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Universal test, treat, and keep: improving ART retention is key in cost-effective HIV control in Uganda

McCreesh, N.; Andrianakis, I.; Nsubuga, R.; Strong, M.; Vernon, I.; McKinley, T.J.; Oakley, J.E.; Goldstein, M.; Hayes, R.; White, R.G.

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N. McCreesh

I. Andrianakis

R. Nsubuga

M. Strong

T.J. McKinley

J.E. Oakley

M. Goldstein

R. Hayes

R.G. White


Background: With ambitious new UNAIDS targets to end AIDS by 2030, and new WHO treatment guidelines, there is increased interest in the best way to scale-up ART coverage. We investigate the cost-effectiveness of various ART scale-up options in Uganda. Methods: Individual-based HIV/ART model of Uganda, calibrated using history matching. 22 ART scale-up strategies were simulated from 2016 to 2030, comprising different combinations of six single interventions (1. increased HIV testing rates, 2. no CD4 threshold for ART initiation, 3. improved ART retention, 4. increased ART restart rates, 5. improved linkage to care, 6. improved pre-ART care). The incremental net monetary benefit (NMB) of each intervention was calculated, for a wide range of different willingness/ability to pay (WTP) per DALY averted (health-service perspective, 3% discount rate). Results: For all WTP thresholds above $210, interventions including removing the CD4 threshold were likely to be most cost-effective. At a WTP of $715 (1 × per-capita-GDP) interventions to improve linkage to and retention/re-enrolment in HIV care were highly likely to be more cost-effective than interventions to increase rates of HIV testing. At higher WTP (> ~ $1690), the most cost-effective option was ‘Universal Test, Treat, and Keep’ (UTTK), which combines interventions 1–5 detailed above. Conclusions: Our results support new WHO guidelines to remove the CD4 threshold for ART initiation in Uganda. With additional resources, this could be supplemented with interventions aimed at improving linkage to and/or retention in HIV care. To achieve the greatest reductions in HIV incidence, a UTTK policy should be implemented.


McCreesh, N., Andrianakis, I., Nsubuga, R., Strong, M., Vernon, I., McKinley, T., …White, R. (2017). Universal test, treat, and keep: improving ART retention is key in cost-effective HIV control in Uganda. BMC Infectious Diseases, 17, Article 322.

Journal Article Type Article
Acceptance Date Apr 25, 2017
Online Publication Date May 3, 2017
Publication Date May 3, 2017
Deposit Date Aug 22, 2016
Publicly Available Date May 9, 2017
Journal BMC Infectious Diseases
Publisher BioMed Central
Peer Reviewed Peer Reviewed
Volume 17
Article Number 322


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This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

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