cost analyses from the employer perspective supplied data on inpatient and outpatient resource utilisation and the costs of absenteeism and replacement of sick workers. The model was fitted to workforce HIV prevalence and separation data while incorporating parameter uncertainty; univariate sensitivity analyses were used to assess the robustness of the model findings. As ART coverage increases from 10% to 97% of eligible employees, increases in survival and retention of HIV-positive employees and associated reductions in absenteeism and benefit payments lead to cost savings compared to a scenario of no treatment provision, with the annual cost of HIV to the company decreasing by 5% (90% credibility interval [CrI] 2%–8%) and the mean cost per HIV-positive employee decreasing by 14% (90% CrI 7%–19%) by 2022. This translates into an average saving of US$950,215 (90% CrI US$220,879–US$1.6 million) per year; 80% of these cost savings are due to reductions in benefit payments and inpatient care costs. Although findings are sensitive to assumptions regarding incidence and absenteeism, ART is cost-saving under considerable parameter uncertainty and in all tested scenarios, including when prevalence is reduced to 1%—except when no benefits were paid out to employees leaving the workforce and when absenteeism rates were half of what data suggested. Scaling up ART further through a universal test and treat strategy doubles savings; incorporating ART for family members reduces savings but is still marginally cost-saving compared to no treatment. Our analysis was limited to the direct cost of HIV to companies and did not examine the impact of HIV prevention policies on the miners or their families, and a few model inputs were based on limited data, though in sensitivity analysis our results were found to be robust to changes to these inputs along plausible ranges.</p>
</sec>
<sec id="sec003"><title>Conclusions</title>
<p>Workplace ART provision can be cost-saving for companies in high HIV prevalence settings due to reductions in healthcare costs, absenteeism, and staff turnover. Company-sponsored HIV counselling and voluntary testing with ensuing treatment of all HIV-positive employees and family members should be implemented universally at workplaces in countries with high HIV prevalence.</p>
</sec>
</abstract>
<abstract abstract-type="toc"><p>Gesine Meyer-Rath and colleagues assess whether workplace ART provision can be cost-saving for mining companies in high HIV prevalence settings.</p>
</abstract>
<abstract abstract-type="editors-summary"><title>Editors' Summary</title>
<sec id="sec004"><title>Background</title>
<p>Every year, more than 2 million people become newly infected with HIV, the virus that causes AIDS, usually by having unprotected sex with an infected partner. People in the early stages of HIV infection rarely have any symptoms, but, over time, HIV destroys CD4 lymphocytes and other immune system cells, and, eventually, HIV-positive individuals become susceptible to numerous other infections. Because many of these infections are extremely serious, early in the AIDS epidemic, most HIV-infected individuals died within ten years of infection. Then, in 1996, effective antiretroviral therapy (ART)—cocktails of drugs that stop HIV replicating—became available. For people living in affluent countries, HIV/AIDS became a chronic condition, but because ART was expensive, HIV/AIDS remained fatal in low- and middle-income countries. In 2003, the international community began to work towards achieving universal access to ART. By 2013, nearly 13 million HIV-positive people—more than a third of the global HIV-infected population—had access to ART.</p>
</sec>
<sec id="sec005"><title>Why Was This Study Done?</title>
<p>HIV disease hits individuals in the prime of their working lives, thereby increasing absenteeism, the turnover of labor, and the operating costs of companies working in countries where HIV infection is common (high HIV prevalence). To reduce the economic impact of HIV/AIDS, some companies provide their workforces in such countries with comprehensive HIV services that include counseling and testing, and ART. For example, mining companies in South Africa (where nearly 20% of the working-age population is HIV-positive) provide HIV services to their workforces. However, although there is strong evidence that HIV disease increases the cost of doing business, a full cost–benefit analysis (the quantification of both the costs and benefits of a business strategy or medical intervention) of ART provision in the workplace based on real-world data has not been undertaken. Here, the researchers use a mathematical model to estimate the economic impact of HIV and the costs and benefits of company-level ART provision by a South African mining company between 2003 and 2022.</p>
