Articles tagged as "Financing"

Health economics of HIV in South Africa

Editor’s notes: There is enormous financial pressure on the HIV response. Advances in science had demonstrated the importance of offering treatment to all people living with HIV with ARV medicines and starting treatment as early as possible.  In addition to stronger condom programming, biomedical prevention tools, such as medical male circumcision, PrEP have also been shown to be highly efficacious for HIV prevention.  Yet international donor support for HIV is no longer increasing and national governments are increasingly having to find budgets with a tight fiscal envelope. It is clear that we need innovation, efficiency and strong advocacy for continuing investment to take us to the end of AIDS as a public health threat by 2030. Health economists often use a threshold related to the GDP of a country in order to determine whether investments are cost-effective or not.  However, as Meyer-Rath and colleagues point out, this threshold can seem arbitrary and unlinked from the actual budget available to the HIV programme.  The authors use their model of the costs and impact of a range of interventions in the South African national programme.  They explore both the most cost-effective sequence of interventions, and the cost-effectiveness thresholds that these imply, within the overall budget envelope that has been committed to the HIV response by the government.  They propose that within the existing budget of around US$1.6 billion per year, maximizing scale-up of the most cost-effective interventions would use the entire budget before some of the more expensive options (such as PrEP) were introduced.  The authors find that the cost-effectiveness threshold at which the budget is exhausted is between US$ 547 and US$ 872 per life-year saved.  This compares poorly with the GDP of South Africa of around US$ 6000 which is often used as a benchmark for cost-effectiveness.  This paper confronts us with hard conclusions from a South African perspective.  It emphasizes the need to find ways to reduce costs and to maximize funding for HIV.  If we do not manage to reduce the epidemic now, the costs in the future will be even higher.

Revealed willingness-to-pay versus standard cost-effectiveness thresholds: evidence from the South African HIV investment case.

Meyer-Rath G, van Rensburg C, Larson B, Jamieson L, Rosen S. PLoS One. 2017 Oct 26;12(10):e0186496. doi: 10.1371/journal.pone.0186496. eCollection 2017.

Background: The use of cost-effectiveness thresholds based on a country's income per capita has been criticized for not being relevant to decision making, in particular in middle-income countries such as South Africa. The recent South African HIV Investment Case produced an alternative cost-effectiveness threshold for HIV prevention and treatment interventions based on estimates of life years saved and the country's committed HIV budget.

Methods: We analysed the optimal mix of HIV interventions over a baseline of the current HIV programme under the committed HIV budget for 2016-2018. We calculated the incremental cost-effectiveness ratio (ICER) as cost per life-year saved (LYS) of 16 HIV prevention and treatment interventions over 20 years (2016-2035). We iteratively evaluated the most cost effective option (defined by an intervention and its coverage) over a rolling baseline to which the more cost effective options had already been added, thereby allowing for diminishing marginal returns to interventions. We constrained the list of interventions to those whose combined cost was affordable under the current HIV budget. Costs are presented from the government perspective, unadjusted for inflation and undiscounted, in 2016 USD.

Results: The current HIV budget of about US$1.6 billion per year was sufficient to pay for the expansion of condom availability, medical male circumcision, universal treatment, and infant testing at 6 weeks to maximum coverage levels, while also implementing a social and behavior change mass media campaign with a message geared at increasing testing uptake and reducing the number of sexual partners. The combined ICER of this package of services was US$547/ LYS. The ICER of the next intervention that was above the affordability threshold was US$872/LYS.

Conclusions: The results of the South African HIV Investment Case point to an HIV cost-effectiveness threshold based on affordability under the current budget of US$547-872 per life year saved, a small fraction of the country's GDP per capita of about US$6000.

Abstract  Full-text [free] access 

HIV
Africa
South Africa
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Pulling out: how to make it work for Kazakhstan

Kazakhstan can achieve ambitious HIV targets despite expected donor withdrawal by combining improved ART procurement mechanisms with allocative and implementation efficiencies.

Shattock AJ, Benedikt C, Bokazhanova A, Duric P, Petrenko I, Ganina L, Kelly SL, Stuart RM, Kerr CC, Vinichenko T, Zhang S, Hamelmann C, Manova M, Masaki E, Wilson DP, Gray RT. PLoS One. 2017 Feb 16;12(2):e0169530. doi: 10.1371/journal.pone.0169530. eCollection 2017.

