Articles tagged as "Financing"

Using HIV infrastructure to test for other diseases can reach many people at a low cost

Cost and efficiency of a hybrid mobile multi-disease 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 Jul 29. [Epub ahead of print]

Background: In 2013-14, 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, multi-disease services, and community mobilization.

Methods: We applied micro-costing methods to estimate costs of population-wide HIV testing in 12 SEARCH Trial communities. Main intervention components of the hybrid approach are census, multi-disease community health campaigns (CHC), and home-based testing (HBT) for CHC non-attendees. 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 via HBT. The cost per HIV+ adult identified was $231 ($87 - $1245), with variability due mainly to HIV prevalence among persons tested (i.e., HIV positivity rate). The marginal costs of multi-disease 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, multi-disease services were offered at low marginal costs.

Abstract access 

Editor’s notes: Ensuring high rates of HIV testing is critical to managing the HIV epidemic in many countries. With a positive diagnosis, recent WHO recommendations suggest that people living with HIV can immediately be put onto treatment which improves their own health, alongside reducing the chance that they will pass on infection to others. There are many different ways to carry out HIV testing, and this study looks at the differences in costs between community health campaigns (which also test for other diseases including hypertension and diabetes), and home-based testing. This paper estimates that it was less costly to carry out a HIV test through a multi-disease community programme than home-based testing. The authors suggest that because of the robust infrastructure that has been developed for HIV testing in Uganda and Kenya, the additional cost for testing for other diseases is very low. There has been some criticism that the response to the HIV epidemic has been at the expense of reducing ill-health from other conditions. Using HIV infrastructure to support testing for diseases like hypertension and diabetes is a good way to counter these criticisms, and improve the overall health of the population. 

Africa
Kenya, Uganda
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Cost-effectiveness analysis of home-based HIV testing and education for pregnant women and their male partners in Kenya

Modeling the cost-effectiveness of home-based HIV testing and education (HOPE) for pregnant women and their male partners in Nyanza Province, Kenya.

Sharma M, Farquhar C, Ying R, Krakowiak D, Kinuthia J, Osoti A, Asila V, Gone M, Mark J, Barnabas RV. J Acquir Immune Defic Syndr. 2016 Aug 1;72 Suppl 2:S174-80. doi: 10.1097/QAI.0000000000001057.

Introduction: Women in sub-Saharan Africa face a 2-fold higher risk of HIV acquisition during pregnancy and postpartum and the majority do not know the HIV status of their male partner. Home-based couple HIV testing for pregnant women can reduce HIV transmission to women and infants while increasing antiretroviral therapy (ART) coverage in men. However, the cost-effectiveness of this program has not been evaluated.

Methods: We modeled the health and economic impact of implementing a home-based partner education and HIV testing (HOPE) intervention for pregnant women and their male partners in a region of Western Kenya (formally Nyanza Province). We used data from the HOPE randomized clinical trial conducted in Kisumu, Kenya, to parameterize a mathematical model of HIV transmission. We conducted an in-country microcosting of the HOPE intervention (payer perspective) to estimate program costs as well as a lower cost scenario of task-shifting to community health workers.

Results: The incremental cost of adding the HOPE intervention to standard antenatal care was $31-37 and $14-16 USD per couple tested with program and task-shifting costs, respectively. At 60% coverage of male partners, HOPE was projected to avert 6987 HIV infections and 2603 deaths in Nyanza province over 10 years with an incremental cost-effectiveness ratio (ICER) of $886 and $615 per disability-adjusted life year averted for the program and task-shifting scenario, respectively. ICERs were robust to changes in intervention coverage, effectiveness, and ART initiation and dropout rates.

Conclusions: The HOPE intervention can moderately decrease HIV-associated morbidity and mortality by increasing ART coverage in male partners of pregnant women. ICERs fall below Kenya's per capita gross domestic product ($1358) and are therefore considered cost-effective. Task-shifting to community health workers can increase intervention affordability and feasibility.