</sec>
<sec id="sec006"><title>What Did the Researchers Do and Find?</title>
<p>The researchers developed a mathematical model to evaluate the past and future impact and costs to the employer of an ART program provided since 2002 by a coal mining company operating at a number of South African colleries. They fed data on the workforce’s characteristics, the annual number of new HIV infections in the workforce, the CD4 cell counts of HIV-positive employees, healthcare resource utilization, and the costs of absenteeism and labor turnover into the model. The model estimated that, as ART coverage increased from 10% to 97% of eligible employees, increases in the survival and retention of HIV-positive employees and reductions in absenteeism and benefit payments would lead to overall cost savings compared to a scenario of no ART provision. Specifically, the annual cost of HIV to the company would decrease by 5% and the average cost per HIV-positive employee would decrease by 14% by 2022. These changes in costs (which mainly accrue from reductions in benefit payments for death and ill-health retirement and in employee healthcare costs) translate into average savings of nearly US$1 million per year. Finally, scaling up ART coverage through a universal test and treat strategy would double savings, whereas providing ART for family members as well as employees would reduce savings but remain marginally cost-saving compared to no ART.</p>
</sec>
<sec id="sec007"><title>What Do These Findings Mean?</title>
<p>These findings suggest that workplace ART provision can be cost-saving for companies operating in settings with a high HIV prevalence because of reductions in healthcare costs, absenteeism, and staff turnover. That is, the costs to the employer of providing ART can be less than the costs saved by reducing healthcare use, absenteeism, and worker turnover. The accuracy of these findings depends on the quality of the data used to run the model. However, additional analyses indicate that ART provision is likely to be cost-saving unless people receive no benefits on leaving the workforce or the absenteeism rate is considerably lower than the available data suggest. Thus, the researchers propose that company-sponsored counseling and voluntary HIV testing with treatment of all HIV-positive employees and family members should be implemented universally at workplaces in countries with a high HIV prevalence. Such a strategy should be cost-saving for employers and might also take some pressure off resource-limited public sector ART programs.</p>
</sec>
<sec id="sec008"><title>Additional Information</title>
<p>This list of resources contains links that can be accessed when viewing the PDF on a device or via the online version of the article at <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.1371/journal.pmed.1001869">http://dx.doi.org/10.1371/journal.pmed.1001869</ext-link>
.</p>
<list list-type="bullet"><list-item><p>Information is available from the US National Institute of Allergy and Infectious Diseases on <ext-link ext-link-type="uri" xlink:href="http://www.niaid.nih.gov/topics/hivaids/Pages/Default.aspx">HIV infection and AIDS</ext-link>
</p>
</list-item>
<list-item><p><ext-link ext-link-type="uri" xlink:href="http://www.aidsmap.com/">NAM/aidsmap</ext-link>
provides basic information about HIV/AIDS, summaries of recent research findings on HIV care and treatment, and <ext-link ext-link-type="uri" xlink:href="http://www.aidsmap.com/inyourownwords">personal stories about living with HIV/AIDS</ext-link>
</p>
</list-item>
<list-item><p>Information is available from <ext-link ext-link-type="uri" xlink:href="http://www.avert.org/">Avert</ext-link>
, an international AIDS charity, on many aspects of HIV/AIDS, including information on <ext-link ext-link-type="uri" xlink:href="http://www.avert.org/hiv-and-aids-treatment-care.htm">ART</ext-link>
, <ext-link ext-link-type="uri" xlink:href="http://www.avert.org/universal-access-hiv-treatment.htm">universal access to ART</ext-link>
, and <ext-link ext-link-type="uri" xlink:href="http://www.avert.org/hiv-aids-south-africa.htm">HIV/AIDS in South Africa</ext-link>
; Avert also provides <ext-link ext-link-type="uri" xlink:href="http://www.avert.org/living-hiv-stories.htm">personal stories about living with HIV/AIDS</ext-link>
</p>
</list-item>
<list-item><p>The World Health Organization provides information on all aspects of <ext-link ext-link-type="uri" xlink:href="http://www.who.int/hiv/en/">HIV/AIDS</ext-link>
(in several languages), including its <ext-link ext-link-type="uri" xlink:href="http://www.who.int/hiv/pub/guidelines/arv2013/download/en/">guidelines on the use of ART for treating and preventing HIV infection</ext-link>