Background: Despite a non-decreasing HIV epidemic, international donors are soon expected to withdraw funding from Kazakhstan. Here we analyze how allocative, implementation, and technical efficiencies could strengthen the national HIV response under assumptions of future budget levels.

Methodology: We used the Optima model to project future scenarios of the HIV epidemic in Kazakhstan that varied in future antiretroviral treatment unit costs and management expenditure-two areas identified for potential cost-reductions. We determined optimal allocations across HIV programs to satisfy either national targets or ambitious targets. For each scenario, we considered two cases of future HIV financing: the 2014 national budget maintained into the future and the 2014 budget without current international investment.

Findings: Kazakhstan can achieve its national HIV targets with the current budget by (1) optimally re-allocating resources across programs and (2) either securing a 35% [30%-39%] reduction in antiretroviral treatment drug costs or reducing management costs by 44% [36%-58%] of 2014 levels. Alternatively, a combination of antiretroviral treatment and management cost-reductions could be sufficient. Furthermore, Kazakhstan can achieve ambitious targets of halving new infections and AIDS-related deaths by 2020 compared to 2014 levels by attaining a 67% reduction in antiretroviral treatment costs, a 19% [14%-27%] reduction in management costs, and allocating resources optimally.

Significance: With Kazakhstan facing impending donor withdrawal, it is important for the HIV response to achieve more with available resources. This analysis can help to guide HIV response planners in directing available funding to achieve the greatest yield from investments. The key changes recommended were considered realistic by Kazakhstan country representatives.

Abstract  Full-text [free] access 

Editor’s notes: The HIV epidemic in Kazakhstan is concentrated around key populations (such as people who inject drugs, female sex workers and their partners, gay men and other men who have sex with men). Unlike in other settings, incidence has not decreased in recent years. However, as Kazakhstan continues to boom economically, international donors are expected to withdraw from the country in the near future and the responsibility for funding HIV-associated programmes will shift towards the state. This article attempts to explore how different kinds of efficiencies in the distribution of resources could strengthen the national HIV response in the coming years.  

The authors modelled future scenarios of the epidemic in Kazakhstan. They looked at whether and how the country could achieve certain targets by 2020 given its budgetary restrictions. They found that the country could achieve its national targets by either securing a 35% reduction in antiretroviral therapy or reducing management costs by 44%.

The topic this paper covers raises a number of important issues. As national governments move towards covering the totality of spending on HIV prevention and treatment, they will be confronted with the need to fund (using national tax revenues) prevention mechanisms. Their mechanisms are aimed at key populations who are often marginalized. Although funding these types of programmes through donor funding may have not caused political challenges, doing so using the state’s funding may. Government budget allocation is often a highly contentious exercise. Potential shifts in national priority setting following donor withdrawal should not be ignored.

Secondly, focussing on key populations is more costly than focussing on the general population. As prevention programmes cover people in key populations who are easier to reach, efforts should shift towards making prevention available to the harder-to-reach sections of key populations. However, this will further increase unit costs per person reached, and probably per infection averted. Given the decrease in external funding for Kazakhstan, it is important for the national response to budget for these additional costs.  This is a necessity to ensure equity in the access to the HIV response.

Asia
Kazakhstan
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Providing HIV treatment in Tanzania costs relatively little, but means a large increase in current health spending

The costs of providing antiretroviral therapy services to HIV-infected individuals presenting with advanced HIV disease at public health centres in Dar es Salaam, Tanzania: Findings from a randomised trial evaluating different health care strategies.

Kimaro GD, Mfinanga S, Simms V, Kivuyo S, Bottomley C, Hawkins N, Harrison TS, Jaffar S, Guinness L, on behalf of the REMSTART trial team. PLoS One. 2017 Feb 24;12(2):e0171917. doi: 10.1371/journal.pone.0171917. eCollection 2017.

Background: Understanding the costs associated with health care delivery strategies is essential for planning. There are few data on health service resources used by patients and their associated costs within antiretroviral (ART) programmes in Africa.

Material and methods: The study was nested within a large trial, which evaluated screening for cryptococcal meningitis and tuberculosis and a short initial period of home-based adherence support for patients initiating ART with advanced HIV disease in Tanzania and Zambia. The economic evaluation was done in Tanzania alone. We estimated costs of providing routine ART services from the health service provider's perspective using a micro-costing approach. Incremental costs for the different novel components of service delivery were also estimated. All costs were converted into US dollars (US$) and based on 2012 prices.