Abstract access

Editor’s notes: HIV remains one of the most serious public health and economic challenges in sub-Saharan Africa. In this study, a deterministic mathematical model was used to assess the cost-effectiveness of providing home-based partner education and HIV testing to couples as a part of routine antenatal care in western Kenya. Detailed cost and effectiveness data were obtained from home-based partner education and an HIV testing programme in Kisumu, Kenya. The model was parameterised using data from that region. The model was analysed for two scenarios; the status quo (with no activity) and the activity scenario in which home-based partner education and HIV testing was added to the status quo with 60% coverage of male partners of pregnant women. Sensitivity analysis was conducted to ascertain the robustness of key model assumption on the study findings.  The authors found home-based partner education and HIV testing activities to be a cost-effective method to reduce HIV disease prevalence in Kenya as it increases ART coverage in male partners of pregnant women. This is a very interesting study which confirms previous findings that community-based HIV counselling and testing is cost-effective. 

Africa
Kenya
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Task-shifting reduces costs for early infant male circumcision

Comparative cost of early infant male circumcision by nurse-midwives and doctors in Zimbabwe.

Mangenah C, Mavhu W, Hatzold K, Biddle AK, Ncube G, Mugurungi O, Ticklay I, Cowan FM, Thirumurthy H. Glob Health Sci Pract. 2016 Jul 13;4 Suppl 1:S68-75. doi: 10.9745/GHSP-D-15-00201. Published online 2016 Jul 2.

Background: The 14 countries that are scaling up voluntary male medical circumcision (VMMC) for HIV prevention are also considering early infant male circumcision (EIMC) to ensure longer-term reductions in HIV incidence. The cost of implementing EIMC is an important factor in scale-up decisions. We conducted a comparative cost analysis of EIMC performed by nurse-midwives and doctors using the AccuCirc device in Zimbabwe.

Methods: Between August 2013 and July 2014, nurse-midwives performed EIMC on 500 male infants using AccuCirc in a field trial. We analyzed the overall unit cost and identified key cost drivers of EIMC performed by nurse-midwives and compared these with costing data previously collected during a randomized noninferiority comparison trial of 2 devices (AccuCirc and the Mogen clamp) in which doctors performed EIMC. We assessed direct costs (consumable and nonconsumable supplies, device, personnel, associated staff training, and waste management costs) and indirect costs (capital and support personnel costs). We performed one-way sensitivity analyses to assess cost changes when we varied key component costs.

Results: The unit costs of EIMC performed by nurse-midwives and doctors in vertical programs were US$38.87 and US$49.77, respectively. Key cost drivers of EIMC were consumable supplies, personnel costs, and the device price. In this cost analysis, major cost drivers that explained the differences between EIMC performed by nurse-midwives and doctors were personnel and training costs, both of which were lower for nurse-midwives.

Conclusions: EIMC unit costs were lower when performed by nurse-midwives compared with doctors. To minimize costs, countries planning to scale up EIMC should consider using nurse-midwives, who are in greater supply than doctors and are the main providers at the primary health care level, where most infants are born.

Abstract  Full-text [free] access 

Editor’s notes: The evidence behind the efficacy for male circumcision in HIV prevention has been proven beyond a reasonable doubt, and 14 countries with a high HIV prevalence are currently scaling up voluntary medical male circumcision. To improve future HIV prevention, WHO and UNICEF also recommend that early infant male circumcision be performed within the first 60 days of life in countries with a high HIV prevalence. In countries such as Zimbabwe, an acute shortage of human resources for health has the potential to hinder scale-up of early infant male circumcision.  However, with new devices such as the AccuCirc® , early infant male circumcision can be performed without advanced surgical skills – raising the potential for task shifting as a way to alleviate pressure on human resources.  

This study compares the unit cost of early infant male circumcision using the AccuCirc® , as performed by doctors and by nurse-midwives. Nurse-midwives on average took a longer time to complete a circumcision (average 18 minutes) as compared to doctors (average 16 minutes).  However, the reductions in salary costs offset this increased time, reducing the unit cost of early infant male circumcision overall. Integrating early infant male circumcision into a public health facility (as compared to a vertical programme) would further reduce the costs. 

