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Portfolios of Biomedical HIV Interventions in South Africa: A Cost-Effectiveness Analysis

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A Capsule Commentary to this article was published on 17 July 2013

ABSTRACT

BACKGROUND

Recent clinical trials of male circumcision, oral pre-exposure prophylaxis (PrEP), and a vaginal microbicide gel have shown partial effectiveness at reducing HIV transmission, stimulating interest in implementing portfolios of biomedical prevention programs.

OBJECTIVE

To evaluate the effectiveness and cost-effectiveness of combination biomedical HIV prevention and treatment scale-up in South Africa, given uncertainty in program effectiveness.

DESIGN

Dynamic HIV transmission and disease progression model with Monte Carlo simulation and cost-effectiveness analysis.

PARTICIPANTS

Men and women aged 15 to 49 years in South Africa.

INTERVENTIONS

HIV screening and counseling, antiretroviral therapy (ART), male circumcision, PrEP, microbicide, and select combinations.

MAIN MEASURES

HIV incidence, prevalence, discounted costs, discounted quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios.

KEY RESULTS

Providing half of all uninfected persons with PrEP averts 28 % of future HIV infections for $9,000/QALY gained, but the affordability of such a program is questionable. Given limited resources, annual HIV screening and ART utilization by 75 % of eligible infected persons could avert one-third of new HIV infections, for approximately $1,000/QALY gained. Male circumcision is more cost-effective, but disproportionately benefits men. A comprehensive portfolio of expanded screening, ART, male circumcision, microbicides, and PrEP could avert 62 % of new HIV infections, reducing HIV prevalence from a projected 14 % to 10 % after 10 years. This strategy doubles treatment initiation and adds 31 million QALYs to the population. Despite uncertainty in program effectiveness, a comprehensive portfolio costs less than $10,000/QALY gained in 33 % of simulation iterations and less than $30,000/QALY gained in 90 % of iterations, assuming an annual microbicide cost of $100.

CONCLUSIONS

A portfolio of modestly-effective biomedical HIV prevention programs, including male circumcision, vaginal microbicides, and oral PrEP, could substantially reduce HIV incidence and prevalence in South Africa and be likely cost-effective. Given limited resources, PrEP is the least cost-effective intervention of those considered.

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Acknowledgements

We wish to thank Margaret Brandeau and Edward Kaplan for their valuable suggestions for improving the manuscript. This study was supported in part by a grant from the National Institute on Drug Abuse (R01-DA15612). An earlier version of this paper was presented at the Society for Medical Decision Making Annual Meeting in October 2011.

Conflicts Of Interest

The authors declare that they have no conflicts of interest.

Author Contributions

Elisa F. Long: study design, model building and coding, data analysis, data interpretation, writing of the manuscript.

Robert R. Stavert: literature search, data collection, data analysis.

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Authors and Affiliations

  1. Yale School of Management, 135 Prospect Street, New Haven, CT, 06520, USA

    Elisa F. Long PhD

  2. Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA

    Robert R. Stavert MD, MBA

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  1. Elisa F. Long PhD
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Correspondence to Elisa F. Long PhD.

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Long, E.F., Stavert, R.R. Portfolios of Biomedical HIV Interventions in South Africa: A Cost-Effectiveness Analysis. J GEN INTERN MED 28, 1294–1301 (2013). https://doi.org/10.1007/s11606-013-2417-1

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