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 

South Africa
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