This study suggests that countries seeking to scale up early infant male circumcision should consider task shifting as a way to reduce costs. Task shifting does pose the risk of increasing workload for lower-level personnel; more nurse-midwives will need to be trained to cope with additional responsibilities to avoid over-burdening existing personnel. However, this is a promising solution to enable scale-up of early infant male circumcision quickly and affordably in settings such as Zimbabwe.

Africa
Zimbabwe
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Immediate initiation of HIV treatment is cost-effective, but needs a large portion of health system spending

Changing HIV treatment eligibility under health system constraints in sub-Saharan Africa: Investment needs, population health gains, and cost-effectiveness.

Hontelez JA, Chang AY, Ogbuoji O, Vlas SJ, Barnighausen T, Atun R. AIDS. 2016 Jun 29. [Epub ahead of print]

Objective: We estimated the investment need, population health gains, and cost-effectiveness of different policy options for scaling-up prevention and treatment of HIV in the 10 countries that currently comprise 80% of all people living with HIV in sub-Saharan Africa (Ethiopia, Kenya, Malawi, Mozambique, Nigeria, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe).

Design: We adapted the established STDSIM model, to capture the health system dynamics: demand-side and supply-side constraints in the delivery of antiretroviral treatment (ART).

Methods: We compared different scenarios of supply-side (i.e. health system capacity) and demand-side (i.e. health seeking behavior) constraints, and determined the impact of changing guidelines to ART eligibility at any CD4 cell count within these constraints.

Results: Continuing current scale-up would require US$178 billion by 2050. Changing guidelines to ART at any CD4 cell count is cost-effective under all constraints tested in the model, especially in demand-side constrained health systems because earlier initiation prevents loss to follow-up of patients not yet eligible. Changing guidelines under current demand-side constraints would avert 1.8 million infections at US$208 per life-year saved.

Conclusions: Treatment eligibility at any CD4 cell count would be cost-effective, even under health system constraints. Excessive loss to follow up and mortality in patients not eligible for treatment can be avoided by changing guidelines in demand-side constrained systems. The financial obligation for sustaining the AIDS response in sub-Saharan Africa over the next 35 years is substantial, and requires strong, long-term commitment of policy makers and donors to continue to allocate substantial parts of their budgets.

Abstract access

Editor’s notes: Recent WHO guidelines recommend that everyone who is diagnosed as HIV positive should be allowed to start treatment immediately, a change to the former guideline where their CD4 count (a measure of disease progression) was the main criteria for starting treatment. This paper uses a model to look at the costs and benefits of changing to this immediate treatment regimen in the sub-Saharan African countries most affected by the epidemic. The authors find that allowing all HIV people living with HIV to access treatment is cost-effective, and this finding does not change when the model assumptions are varied. However, the impact of this change on the health system budgets in these countries is very substantial, and the authors suggest that a large commitment is necessary from policymakers and donors to sustain this response as short-term spending will not be enough to make an impact.

Africa
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Viral load testing is more cost-effective than CD4 testing

Laboratory monitoring of antiretroviral therapy for HIV infection: cost-effectiveness and budget impact of current and novel strategies.

Ouattara EN, Robine M, Eholie SP, MacLean RL, Moh R, Losina E, Gabillard D, Paltiel AD, Danel C, Walensky RP, Anglaret X, Freedberg KA. Clin Infect Dis. 2016 Jun 1;62(11):1454-62. doi: 10.1093/cid/ciw117. Epub 2016 Mar 1.

Background: Optimal laboratory monitoring of antiretroviral therapy (ART) for human immunodeficiency virus (HIV) remains controversial. We evaluated current and novel monitoring strategies in Cote d'Ivoire, West Africa.