Results: Of 870 individuals enrolled in Tanzania, 434 were enrolled in the intervention arm and 436 in the standard care/control arm. Overall, the median (IQR) age and CD4 cell count at enrolment were 38 [31, 44] years and 52 [20, 89] cells/mm3, respectively. The mean per patient costs over the first three months and over a one year period of follow up following ART initiation in the standard care arm were US$ 107 (95%CI 101-112) and US$ 265 (95%CI 254-275) respectively. ART drugs, clinic visits and hospital admission constituted 50%, 19%, and 19% of the total cost per patient year, while diagnostic tests and non-ART drugs (co-trimoxazole) accounted for 10% and 2% of total per patient year costs. The incremental costs of the intervention to the health service over the first three months was US$ 59 (p<0.001; 95%CI 52-67) and over a one year period was US$ 67(p<0.001; 95%CI 50-83). This is equivalent to an increase of 55% (95%CI 51%-59%) in the mean cost of care over the first three months, and 25% (95%CI 20%-30%) increase over one year of follow up.

Abstract  Full-text [free] access 

Editor’s notes: There are very few data on the cost of providing HIV treatment in sub-Saharan Africa. The authors of this paper analysed cost data from a trial of screening services for opportunistic infections, to estimate the additional costs of HIV treatment to the health service. The most costly part of treatment was the antiretroviral medicines themselves, followed by clinic visits and hospital admissions. Diagnostic tests and treatments for other conditions were relatively inexpensive. The overall costs of treatment to the health system were fairly low in absolute terms. At around US$67 per year this is on the cheaper side of many cost studies. However, HIV treatment increases overall health system costs by a quarter. This could have significant implications for health system funding requirements in Tanzania as treatment is offered to the many people who need it in the UNAIDS 90-90-90 treatment target.

Africa
United Republic of Tanzania
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The Affordable Care Act at work – increasing health care access for people living with HIV in California

Implementation and operational research: affordable care act implementation in a California health care system leads to growth in HIV-positive patient enrollment and changes in patient characteristics.

Satre DD, Altschuler A, Parthasarathy S, Silverberg MJ, Volberding P, Campbell CI. J Acquir Immune Defic Syndr. 2016 Dec 15;73(5):e76-e82.

Objectives: This study examined implementation of the Affordable Care Act (ACA) in relation to HIV-positive patient enrollment in an integrated health care system; as well as changes in new enrollee characteristics, benefit structure, and health care utilization after key ACA provisions went into effect in 2014.

Methods: This mixed-methods study was set in Kaiser Permanente Northern California (KPNC). Qualitative interviews with 29 KPNC leaders explored planning for ACA implementation. Quantitative analyses compared newly enrolled HIV-positive patients in KPNC between January and December 2012 ("pre-ACA," N = 661) with newly enrolled HIV-positive patients between January and December 2014 ("post-ACA," N = 880) on demographics; medical, psychiatric, and substance use disorder diagnoses; HIV clinical indicators; and type of health care utilization.

Results: Interviews found that ACA preparation focused on enrollment growth, staffing, competition among health plans, concern about cost sharing, and HIV pre-exposure prophylaxis (PrEP) services. Quantitative analyses found that post-ACA HIV-positive patient enrollment grew. New enrollees in 2014 were more likely than 2012 enrollees to be enrolled in high-deductible plans (P < 0.01) or through Medicaid (P < 0.01), and marginally more likely to have better HIV viral control (P < 0.10). They also were more likely to be diagnosed with asthma (P < 0.01) or substance use disorders (P < 0.05) and to have used primary care health services in the 6 months postenrollment (P < 0.05) than the pre-ACA cohort.

Conclusions: As anticipated by KPNC interviewees, ACA implementation was followed by HIV-positive patient enrollment growth and changing benefit structures and patient characteristics. Although HIV viral control improved, comorbid diagnosis findings reinforced the importance of coordinated health care.

