Ending AIDS in South Africa: How long will it take? How much will it cost?

South Africa has more people infected with HIV but, by providing access to anti-retroviral therapy (ART), has kept more people alive than any other country. The effectiveness, availability and affordability of potent anti-retroviral therapy (ART) make it possible to contemplate ending the epidemic of HIV/AIDS. We consider what would have happened without ART, the impact of the current roll-out of ART, what might be possible if early treatment becomes available to all, and what could have happened if ART had been provided much earlier in the epidemic. In 2013 the provision of ART has reduced the prevalence of HIV from an estimated 15% to 9% among adults not on ART, the annual incidence from 2% to 0.9%, and the AIDS related deaths from 0.9% to 0.3% p.a. saving 1.5 million lives and US$727M. Regular testing and universal access to ART could reduce the prevalence among adults not on ART in 2023 to 0.06%, annual incidence to 0.05%, and eliminate AIDS deaths. Cumulative costs between 2013 ands 2023 would increase by US$692M only 4% of the total cost of US$17Bn. If a universal testing and early treatment had started in 1998 the prevalence of HIV among adults not on ART in 2013 would have fallen to 0.03%, annual incidence to 0.03%, and saved 2.5 million lives. The cost up to 2013 would have increased by US$18Bn but this would have been cost effective at US$7,200 per life saved. Future surveys of HIV among women attending ante-natal clinics should include testing women for the presence of anti-retroviral drugs, measuring their viral loads, and using appropriate assays for estimating HIV incidence. These data would make it possible to develop better and more reliable estimates of the current state of the epidemic, the success of the current ART programme, levels of viral load suppression for those on ART and the incidence of infection.