Methods: We used the Cost-Effectiveness of Preventing AIDS Complications -International model to compare clinical outcomes, cost-effectiveness, and budget impact of 11 ART monitoring strategies varying by type (CD4 and/or viral load [VL]) and frequency. We included "adaptive" strategies (biannual then annual monitoring for patients on ART/suppressed). Mean CD4 count at ART initiation was 154/µL. Laboratory test costs were CD4=$11 and VL=$33. The standard of care (SOC; biannual CD4) was the comparator. We assessed cost-effectiveness relative to Cote d'Ivoire's 2013 per capita GDP ($1500).

Results: Discounted life expectancy was 16.69 years for SOC, 16.97 years with VL confirmation of immunologic failure, and 17.25 years for adaptive VL. Mean time on failed first-line ART was 3.7 years for SOC and <0.9 years for all routine/adaptive VL strategies. VL failure confirmation was cost-saving compared with SOC. Adaptive VL had an incremental cost-effectiveness ratio (ICER) of $4100/year of life saved compared with VL confirmation and increased the 5-year budget by $310/patient compared with SOC. Adaptive VL achieved an ICER <1x GDP if second-line ART and VL costs simultaneously decreased to $156 and $13, respectively.

Conclusions: VL confirmation of immunologic failure is more effective and less costly than CD4 monitoring in Cote d'Ivoire. Adaptive VL monitoring reduces time on failing ART, is cost-effective, and should become standard in Cote d'Ivoire and similar settings.

Abstract access 

Editor’s notes: Monitoring whether or not people are able to effectively use HIV antiretroviral therapy (ART) to supress viral load is important to maintaining individual and population health. There are two ways to monitor whether or not people are able to adhere to ART, assessing CD4 cell count or viral load. These tests require different amounts of expensive laboratory resources. This paper explores 11 ways in which ART regimens can be monitored in Cote d’Ivoire to assess the potential impact and cost-effectiveness of different strategies compared to current care (twice-yearly CD4 tests). The authors estimate that adding viral load failure confirmation to current practice would be cost saving. Adaptive viral load monitoring is found to be cost-effective. This approach involves decreasing monitoring from twice-annually to annually among people who present with suppressed viral loads for one year. In many countries, viral load monitoring is not generally available. This research is important because it illustrates that viral load monitoring strategies can be cost saving compared to CD4 counts, in line with WHO recommendations. 

Africa
Côte d'Ivoire
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Increased economic resources can reduce sexual vulnerability in young women

Economic resources and HIV preventive behaviors among school-enrolled young women in rural South Africa (HPTN 068).

Jennings L, Pettifor A, Hamilton E, Ritchwood TD, Xavier Gomez-Olive F, MacPhail C, Hughes J, Selin A, Kahn K. AIDS Behav. 2016 Jun 3. [Epub ahead of print]

Individual economic resources may have greater influence on school-enrolled young women's sexual decision-making than household wealth measures. However, few studies have investigated the effects of personal income, employment, and other financial assets on young women's sexual behaviors. Using baseline data from the HIV Prevention Trials Network (HPTN) 068 study, we examined the association of ever having sex and adopting sexually-protective practices with individual-level economic resources among school-enrolled women, aged 13-20 years (n = 2533). Age-adjusted results showed that among all women employment was associated with ever having sex (OR 1.56, 95 % CI 1.28-1.90). Among sexually-experienced women, paid work was associated with changes in partner selection practices (OR 2.38, 95 % CI 1.58-3.58) and periodic sexual abstinence to avoid HIV (OR 1.71, 95 % CI 1.07-2.75). Having money to spend on oneself was associated with reducing the number of sexual partners (OR 1.94, 95 % CI 1.08-3.46), discussing HIV testing (OR 2.15, 95 % CI 1.13-4.06), and discussing condom use (OR 1.99, 95 % CI 1.04-3.80). Having a bank account was associated with condom use (OR 1.49, 95 % CI 1.01-2.19). Economic hardship was positively associated with ever having sex, but not with sexually-protective behaviors. Maximizing women's individual economic resources may complement future prevention initiatives.

