Targeted HIV prevention is extremely cost-effective at scale

Cost-effectiveness of HIV prevention for high-risk groups at scale: an economic evaluation of the Avahan programme in south India.

Vassall A, Pickles M, Chandrashekar S, Boily MC, Shetty G, Guinness L, Lowndes CM, Bradley J, Moses S, Alary M, Charme India G, Vickerman P. Lancet Glob Health. 2014 Sep;2(9):e531-40. doi: 10.1016/S2214-109X(14)70277-3. Epub 2014 Aug 27.

Background: Avahan is a large-scale, HIV preventive intervention, targeting high-risk populations in south India. We assessed the cost-effectiveness of Avahan to inform global and national funding institutions who are considering investing in worldwide HIV prevention in concentrated epidemics.

Methods: We estimated cost effectiveness from a programme perspective in 22 districts in four high-prevalence states. We used the UNAIDS Costing Guidelines for HIV Prevention Strategies as the basis for our costing method, and calculated effect estimates using a dynamic transmission model of HIV and sexually transmitted disease transmission that was parameterised and fitted to locally observed behavioural and prevalence trends. We calculated incremental cost-effective ratios (ICERs), comparing the incremental cost of Avahan per disability-adjusted life-year (DALY) averted versus a no-Avahan counterfactual scenario. We also estimated incremental cost per HIV infection averted and incremental cost per person reached.

Findings: Avahan reached roughly 150 000 high-risk individuals between 2004 and 2008 in the 22 districts studied, at a mean cost per person reached of US$327 during the 4 years. This reach resulted in an estimated 61 000 HIV infections averted, with roughly 11 000 HIV infections averted in the general population, at a mean incremental cost per HIV infection averted of $785 (SD 166). We estimate that roughly 1 million DALYs were averted across the 22 districts, at a mean incremental cost per DALY averted of $46 (SD 10). Future antiretroviral treatment (ART) cost savings during the lifetime of the cohort exposed to HIV prevention were estimated to be more than $77 million (compared with the slightly more than $50 million spent on Avahan in the 22 districts during the 4 years of the study).

Interpretation: This study provides evidence that the investment in targeted HIV prevention programmes in south India has been cost effective, and is likely to be cost saving if a commitment is made to provide ART to all that can benefit from it. Policy makers should consider funding and sustaining large-scale targeted HIV prevention programmes in India and beyond.

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Editor’s notes: This study evaluates the cost-effectiveness of Avahan, one of the largest targeted HIV prevention programmes in the world. The authors find that prevention activities targeted to high-risk populations is extremely cost-effective, and likely to be cost-saving in the long run. Although there have been previous studies to the same effect on small projects or pilot programmes, these results are important for several reasons. First, the large scale of the study provides solid evidence on the cost-effectiveness of this activity in the real world, and at scale. Second, the inclusion of costs above the NGO level is unique, and reflects a vital investment for countries seeking to scale up HIV prevention activities. Further, the precision of estimates due to the comprehensive original data collection and fitting of the model is unparalleled. This study should encourage confidence in policy makers of the continuing strength of ‘prevention as prevention’ in the effort to stem the HIV epidemic in the context of scarce resources for HIV programmes. 

Asia
India
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