Abstract access  

Editor’s notes: This paper provides a very useful assessment of the Affordable Care Act (ACA) (commonly called ‘Obama-Care’) coverage for people living with HIV in part of California. As the authors note, a goal of the Affordable Care Act was to increase health-care coverage for people with chronic conditions. They also note that before the implementation of the ACA, many people living with HIV lacked health-care insurance covering HIV-medications and HIV medical care. It has the potential to make a difference to people with chronic conditions. The ACA has removed exclusions for insurance access, like pre-existing conditions. It has also removed caps on costs and provides financial support for health care premiums. 

As anticipated by the authors, the passing of the ACA had provided greater access to care for people living with HIV. However, challenges exist in supporting people living with HIV who have co-morbidities. The authors note that people living with HIV in need of psychiatric care, or because of substance use, were not always reached. This is partly because people do not come forward for care.  The authors suggest that integrated care where HIV-care is provided with support for other chronic conditions can help reach more people to come forward.

At a time of change in the United States, this paper is timely in highlighting the value of the Affordable Care Act for people living with HIV.  

Northern America
United States of America
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Community-based HIV testing for MSM: available at an acceptable cost in Europe

Economic evaluation of HIV testing for men who have sex with men in community-based organizations - results from six European cities.

Perelman J, Rosado R, Amri O, Morel S, Rojas Castro D, Chanos S, Cigan B, Lobnik M, Fuertes R, Pichon F, Slaaen Kaye P, Agusti C, Fernandez-Lopez L, Lorente N, Casabona J. AIDS Care. 2016 Dec 27:1-5. doi: 10.1080/09540121.2016.1271392. [Epub ahead of print]

The non-decreasing incidence of HIV among men who have sex with men (MSM) has motivated the emergence of Community Based Voluntary Counselling and Testing (CBVCT) services specifically addressed to MSM. The CBVCT services are characterized by facilitated access and linkage to care, a staff largely constituted by voluntary peers, and private not-for-profit structures outside the formal health system institutions. Encouraging results have been measured about their effectiveness, but these favourable results may have been obtained at high costs, questioning the opportunity to expand the experience. We performed an economic evaluation of HIV testing for MSM at CBVCT services, and compared them across six European cities. We collected retrospective data for six CBVCT services from six cities (Copenhagen, Paris, Lyon, Athens, Lisbon, and Ljubljana), for the year 2014, on the number of HIV tests and HIV reactive tests, and on all expenditures to perform the testing activities. The total costs of CBVCTs varied from 54 390€ per year (Ljubljana) to 245 803€ per year (Athens). The cost per HIV test varied from to 41€ (Athens) to 113€ (Ljubljana). The cost per HIV reactive test varied from 1966€ (Athens) to 9065€ (Ljubljana). Our results show that the benefits of CBVCT services are obtained at an acceptable cost, in comparison with the literature (values, mostly from the USA, range from 1600$ to 16 985$ per HIV reactive test in clinical and non-clinical settings). This result was transversal to several European cities, highlighting that there is a common CBVCT model, the cost of which is comparable regardless of the epidemiological context and prices. The CBVCT services represent an effective and "worth it" experience, to be continued and expanded in future public health strategies towards HIV.

Abstract access

Editor’s notes: Although HIV incidence among some key populations in Europe has declined in recent years, new cases among gay men and other men who have sex with men have steadily increased over the last decade. Among those new cases, over a third are reported late, leading to worse health outcomes for the person, as well as an increased risk of onward transmission. As a result, community-based voluntary counselling and testing has been rolled out in European cities to encouraging results in terms of effectiveness.

In that context, the authors of this paper have carried out an economic evaluation of community-based voluntary counselling and testing programmes in six cities across Europe (Athens, Copenhagen, Lisbon, Lyon, Paris and Ljubljana). They collected total annual costs of running the programmes. They found that the cost per HIV test ranged from €41 in Athens to €113 in Ljubljana and the cost per reactive HIV test ranged from €1966 to €9065 in the same two cities. The authors found that these costs are acceptable compared to those found in the literature.

Oddly, one of the more interesting results found in the article, but not discussed within the text, is the cost per reactive HIV test link to care. This varied in absolute terms (€2297- €20 215) likely due to different linkages to care rates, from 100% in Copenhagen to under 40% in Paris. Given the ultimate aims of testing (which ought to be to improve health outcomes and reduce onward transmission) this is a more important figure than the cost per test. Further research therefore should explore the unit costs further down the treatment cascade resulting from these programmes. These would be, for example, cost per person on treatment and cost per person with a suppressed viral load. 