Abstract access

Editor’s notes: Young women bear a disproportionate amount of the burden of the HIV epidemic in Africa. There are strong socioeconomic drivers of the epidemic, and gender inequalities and poverty combine to make adolescent girls and young women particularly vulnerable to HIV infection.  Economic programmes have been used in many countries to influence specific behaviours and to improve health outcomes. However, the evidence of their effectiveness in the context of HIV prevention is mixed. This study examined the association of individual economic resources with sexual behaviour in adolescent girls and young women. Although people with greater economic resources were more likely to have had sex, thus increasing their exposure to HIV infection, they were also more likely to engage in behaviours that were protective against HIV.  Not all economic resources had a positive effect on behaviour, underscoring the fact that sexual decision-making is complex and multi-faceted. The study population was unmarried, in school, and living with at least one parent or guardian, so the findings may not be generalisable to young women who are out of school or in less stable living arrangements. Improving the individual economic status of adolescent girls and young women may have a positive impact on HIV prevention behaviour. However, women’s choices may be constrained by social norms and entrenched inequalities. This study raises further questions about how economic resources may influence HIV risk in young women, but also in young men. 

Africa
South Africa
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Circumcising young adults: a higher return on investment

Effectiveness of and financial returns to voluntary medical male circumcision for HIV prevention in South Africa: an incremental cost-effectiveness analysis.

Haacker M, Fraser-Hurt N, Gorgens M. PLoS Med. 2016 May 3;13(5):e1002012. doi: 10.1371/journal.pmed.1002012. eCollection 2016.

Background: Empirical studies and population-level policy simulations show the importance of voluntary medical male circumcision (VMMC) in generalized epidemics. This paper complements available scenario-based studies (projecting costs and outcomes over some policy period, typically spanning decades) by adopting an incremental approach-analyzing the expected consequences of circumcising one male individual with specific characteristics in a specific year. This approach yields more precise estimates of VMMC's cost-effectiveness and identifies the outcomes of current investments in VMMC (e.g., within a fiscal budget period) rather than of investments spread over the entire policy period.

Methods/findings: The model has three components. We adapted the ASSA2008 model, a demographic and epidemiological model of the HIV epidemic in South Africa, to analyze the impact of one VMMC on HIV incidence over time and across the population. A costing module tracked the costs of VMMC and the resulting financial savings owing to reduced HIV incidence over time. Then, we used several financial indicators to assess the cost-effectiveness of and financial return on investments in VMMC. One circumcision of a young man up to age 20 prevents on average over 0.2 HIV infections, but this effect declines steeply with age, e.g., to 0.08 by age 30. Net financial savings from one VMMC at age 20 are estimated at US$617 at a discount rate of 5% and are lower for circumcisions both at younger ages (because the savings occur later and are discounted more) and at older ages (because male circumcision becomes less effective). Investments in male circumcision carry a financial rate of return of up to 14.5% (for circumcisions at age 20). The cost of a male circumcision is refinanced fastest, after 13 y, for circumcisions at ages 20 to 25. Principal limitations of the analysis arise from the long time (decades) over which the effects of VMMC unfold-the results are therefore sensitive to the discount rate applied, and more generally to the future course of the epidemic and of HIV/AIDS-related policies pursued by the government.

Conclusions: VMMC in South Africa is highly effective in reducing both HIV incidence and the financial costs of the HIV response. The return on investment is highest if males are circumcised between ages 20 and 25, but this return on investment declines steeply with age.

Abstract  Full-text [free] access 

Editor’s notes: Voluntary medical male circumcision is known to be an effective HIV-infection prevention method. While many models and papers have explored the cost and cost-effectiveness of voluntary medical male circumcision at a population level, the authors carry out their analysis using an incremental approach, looking at the expected consequences of circumcising one male individual within a specific year. Their findings are consistent with previous work on the topic, namely that voluntary medical male circumcision is highly effective in countries with high HIV prevalence and is, under many circumstances, cost-saving. They also find that voluntary medical male circumcision is most effective when performed at age 20, and effectiveness declines at higher ages due to diminished direct and indirect effects on HIV incidence.

