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

Smith JA, Sharma M, Levin C, Baeten JM, van Rooyen H, Celum C, Hallett TB, Barnabas RV - Lancet HIV (2015)

Bottom Line: 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.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-effectiveness ratios are less than 20% of South Africa's gross domestic product per person, and are therefore classed as very cost effective.

View Article: PubMed Central - PubMed

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 μL, $1090 at lower than 350 cells per μL, $1150 at lower than 500 cells per μL, 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-effectiveness 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.

Funding: National Institutes of Health, Bill & Melinda Gates Foundation, Wellcome Trust.

No MeSH data available.


Related in: MedlinePlus

Incremental cost-effectiveness ratiosFigure shows ICERs comparing home HTC with status quo at each threshold for antiretroviral therapy initiation. Panels A and B show median of 5000 simulations, with median cost plotted against median effect. Ellipses contain 95% of 5000 simulations; error bars show 90% of the variability in model outputs (5th to 95th percentiles). (A) Infections averted. (B) DALYs averted. (C) Infections averted, by cost model. (D) DALYs averted, by cost model. ICER=incremental cost-effectiveness ratio. HTC=HIV counselling and testing. ART=antiretroviral therapy.
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fig5: Incremental cost-effectiveness ratiosFigure shows ICERs comparing home HTC with status quo at each threshold for antiretroviral therapy initiation. Panels A and B show median of 5000 simulations, with median cost plotted against median effect. Ellipses contain 95% of 5000 simulations; error bars show 90% of the variability in model outputs (5th to 95th percentiles). (A) Infections averted. (B) DALYs averted. (C) Infections averted, by cost model. (D) DALYs averted, by cost model. ICER=incremental cost-effectiveness ratio. HTC=HIV counselling and testing. ART=antiretroviral therapy.

Mentions: The baseline scenario, with antiretroviral therapy eligibility at 200 cells per μL or lower and the research costing model (figure 5), produced median ICER values of $22 000 per HIV infection averted (90% model variability $11 300–75 900) and $1340 per DALY averted ($1080–1760). A small proportion (2·0%) of the ICER distribution for the incremental cost per infection averted with antiretroviral therapy eligibility at 200 cells per μL or lower were located in the northwest quadrant of the cost-effectiveness plane (figure 5). The incremental cost per infection averted seemed to decrease with expanding eligibility for antiretroviral therapy, but we did not note any clear trend for the incremental cost per DALY averted (figure 5).


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

Smith JA, Sharma M, Levin C, Baeten JM, van Rooyen H, Celum C, Hallett TB, Barnabas RV - Lancet HIV (2015)

Incremental cost-effectiveness ratiosFigure shows ICERs comparing home HTC with status quo at each threshold for antiretroviral therapy initiation. Panels A and B show median of 5000 simulations, with median cost plotted against median effect. Ellipses contain 95% of 5000 simulations; error bars show 90% of the variability in model outputs (5th to 95th percentiles). (A) Infections averted. (B) DALYs averted. (C) Infections averted, by cost model. (D) DALYs averted, by cost model. ICER=incremental cost-effectiveness ratio. HTC=HIV counselling and testing. ART=antiretroviral therapy.
© Copyright Policy - CC BY
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4384819&req=5

fig5: Incremental cost-effectiveness ratiosFigure shows ICERs comparing home HTC with status quo at each threshold for antiretroviral therapy initiation. Panels A and B show median of 5000 simulations, with median cost plotted against median effect. Ellipses contain 95% of 5000 simulations; error bars show 90% of the variability in model outputs (5th to 95th percentiles). (A) Infections averted. (B) DALYs averted. (C) Infections averted, by cost model. (D) DALYs averted, by cost model. ICER=incremental cost-effectiveness ratio. HTC=HIV counselling and testing. ART=antiretroviral therapy.
Mentions: The baseline scenario, with antiretroviral therapy eligibility at 200 cells per μL or lower and the research costing model (figure 5), produced median ICER values of $22 000 per HIV infection averted (90% model variability $11 300–75 900) and $1340 per DALY averted ($1080–1760). A small proportion (2·0%) of the ICER distribution for the incremental cost per infection averted with antiretroviral therapy eligibility at 200 cells per μL or lower were located in the northwest quadrant of the cost-effectiveness plane (figure 5). The incremental cost per infection averted seemed to decrease with expanding eligibility for antiretroviral therapy, but we did not note any clear trend for the incremental cost per DALY averted (figure 5).

Bottom Line: 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.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-effectiveness ratios are less than 20% of South Africa's gross domestic product per person, and are therefore classed as very cost effective.

View Article: PubMed Central - PubMed

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 μL, $1090 at lower than 350 cells per μL, $1150 at lower than 500 cells per μL, 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-effectiveness 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.

Funding: National Institutes of Health, Bill & Melinda Gates Foundation, Wellcome Trust.

No MeSH data available.


Related in: MedlinePlus