Europe
Denmark, France, Greece, Portugal, Slovenia
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Is universal antenatal HIV testing still cost-effective?

Should HIV testing for all pregnant women continue? Cost-effectiveness of universal antenatal testing compared to focused approaches across high to very low HIV prevalence settings.

Ishikawa N, Dalal S, Johnson C, Hogan DR, Shimbo T, Shaffer N, Pendse RN, Lo YR, Ghidinelli MN, Baggaley R. J Int AIDS Soc. 2016 Dec 14;19(1):21212. doi: 10.7448/IAS.19.1.21212. eCollection 2016.

Introduction: HIV testing is the entry point for the elimination of mother-to-child transmission of HIV. Decreasing external funding for the HIV response in some low- and middle-income countries has triggered the question of whether a focused approach to HIV testing targeting pregnant women in high-burden areas should be considered. This study aimed at determining and comparing the cost-effectiveness of universal and focused HIV testing approaches for pregnant women across high to very low HIV prevalence settings.

Methods: We conducted a modelling analysis on health and cost outcomes of HIV testing for pregnant women using four country-based case scenarios (Namibia, Kenya, Haiti and Viet Nam) to illustrate high, intermediate, low and very low HIV prevalence settings. We used subnational prevalence data to divide each country into high-, medium- and low-burden areas, and modelled different antenatal and testing coverage in each.

Results: When HIV testing services were only focused in high-burden areas within a country, mother-to-child transmission rates remained high ranging from 18 to 23%, resulting in a 25 to 69% increase in new paediatric HIV infections and increased future treatment costs for children. Universal HIV testing was found to be dominant (i.e. more QALYs gained with less cost) compared to focused approaches in the Namibia, Kenya and Haiti scenarios. The universal approach was also very cost-effective compared to focused approaches, with $ 125 per quality-adjusted life years gained in the Viet Nam-based scenario of very low HIV prevalence. Sensitivity analysis further supported the findings.

Conclusions: Universal approach to antenatal HIV testing achieves the best health outcomes and is cost-saving or cost-effective in the long term across the range of HIV prevalence settings. It is further a prerequisite for quality maternal and child healthcare and for the elimination of mother-to-child transmission of HIV.

Abstract  Full-text [free] access 

Editor’s notes: This paper describes research undertaken to support the consolidated guidelines on HIV testing services, published by World Health Organization in 2015. This analysis was conducted in response to growing questions as to whether focused HIV testing in high prevalence areas can improve value for money in investment for HIV testing.

A model was parameterized to represent four scenarios with high, intermediate, low, and very low HIV prevalence settings (Namibia, Kenya, Haiti, and Viet Nam). Three approaches to HIV testing in antenatal care are considered in comparison with current coverage in each setting. These three approaches were: a very focused approach, a targeted approach, and a universal testing approach for all pregnant women.  The authors estimate the costs and effects of each scenario, including the future costs of treating paediatric HIV for 20 years. Universal testing was found to be cost-saving in Namibia, Kenya and Haiti and was found to be cost-effective in Viet Nam ($125 per QALY gained).  The targeted testing approach was also more cost-effective than current coverage in all settings.

The clear policy implication from this analysis is that HIV testing for pregnant women saves both money and lives in the long term. Universal HIV testing in antenatal care can be regarded as a good investment in almost any HIV prevalence setting. However, it is also important to note that targeted testing was more cost-effective than current coverage in all settings. Countries that are currently struggling to provide testing in antenatal care may need to consider factors other than cost-effectiveness in their planning and strategy for scaling up. This is important in order to address HIV at a national scale.  

Africa, Asia, Latin America
Haiti, Kenya, Namibia, Viet Nam
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Using HIV testing infrastructure for other diseases can be very low cost

Implementation and operational research: cost and efficiency of a hybrid mobile multidisease testing approach with high HIV testing coverage in east Africa.

Chang W, Chamie G, Mwai D, Clark TD, Thirumurthy H, Charlebois ED, Petersen M, Kabami J, Ssemmondo E, Kadede K, Kwarisiima D, Sang N, Bukusi EA, Cohen CR, Kamya M, Havlir DV, Kahn JG. J Acquir Immune Defic Syndr. 2016 Nov 1;73(3):e39-e45.