While it would indeed be wise for countries to consider long-term impacts of programmes, governments often make decisions in the short-term. It is therefore important for governments to understand the benefits of a programme or policy that are accrued during the timeframe of presidential or congressional terms. The findings and the approach used in this study are very important because they present evidence of impact of investment within a government’s current budget process. By providing a way to measure the immediate return on investment, the authors of this paper help inform policymakers in a way that is tangible, pragmatic, and, unfortunately, not often used.  

Africa
South Africa
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Inequalities in access to health care for older people living with HIV in South Africa

Health expenditure and catastrophic spending among older adults living with HIV.

Negin J, Randell M, Raban MZ, Nyirenda M, Kalula S, Madurai L, Kowal P. Glob Public Health. 2016 Apr 30:1-15. [Epub ahead of print]

Introduction: The burden of HIV is increasing among adults aged over 50, who generally experience increased risk of comorbid illnesses and poorer financial protection. We compared patterns of health utilisation and expenditure among HIV-positive and HIV-negative adults over 50.

Methods: Data were drawn from the Study on global AGEing and adult health in South Africa with analysis focusing on individual and household-level data of 147 HIV-positive and 2725 HIV-negative respondents.

Results: HIV-positive respondents reported lower utilisation of private health-care facilities (11.8%) than HIV-negative respondents (25.0%) (p = .03) and generally had more negative attitudes towards health system responsiveness than HIV-negative counterparts. Less than 10% of HIV-positive and HIV-negative respondents experienced catastrophic health expenditure (CHE). Women (OR 1.8; p < .001) and respondents from rural settings (OR 2.9; p < .01) had higher odds of CHE than men or respondents in urban settings. Over half the respondents in both groups indicated that they had received free health care.

Conclusions: These findings suggest that although HIV-positive and HIV-negative older adults in South Africa are protected to some extent from CHE, inequalities still exist in access to and quality of care available at health-care services - which can inform South Africa's development of a national health insurance scheme.

Abstract access

Editor’s notes: The study provides a valuable overview of the health expenditures of HIV-positive and negative older people (50 years and older) in South Africa. It should be noted that the data used in this analysis are from 2007-2008. Therefore, it is likely that some things may have changed as anti-retroviral therapy has become more available. Perhaps some of the negative experiences reported by people living with HIV may have changed. However, it is likely that waiting times in clinics and concerns about drug-stockouts, may not have changed. Nearly a decade on, the number of people in need of HIV-associated care, and the resulting burden on the health service remain immense. The authors point to the valuable role of the social security system in reducing the financial impact of HIV, and mitigating catastrophic health expenditures. 

The authors have produced an important paper, highlighting some of the inequities in health care access. Many of these inequities are likely to have persisted. It would be invaluable to have a similar analysis of more recent data in order to chart progress. 

Africa
South Africa
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Injectable PrEP, if targeted well, could be good value for money

Cost-effectiveness of injectable preexposure prophylaxis for HIV prevention in South Africa.

Glaubius RL, Hood G, Penrose KJ, Parikh UM, Mellors JW, Bendavid E, Abbas UL. Clin Infect Dis. 2016 May 18. pii: ciw321. [Epub ahead of print]

Background: Long-acting injectable antiretrovirals such as rilpivirine (RPV) could promote adherence to preexposure prophylaxis (PrEP) for HIV prevention. However, the cost-effectiveness of injectable PrEP is unclear.

Methods: We constructed a dynamic model of the heterosexual HIV epidemic in KwaZulu-Natal, South Africa, and analyzed scenarios of RPV PrEP scale-up for combination HIV prevention in comparison with a reference scenario without PrEP. We estimated new HIV infections, life-years and costs, and incremental cost-effectiveness ratios, over ten-year and lifetime horizons, assuming a societal perspective.

