Cost-eff ectiveness of community-based strategies to strengthen the continuum of HIV care in rural South Africa: a health economic modelling analysis

Authored by Jennifer A Smith, Connie Celum, Jared M Baeten, Timothy B Hallett, Monisha Sharma, Carol Levin, Rooyen Heidi van, Ruanne V Barnabas

Date Published: 2015

DOI: 10.1016/s2352-3018(15)00016-8

Sponsors: Bill and Melinda Gates Foundation United States National Institutes of Health (NIH)

Platforms: MATLAB

Model Documentation: Other Narrative Flow charts

Model Code URLs: Model code not found

Abstract

Background Home HIV counselling and testing (HTC) achieves high coverage of testing and linkage to care compared with existing facility-based approaches, particularly among asymptomatic individuals. In a modelling analysis we aimed to assess the effect on population-level health and cost-effectiveness of a community-based package of home HTC in KwaZulu-Natal, South Africa. Methods We parameterised an individual-based model with data from home HTC and linkage field studies that achieved high coverage (91\%) and linkage to antiretroviral therapy (80\%) in rural KwaZulu-Natal, South Africa. Costs were derived from a linked microcosting study. The model simulated 10 000 individuals over 10 years and incremental cost-effectiveness ratios were calculated for the intervention relative to the existing status quo of facility-based testing, with costs discounted at 3\% annually. Findings The model predicted implementation of home HTC in addition to current practice to decrease HIV-associated morbidity by 10-22\% and HIV infections by 9-48\% with increasing CD4 cell count thresholds for antiretroviral therapy initiation. Incremental programme costs were US\$2.7 million to \$4.4 million higher in the intervention scenarios than at baseline, and costs increased with higher CD4 cell count thresholds for antiretroviral therapy initiation; antiretroviral therapy accounted for 48-87\% of total costs. Incremental cost-effectiveness ratios per disability-adjusted life-year averted were \$1340 at an antiretroviral therapy threshold of CD4 count lower than 200 cells per mu L, \$1090 at lower than 350 cells per mu L, \$1150 at lower than 500 cells per mu L, and \$1360 at universal access to antiretroviral therapy. Interpretation Community-based HTC with enhanced linkage to care can result in increased HIV testing coverage and treatment uptake, decreasing the population burden of HIV-associated morbidity and mortality. The incremental cost-eff ectiveness ratios are less than 20\% of South Africa's gross domestic product per person, and are therefore classed as very cost effective. Home HTC can be a viable means to achieve UNAIDS' ambitious new targets for HIV treatment coverage. Copyright (C) Smith et al. Open Access article distributed under the terms of CC BY.

Tags

Uganda Impact Sub-saharan africa Prevention Coverage Antiretroviral therapy Kenya Trial Testing strategies Cohort analysis