Background: In 2013-2014, we achieved 89% adult HIV testing coverage using a hybrid testing approach in 32 communities in Uganda and Kenya (SEARCH: NCT01864603). To inform scalability, we sought to determine: (1) overall cost and efficiency of this approach; and (2) costs associated with point-of-care (POC) CD4 testing, multidisease services, and community mobilization.

Methods: We applied microcosting methods to estimate costs of population-wide HIV testing in 12 SEARCH trial communities. Main intervention components of the hybrid approach are census, multidisease community health campaigns (CHC), and home-based testing for CHC nonattendees. POC CD4 tests were provided for all HIV-infected participants. Data were extracted from expenditure records, activity registers, staff interviews, and time and motion logs.

Results: The mean cost per adult tested for HIV was $20.5 (range: $17.1-$32.1) (2014 US$), including a POC CD4 test at $16 per HIV+ person identified. Cost per adult tested for HIV was $13.8 at CHC vs. $31.7 by home-based testing. The cost per HIV+ adult identified was $231 ($87-$1245), with variability due mainly to HIV prevalence among persons tested (ie, HIV positivity rate). The marginal costs of multidisease testing at CHCs were $1.16/person for hypertension and diabetes, and $0.90 for malaria. Community mobilization constituted 15.3% of total costs.

Conclusions: The hybrid testing approach achieved very high HIV testing coverage, with POC CD4, at costs similar to previously reported mobile, home-based, or venue-based HIV testing approaches in sub-Saharan Africa. By leveraging HIV infrastructure, multidisease services were offered at low marginal costs.

Abstract access  

Editor’s notes: The scale up of HIV testing services over recent years has meant that infrastructure for HIV testing is, in many places, much stronger than that of other diseases. This study assessed the costs and cost-effectiveness of both HIV testing services and additional multi disease testing in 32 communities of Uganda and Kenya. As has been found in other studies, testing people through community health campaigns cost less than home-based testing. However, the cost per HIV positive person identified varied widely according to the underlying HIV prevalence. The costs of including additional disease testing services – for hypertension, diabetes and malaria – were low. A more holistic approach to health testing could lead to substantial health benefits for relatively low cost.

Africa
Kenya, Uganda
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Voluntary male circumcision still a cost-effective intervention in the era of 90-90-90

Impact and cost of scaling up voluntary medical male circumcision for HIV prevention in the context of the new 90-90-90 HIV treatment targets.

Kripke K, Reed J, Hankins C, Smiley G, Laube C, Njeuhmeli E. PLoS One. 2016 Oct 26;11(10):e0155734. doi: 10.1371/journal.pone.0155734. eCollection 2016.

Background: The report of the Joint United Nations Programme on HIV/AIDS (UNAIDS) for World AIDS Day 2014 highlighted a Fast-Track Strategy that sets ambitious treatment and prevention targets to reduce global HIV incidence to manageable levels by 2020 and end the AIDS epidemic by 2030. The 90-90-90 treatment targets for 2020 call for 90% of people living with HIV to know their HIV status, 90% of people who know their status to receive treatment, and 90% of people on HIV treatment to be virally suppressed. This paper examines how scale-up of voluntary medical male circumcision (VMMC) services in four priority countries in sub-Saharan Africa could contribute to ending the AIDS epidemic by 2030 in the context of concerted efforts to close the treatment gap, and what the impact of VMMC scale-up would be if the 90-90-90 treatment targets were not completely met.

Methods: Using the Goals module of the Spectrum suite of models, this analysis modified ART (antiretroviral treatment) scale-up coverage from base scenarios to reflect the 90-90-90 treatment targets in four countries (Lesotho, Malawi, South Africa, and Uganda). In addition, a second scenario was created to reflect viral suppression levels of 75% instead of 90%, and a third scenario was created in which the 90-90-90 treatment targets are reached in women, with men reaching more moderate coverage levels. Regarding male circumcision (MC) coverage, the analysis examined both a scenario in which VMMCs were assumed to stop after 2015, and one in which MC coverage was scaled up to 90% by 2020 and maintained at 90% thereafter.

Results: Across all four countries, scaling up VMMC is projected to provide further HIV incidence reductions in addition to those achieved by reaching the 90-90-90 treatment targets. If viral suppression levels only reach 75%, scaling up VMMC leads to HIV incidence reduction to nearly the same levels as those achieved with 90-90-90 without VMMC scale-up. If only women reach the 90-90-90 targets, scaling up VMMC brings HIV incidence down to near the levels projected with 90-90-90 without VMMC scale-up. Regarding cost, scaling up VMMC increases the annual costs during the scale-up phase, but leads to lower annual costs after the MC coverage target is achieved.

