age) to states that extend eligibility to individuals in the early stages of HIV disease. Both options are described in detail in Chapter 5. For brevity, “the Committee” is replaced by “we.”


The approach to the analysis was to pose and then answer three broad questions for each option:

  • What are the likely health benefits of implementing an alternative approach to public financing of HIV care in terms of mortality and life expectancy? In other words, what incremental gains in health does an additional investment in HIV care buy?

  • What is the cost effectiveness of implementing an alternative approach?

  • What is the cost of implementing the proposed alternative approach?


To answer these questions, we conducted an analysis that involved five steps:

  1. Estimate the number of people not currently receiving highly active antiretroviral therapy (HAART) who are likely to begin HAART with alternative methods for financing care.

  2. Estimate the cost and health implications over 10 years of each financing option, including the anticipated gain in life expectancy (adjusted for quality of life) and reduced mortality (premature deaths averted) among those who participate in the programs.

  3. Estimate the cost per quality-adjusted life-year (QALY) gained associated with enrollment in each financing option and compare the estimates to other investments in health.

  4. Estimate the short-term (first-year) cost implications for each public payer.

  5. Compare the results for each option to one another.

Our approach was to gauge the potential increase in HAART use associated with a policy to expand access to HIV care by estimating how many individuals are currently in need of HAART and, of those, how many do not receive HAART. We refer to the number of people who need but do not receive HAART as the “HAART use deficit.” Our estimates of current HAART use are based primarily on data collected between 1996 and 1998, the beginning of the HAART era, which presents a limitation to our analysis.

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