</p>
</list-item>
<list-item><p>The <ext-link ext-link-type="uri" xlink:href="http://www.unaids.org/en/resources/campaigns/World-AIDS-Day-Report-2014">UNAIDS Fast-Track Strategy to End the AIDS Epidemic by 2030</ext-link>
provides up-to-date information about the AIDS epidemic and efforts to halt it; UNAIDS also provides detailed information about <ext-link ext-link-type="uri" xlink:href="http://www.unaids.org/en/regionscountries/countries/southafrica">HIV/AIDS in South Africa</ext-link>
</p>
</list-item>
<list-item><p>Wikipedia has a page about <ext-link ext-link-type="uri" xlink:href="https://en.wikipedia.org/wiki/Cost%E2%80%93benefit_analysis">cost–benefit analysis</ext-link>
(note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)</p>
</list-item>
<list-item><p>The <ext-link ext-link-type="uri" xlink:href="http://www.hivmodelling.org/">HIV Modelling Consortium</ext-link>
has a database of models used in analyzing the impact of HIV and ART, including models such as the one used in this analysis</p>
</list-item>
<list-item><p>The <ext-link ext-link-type="uri" xlink:href="http://www.iaen.org/">International AIDS Economics Network</ext-link>
has a library of research on the economics of HIV around the world</p>
</list-item>
</list>
</sec>
</abstract>
<funding-group><funding-statement>Funding for this study was obtained through a grant by GlaxoSmithKline to the Aurum Institute and direct funding from Anglo American. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.</funding-statement>
</funding-group>
<counts><fig-count count="4"></fig-count>
<table-count count="8"></table-count>
<page-count count="26"></page-count>
</counts>
<custom-meta-group><custom-meta id="data-availability"><meta-name>Data Availability</meta-name>
<meta-value>The fully parameterised model which incorporates all data and which was used to produce all projections within this paper can be downloaded from OpenBU via <ext-link ext-link-type="uri" xlink:href="http://hdl.handle.net/2144/10817">http://hdl.handle.net/2144/10817</ext-link>
.</meta-value>
</custom-meta>
</custom-meta-group>
</article-meta>
<notes><title>Data Availability</title>
<p>The fully parameterised model which incorporates all data and which was used to produce all projections within this paper can be downloaded from OpenBU via <ext-link ext-link-type="uri" xlink:href="http://hdl.handle.net/2144/10817">http://hdl.handle.net/2144/10817</ext-link>
.</p>
</notes>
</front>
</pmc>
<affiliations><list><country><li>Afrique du Sud</li>
<li>Royaume-Uni</li>
<li>États-Unis</li>
</country>
<region><li>Angleterre</li>
<li>Gauteng</li>
<li>Grand Londres</li>
<li>Massachusetts</li>
</region>
<settlement><li>Johannesbourg</li>
<li>Londres</li>
</settlement>
<orgName><li>Université du Witwatersrand</li>
</orgName>
</list>
<tree><country name="Royaume-Uni"><region name="Angleterre"><name sortKey="Meyer Rath, Gesine" sort="Meyer Rath, Gesine" uniqKey="Meyer Rath G" first="Gesine" last="Meyer-Rath">Gesine Meyer-Rath</name>
</region>
<name sortKey="Churchyard, Gavin" sort="Churchyard, Gavin" uniqKey="Churchyard G" first="Gavin" last="Churchyard">Gavin Churchyard</name>
<name sortKey="Grant, Alison" sort="Grant, Alison" uniqKey="Grant A" first="Alison" last="Grant">Alison Grant</name>
<name sortKey="Vickerman, Peter" sort="Vickerman, Peter" uniqKey="Vickerman P" first="Peter" last="Vickerman">Peter Vickerman</name>
<name sortKey="Watts, Charlotte" sort="Watts, Charlotte" uniqKey="Watts C" first="Charlotte" last="Watts">Charlotte Watts</name>
</country>
<country name="États-Unis"><region name="Massachusetts"><name sortKey="Meyer Rath, Gesine" sort="Meyer Rath, Gesine" uniqKey="Meyer Rath G" first="Gesine" last="Meyer-Rath">Gesine Meyer-Rath</name>
</region>
</country>
<country name="Afrique du Sud"><region name="Gauteng"><name sortKey="Meyer Rath, Gesine" sort="Meyer Rath, Gesine" uniqKey="Meyer Rath G" first="Gesine" last="Meyer-Rath">Gesine Meyer-Rath</name>
</region>
<name sortKey="Brink, Brian" sort="Brink, Brian" uniqKey="Brink B" first="Brian" last="Brink">Brian Brink</name>
<name sortKey="Churchyard, Gavin" sort="Churchyard, Gavin" uniqKey="Churchyard G" first="Gavin" last="Churchyard">Gavin Churchyard</name>
<name sortKey="Muirhead, Debbie" sort="Muirhead, Debbie" uniqKey="Muirhead D" first="Debbie" last="Muirhead">Debbie Muirhead</name>
<name sortKey="Pienaar, Jan" sort="Pienaar, Jan" uniqKey="Pienaar J" first="Jan" last="Pienaar">Jan Pienaar</name>
<name sortKey="Van Zyl, Andrew" sort="Van Zyl, Andrew" uniqKey="Van Zyl A" first="Andrew" last="Van Zyl">Andrew Van Zyl</name>
</country>
</tree>
</affiliations>
</record>
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