Conclusions: The scenarios modeled in this paper show that the highly durable and effective male circumcision intervention increases epidemic impact levels over those of treatment-only strategies, including the case if universal levels of viral suppression in men and women are not achieved by 2020. In the context of 90-90-90, prioritizing continued successful scale-up of VMMC increases the possibility that future generations will be free not only of AIDS but also of HIV.

Abstract  Full-text [free] access 

Editor’s notes: Voluntary medical male circumcision (VMMC) has been shown to reduce the risk of female-to-male HIV transmission by up to 60%. It is a highly cost-effective HIV prevention activity. Since 2007, extensive efforts have been made to scale up VMMC in settings with high HIV prevalence and low levels of male circumcision, with the aim of reaching 80% VMMC coverage in 14 priority countries by 2016.  At the end of 2015, more than 11 million men in east and southern Africa had received VMMC.  In this modelling study, the authors look at the impact of scaling up VMMC to 90% coverage in four priority countries. The paper illustrates that VMMC scale-up can achieve additional reductions in HIV incidence above reductions achieved through testing and treatment alone. In the scenarios where the UNAIDS 90-90-90 treatment target is not completely met, VMMC scale-up can reduce HIV incidence to levels comparable to what would be achieved with the 90-90-90 treatment target. VMMC scale-up also resulted in lower long-term annual programme costs in all four settings. In 2015, UNAIDS set a target of an additional 27 million men in high-HIV prevalence settings receiving VMMC by 2021. Achieving this target will require new service delivery models, and innovative approaches to overcome current barriers that discourage men from accessing health care. VMMC is only one component in combination HIV prevention. It has advantages in being a single event that does not require ongoing adherence, offers men lifelong benefits, and is a valuable entry point for providing a broader range of health services to men including HIV testing. As this study demonstrates, VMMC remains a cost-effective strategy for reducing HIV incidence, even in the context of universal testing and treatment.  

Africa
Lesotho, Malawi, South Africa, Uganda
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Costs for HIV services vary widely across different countries

Costs along the service cascades for HIV testing and counselling and prevention of mother-to-child transmission.

Bautista-Arredondo S, Sosa-Rubi SG, Opuni M, Contreras-Loya D, Kwan A, Chaumont C, Chompolola A, Condo J, Galarraga O, Martinson N, Masiye F, Nsanzimana S, Ochoa-Moreno I, Wamai R, Wang'ombe.  J. AIDS. 2016 Oct 23;30(16):2495-2504. Published online 2016 Sep 28.  doi:  10.1097/QAD.0000000000001208

Objective: We estimate facility-level average annual costs per client along the HIV testing and counselling (HTC) and prevention of mother-to-child transmission (PMTCT) service cascades.

Design: Data collected covered the period 2011-2012 in 230 HTC and 212 PMTCT facilities in Kenya, Rwanda, South Africa, and Zambia.

Methods: Input quantities and unit prices were collected, as were output data. Annual economic costs were estimated from the service providers' perspective using micro-costing. Average annual costs per client in 2013 United States dollars (US$) were estimated along the service cascades.

Results: For HTC, average cost per client tested ranged from US$5 (SD US$7) in Rwanda to US$31 (SD US$24) in South Africa, whereas average cost per client diagnosed as HIV-positive ranged from US$122 (SD US$119) in Zambia to US$1367 (SD US$2093) in Rwanda. For PMTCT, average cost per client tested ranged from US$18 (SD US$20) in Rwanda to US$89 (SD US$56) in South Africa; average cost per client diagnosed as HIV-positive ranged from US$567 (SD US$417) in Zambia to US$2021 (SD US$3210) in Rwanda; average cost per client on antiretroviral prophylaxis ranged from US$704 (SD US$610) in South Africa to US$2314 (SD US$3204) in Rwanda; and average cost per infant on nevirapine ranged from US$888 (SD US$884) in South Africa to US$2359 (SD US$3257) in Rwanda.

Conclusion: We found important differences in unit costs along the HTC and PMTCT service cascades within and between countries suggesting that more efficient delivery of these services is possible.

