HIV prevention cost-effectiveness: a systematic review

Abstract

BackgroundAfter more than 25 years, public health programs have not been able to sufficiently reduce the number of new HIV infections. Over 7,000 people become infected with HIV every day. Lack of convincing evidence of cost-effectiveness (CE) may be one of the reasons why implementation of effective programs is not occurring at sufficient scale. This paper identifies, summarizes and critiques the CE literature related to HIV-prevention interventions in low- and middle-income countries during 2005-2008.MethodsSystematic identification of publications was conducted through several methods: electronic databases, internet search of international organizations and major funding/implementing agencies, and journal browsing. Inclusion criteria included: HIV prevention intervention, year for publication (2005-2008), setting (low- and middle-income countries), and CE estimation (empirical or modeling) using outcomes in terms of cost per HIV infection averted and/or cost per disability-adjusted life year (DALY) or quality-adjusted life year (QALY).ResultsWe found 21 distinct studies analyzing the CE of HIV-prevention interventions published in the past four years (2005-2008). Seventeen CE studies analyzed biomedical interventions; only a few dealt with behavioral and environmental/structural interventions. Sixteen studies focused on sub-Saharan Africa, and only a handful on Asia, Latin America and Eastern Europe. Many HIV-prevention interventions are very cost effective in absolute terms (using costs per DALY averted), and also in country-specific relative terms (in cost per DALY measured as percentage of GDP per capita).ConclusionThere are several types of interventions for which CE studies are still not available or insufficient, including surveillance, abstinence, school-based education, universal precautions, prevention for positives and most structural interventions. The sparse CE evidence available is not easily comparable; thus, not very useful for decision making. More than 25 years into the AIDS epidemic and billions of dollars of spending later, there is still much work to be done both on costs and effectiveness to adequately inform HIV prevention planning.

Is there scope for cost savings and efficiency gains in HIV services? A systematic review of the evidence from low- and middle-income countries

“…Given the scarce financial resources available and competing donor priorities, methods to improve efficiency in the delivery of HIV services are gaining increased global attention. [3][4][5][6] In general, an "efficient" HIV service cannot be improved without the further use of existing resources and cannot be maintained at its current level with fewer resources. The word "efficiency" has several dimensions when applied to HIV services.…”

“…"Economies of scale" are the reductions in the unit cost of a service that might be achieved when the volume of that service's provision is increased, whereas "economies of scope" are the reductions in the unit cost of a service that might be observed when that service is provided jointly with other services. 3,4,[7][8][9][10][11][12] There have been several recent reviews of the data available on the costs and cost-effectiveness of HIV interventions. 3,4,[7][8][9][10][11][12][13] Most of these reviews were focused on allocative efficiency.…”

“…3,4,[7][8][9][10][11][12] There have been several recent reviews of the data available on the costs and cost-effectiveness of HIV interventions. 3,4,[7][8][9][10][11][12][13] Most of these reviews were focused on allocative efficiency. 3,4,7,9,12 The results of the few previous studies on the technical efficiency of HIV services indicate not only that there is considerable variation -between service providers and between settings -in the unit costs of providing similar HIV services, but also that there is, in general, much scope for improving the technical efficiency of HIV services.…”

A Systematic Review of Economic Aspects of Cervical Cancer Screening Strategies Worldwide: Discrepancy between Economic Analysis and Policymaking

“…A cost-effectiveness analysis (CEA) compares two or more alternative interventions based on the differences in their costs and effectiveness and some CEA studies can simulate final outcomes from current data (Galarraga et al, 2009). Cost in economic evaluation represents a measure of resources used in each strategy, and effectiveness is the health effect of strategies which can be measured both in clinical terms like sensitivity, and specificity of methods, or economic terms such as QALY (Hernandez et al, 2008).…”

Disease prevention and health promotion programs: benefits, implementation, quality assurance and open questions—a summary of the evidence

“…Therefore, despite years of high spending in an area such as HIV/AIDS prevention, and despite favorable results for some approaches such as for life skills training (Yankah and Aggleton 2008), inadequate progress has been made in this field. By 2008, only 21 stronger studies were available, including 17 on biomedical interventions and only a few on behavioral or structural interventions (Galarraga et al 2009). Methodologically inferior evaluations, however, usually underestimate the effects of interventions due to measurement imprecision (H. Thomas 2006).…”