We collected qualitative data (semi-structured interviews with 11 healthcare providers and 10 patients; 8 focus groups with 41 patients) to identify barriers to linkage to care among people living with HIV in South Africa who were not yet taking antiretroviral treatment. Patients and providers identified HIV stigma as a sizable barrier. Patients felt that stigma-related issues were largely beyond their control, fearing discrimination if they disclosed to employers or were seen visiting clinics in their community. Providers believed that patients should take responsibility for overcoming internal stigma and disclosing serostatus. Patients had considerable concerns about inconvenient clinic hours, long queues, difficulty in appointment scheduling, and disrespect from staff. Providers seemed to minimize the effects of such barriers and not recognize the extent of patient dissatisfaction. Better communication and understanding between patients and providers is needed to facilitate greater patient satisfaction and retention in HIV care.

BackgroundWe examined efficacy, toxicity, relapse, cost, and quality-of-life thresholds of hypothetical HIV cure interventions that would make them cost-effective compared to life-long antiretroviral therapy (ART).MethodsWe used a computer simulation model to assess three HIV cure strategies: Gene Therapy, Chemotherapy, and Stem Cell Transplantation (SCT), each compared to ART. Efficacy and cost parameters were varied widely in sensitivity analysis. Outcomes included quality-adjusted life expectancy, lifetime cost, and cost-effectiveness in dollars/quality-adjusted life year ($/QALY) gained. Strategies were deemed cost-effective with incremental cost-effectiveness ratios <$100,000/QALY.ResultsFor patients on ART, discounted quality-adjusted life expectancy was 16.4 years and lifetime costs were $591,400. Gene Therapy was cost-effective with efficacy of 10%, relapse rate 0.5%/month, and cost $54,000. Chemotherapy was cost-effective with efficacy of 88%, relapse rate 0.5%/month, and cost $12,400/month for 24 months. At $150,000/procedure, SCT was cost-effective with efficacy of 79% and relapse rate 0.5%/month. Moderate efficacy increases and cost reductions made Gene Therapy cost-saving, but substantial efficacy/cost changes were needed to make Chemotherapy or SCT cost-saving.ConclusionsDepending on efficacy, relapse rate, and cost, cure strategies could be cost-effective compared to current ART and potentially cost-saving. These results may help provide performance targets for developing cure strategies for HIV.

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