Abstract  Full-text [free] access 

Editor’s notes: With resources for HIV prevention and treatment services becoming limited, more focus is being placed on maximising the benefit gain from current service provision. This paper examines the cost of different HIV services in four sub-Saharan African countries to see how costs vary for the provision of different services. The authors find a wide variation in costs across different countries. For example, HIV testing appears to have a relatively high cost in South Africa, however South Africa’s cost per person on ARV treatment is lower than other countries. This variation suggests that a more efficient delivery of HIV services could give greater benefit for the same amount of funding required. 

Africa
Kenya, Rwanda, South Africa, Zambia
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Pre-exposure prophylaxis for HIV prevention is cost-effective in the Netherlands

Cost-effectiveness analysis of pre-exposure prophylaxis for HIV-1 prevention in the Netherlands: a mathematical modelling study.

Nichols BE, Boucher CA, van der Valk M, Rijnders BJ, van de Vijver DA. Lancet Infect Dis. 2016 Sep 22. pii: S1473-3099(16)30311-5. doi: 10.1016/S1473-3099(16)30311-5. [Epub ahead of print]

Background: Pre-exposure prophylaxis (PrEP) with tenofovir and emtricitabine prevents HIV infections among men who have sex with men (MSM). PrEP can be given on a daily or intermittent basis. Unfortunately, PrEP is not reimbursed in most European countries. Cost-effectiveness analyses of PrEP among MSM in Europe are absent but are key for decision makers to decide upon PrEP implementation.

Methods: We developed a deterministic mathematical model, calibrated to the well-defined Dutch HIV epidemic among MSM, to predict the effect and cost-effectiveness of PrEP. PrEP was targeted to 10% of highly sexually active Dutch MSM over the coming 40 years. Cost-effectiveness ratios were calculated to predict the cost-effectiveness of daily and on-demand PrEP. Cost-effectiveness ratios below euro20 000 were considered to be cost-effective in this analysis.

Findings: Within the context of a stable HIV epidemic, at 80% effectiveness and current PrEP pricing, PrEP can cost as much as euro11 000 (IQR 9400-14 100) per quality-adjusted life-year (QALY) gained when used daily, or as little as euro2000 (IQR 1300-3000) per QALY gained when used on demand. At 80% effectiveness, daily PrEP can be considered cost-saving if the price of PrEP is reduced by 70%, and on-demand PrEP can be considered cost-saving if the price is reduced by 30-40%.

Interpretation: PrEP for HIV prevention among MSM in the Netherlands is cost-effective. The use of PrEP is most cost-effective when the price of PrEP is reduced through on-demand use or through availability of generic PrEP, and can quickly be considered cost-saving.

Abstract access  

Editor’s notes: Evidence surrounding the clinical effectiveness of pre-exposure prophylaxis to prevent HIV infection has been building for years (see HIV This Month January 2016 and February 2015).  This article now adds to the evidence with indications that pre-exposure prophylaxis is also cost-effective in a European setting.

The authors use a deterministic mathematical model to represent the HIV epidemic in the Netherlands among gay men and other men who have sex with men. They estimate the cost and cost-effectiveness of two models of pre-exposure prophylaxis usage: a daily dosage, and an ‘on demand’ dosage.  Their base case analysis found that both usage models fall under a willingness-to-pay ratio of €20 000 per QALY gained over a 40-year time horizon, although the ‘on demand’ model was least expensive at only €2000 (IQR 1300–3000) per QALY gained.  The model reflected some uncertainty around the results. However, very few results from the sensitivity analysis indicated a cost-per-QALY ratio above €20 000. Several scenarios indicated that pre-exposure prophylaxis was cost-saving. 

Pre-exposure prophylaxis was approved by the European Medicines Agency in July 2016, however it is currently not reimbursed by most European governments. This paper provides important evidence to make a case in favour of recommending reimbursement. Although the willingness-to-pay threshold used (€20 000/QALY) does not have any formal recognition in the Netherlands, several independent analyses soliciting the Dutch society’s value of a QALY reflect values much higher than this. As noted in the comment accompanying this paper (Niessen and Jaffar), the potential cost of implementing pre-exposure prophylaxis on a large-scale could be higher than current budgetary priorities allow. Still, this is an important study adding to the mounting evidence that countries should begin to consider how pre-exposure prophylaxis can be made available to people at highest risk of HIV infection.  

Europe
Netherlands
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