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

Abstract

SummaryBackgroundHome 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.MethodsWe 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.FindingsThe 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.InterpretationCommunity-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.FundingNational Institutes of Health, Bill & Melinda Gates Foundation, Wellcome Trust.

Factor Influencing HIV Care Continuum among People Living with HIV in Western Kenya

“…Therefore, effective HIV treatment and prevention programs requires that HIV counseling and testing (HTC) services and linkages of patients to HIV care and support to reduce HIV associated morbidity and mortality [4], especially in sub-Saharan Africa where 1.5 million cases of new HIV infection occur annually [5,6]. However, in this region only a third of adults have tested for HIV and even among those who have tested positive only a few are on ART [4,7].…”

“…However, in this region only a third of adults have tested for HIV and even among those who have tested positive only a few are on ART [4,7]. This has been attributed to poor linkage to care following HIV testing [8][9][10].…”

“…Human immunodeficiency virus testing coverage varies between countries and even within countries [4,11]. For example, HIV testing coverage in Kenya in men is around 36% while for women it is around 47% and there has been a steady increase for adults tested for HIV from 860,000 in 2008 to 6.4 million in 2013 [12].…”

“…For example, HIV testing coverage in Kenya in men is around 36% while for women it is around 47% and there has been a steady increase for adults tested for HIV from 860,000 in 2008 to 6.4 million in 2013 [12]. However, national coverage may mask intra-county variation in uptake of HTC [4]. Therefore, to achieve widespread testing and initiation into antiretroviral therapy, there is a need to overcome challenges associated with low HTC uptake like economic costs to patients in terms of transportation, waiting time, concerns about confidentiality, low perceived risk of HIV infection and policy on eligibility to antiretroviral therapy [13].…”

“…Even though scaling up of ART has greatly reduced HIV associated mortality [4,19]. The mortality rates are still considerably higher in poor resource countries relative to more industrialized nations partly due to late initiation into ART therapy [7].…”