HIV testing and counselling couples together for affordable HIV prevention in Africa

Abstract

BackgroundThe impact and cost-effectiveness of couples’ voluntary HIV counselling and testing (CVCT) has not been quantified in real-world settings. We quantify cost-per-HIV-infection averted by CVCT in Zambia from the donor’s perspective.MethodsFrom 2010 to 2016, CVCT was established in 73 Zambian government clinics. The cost-per-HIV-infection averted (CHIA) of CVCT was calculated using observed expenditures and effectiveness over longitudinal follow-up. These observed measures parameterized hypothetical 5-year nationwide implementations of: ‘CVCT’; ‘treatment-as-prevention (TasP) for discordant couples’ identified by CVCT; and ‘population TasP’ for all HIV+ cohabiting persons identified by individual testing.ResultsIn all, 207 428 couples were tested (US $52/couple). Among discordant couples in which HIV+ partners self-reported antiretroviral therapy (ART), HIV incidence was 8.5/100 person-years before and 1.8/100 person-years after CVCT (79% reduction). Corresponding reductions for non-ART-using discordant and concordant negative couples were 63% and 47%, respectively. CVCT averted an estimated 58% of new infections at US $659 CHIA. In nationwide implementation models, CVCT would prevent 17 times the number of infections vs ‘TasP for discordant couples’ at 86% of the cost, and nine times the infections vs ‘population TasP’ at 28% of the cost.ConclusionsCVCT is a cost-effective, feasible prevention strategy in Zambia. We demonstrate the novel, added effectiveness of providing CVCT to ART users, for whom ART use alone only partially mitigated transmission risk. Our results indicate a major policy shift (supporting development of CVCT indicators, budgets and targets) and have clinical implications (suggesting promotion of CVCT in ART clinics as a high-impact prevention strategy).

Cost-effectiveness of HIV Prevention Interventions in Sub-Saharan Africa: A Systematic Review

“…1). These 60 peer-reviewed studies provided cost-effectiveness results for the following HIV prevention interventions: 14 studies on VMMC, 13 studies on PrEP, five studies on TasP, 15 studies on PMTCT, nine studies on other biomedical interventions, one study on behaviour change, and three studies on structural interventions [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45], [46], [47], [48], [49], [50], [51], [52], [53], [54], [55], [56], [57], [58], [59], [60], [61], [62], [63], [64], [65], [66], [67], [68], [69], [70], [71], [72], [73], [74]. Among PMTCT studies, 14 considered Prong III strategies, while one focused on Prong II.

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A couple-focused, integrated unplanned pregnancy and HIV prevention program in urban and rural Zambia

“…From the literature and from World Health Organization Guidelines, 26 we ajog.org GYNECOLOGY Original Research know that CVCT on its own is an effective HIV prevention intervention 14,27 and that fertility goal-based counseling can increase the uptake of LARC methods among couples. 28 When integrated in our 3 year program, CVCT plus CFPC and LARC averted an estimated 12,847 urban and 8279 rural HIV infections and 98,626 urban unplanned pregnancies.…”

“…The number of HIV infections averted by the program were calculated as described in detail by Wall et al 14 Briefly, to estimate heterosexual HIV prevention, a compartmental mathematical model was developed using HIV incidence observed in 207, 428 concordant HIV-negative and discordant couples before and after CVCT in Zambian clinics and stratifying by antiretroviral therapy use in the HIVpositive partner in discordant couples. To calculate perinatal HIV infections averted, we used the HIV prevalence (17%) among women in clinics, the perinatal transmission rate (5%), and the percentage of pregnancies resulting in live births (53%) in Zambia.…”

“…8 Couples voluntary HIV counseling and testing (CVCT) is an effective HIV prevention strategy that increases the knowledge of partner status, reduces risky sexual behavior, and prevents sexually transmitted infections. 9e13 In Zambia, CVCT has been shown to reduce 58% of new HIV infections when implemented in government clinics, 14 and the impact is sustained. 15 Integrating CVCT with family-planning services enables male involvement in the decision-making process, which could increase uptake and limit discontinuation of contraception methods.…”

A cluster randomized trial to reduce HIV risk from outside partnerships in Zambian HIV-Negative couples using a novel behavioral intervention, “Strengthening Our Vows”: Study protocol and baseline data

“…Though the DC remained at comparatively higher risk (1.78/100 Couple-Years HIV incidence after CVCT + condoms + ART) than the CNC (0.53/100 CY), the CNC were a much larger percentage of all couples. As a result, 47% of the new infections that occurred after CVCT were in CNC and 53% were in DC [ 5 ].…”