Results: Compared with no PrEP, unprioritized scale-up of RVP PrEP covering 2.5%-15% of adults prevented up to 9% of new infections over ten years. HIV prevention doubled (17%) when the same coverage was prioritized to 20-29 year-old women, costing $10 880-$19 213 per infection prevented. Prioritization of PrEP to 80% of individuals at highest behavioral risk achieved comparable prevention (4%-8%) at <1% overall coverage, costing $298-$1242 per infection prevented. Over lifetime, PrEP scale-up among 20-29 year-old women was very cost-effective (<$1600 per life-year gained), dominating unprioritized PrEP, while risk-prioritization was cost-saving. PrEP's ten-year impact decreased by almost 50% with increases in incremental cost-effectiveness ratios (up to 4.2-fold) in conservative base-case analysis. Sensitivity analysis identified PrEP's costs, efficacy and reliability of delivery, as the principal drivers of uncertainty in PrEP's cost-effectiveness, and PrEP remained cost-effective under the assumption of universal access to second-line antiretroviral therapy.

Conclusions: Compared with no PrEP, prioritized scale-up of RPV PrEP in KwaZulu-Natal could be very cost-effective or cost-saving, but suboptimal PrEP would erode benefits and increase costs.

Abstract access

Editor’s notes: Pre-exposure prophylaxis (PrEP) has been shown to work when people are able to use it well.  But recent trials have illustrated that people are not always able to take tablets or use vaginal gels frequently enough to maximise protection. A promising area in HIV prevention research is long-lasting injectable PrEP, which would only require application once every month or so. This paper estimates whether injectable PrEP might be cost effective in South Africa.  The authors explore how this form of PrEP should be targeted to different groups. Injectable PrEP is estimated to be very cost-effective in general, and would save money if people at highest risk were able to gain access. However, because an injectable product has not been fully developed yet, this analysis requires many assumptions. The authors test how changes in these assumptions might give a different conclusion. They find that the most important factors are the cost of injectable PrEP products themselves, how well they work, and whether they can be made available to people who need them.

Africa
South Africa
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Pilot integration of HIV and nutrition services shows great potential for health impact

Outcomes and cost-effectiveness of integrating HIV and nutrition service delivery: pilots in Malawi and Mozambique.

Bergmann JN, Legins K, Sint TT, Snidal S, Group UR, Amor YB, McCord GC. AIDS Behav. 2016 Apr 19. [Epub ahead of print]

This paper provides the first estimates of impact and cost-effectiveness for integrated HIV and nutrition service delivery in sub-Saharan Africa. HIV and undernutrition are synergistic co-epidemics impacting millions of children throughout the region. To alleviate this co-epidemic, UNICEF supported small-scale pilot programs in Malawi and Mozambique that integrated HIV and nutrition service delivery. We use trends from integration sites and comparison sites to estimate the number of lives saved, infections averted and/or undernutrition cases cured due to programmatic activities, and to estimate cost-effectiveness. Results suggest that Malawi's program had a cost-effectiveness of $11-29/DALY, while Mozambique's was $16-59/DALY. Some components were more effective than others ($1-4/DALY for Malawi's Male motivators vs. $179/DALY for Mozambique's One stop shops). These results suggest that integrating HIV and nutrition programming leads to a positive impact on health outcomes and should motivate additional work to evaluate impact and determine cost-effectiveness using an appropriate research design.

Abstract access

Editor’s notes: This paper presents outcomes and cost-effectiveness of a variety of programmes intended to facilitate integration of HIV treatment and care services with community management of acute malnutrition (CMAM) services in Malawi and Mozambique. In Malawi, programmes included SMS reminders to encourage attendance and adherence, “male motivators” who encouraged men to be involved in children’s health, and child health passports. In Mozambique, programmes included one-stop shops where children could access HIV-associated and vaccination services. Flowcharts to facilitate referral between HIV and nutrition services were also tried. Difference in difference estimates indicate substantial improvements in child health outcomes, and cost-effectiveness estimates are in line with other services. The programmes were funded by UNICEF, and not designed for research purposes. The authors therefore acknowledge some limitations in the external validity of their findings.  This paper should be taken as proof of concept rather than a final word on the effectiveness or cost-effectiveness of these activities. However, these preliminary estimates illustrate that there is great potential in facilitating integration of these two services.  Further research into integration of nutritional support services with HIV services is necessary.

Africa
Malawi, Mozambique
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