Journal of General Internal Medicine

, Volume 28, Issue 10, pp 1294–1301 | Cite as

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

Original Research



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.


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


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


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


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


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


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.


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.


HIV epidemic mathematical model simulation cost-effectiveness analysis combination HIV prevention 



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.

Supplementary material

11606_2013_2417_MOESM1_ESM.pdf (287 kb)
ESM 1 (PDF 286 kb)


  1. 1.
    Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2013;380(9859):2095–2128.CrossRefGoogle Scholar
  2. 2.
    Salomon JA, Vos T, Hogan DR, et al. Common values in assessing health outcomes from disease and injury: disability weights measurement study for the Global Burden of Disease Study 2010. Lancet. 2013;380(9859):2129–2143.CrossRefGoogle Scholar
  3. 3.
    Wang H, Dwyer-Lindgren L, Lofgren KT, et al. Age-specific and sex-specific mortality in 187 countries, 1970-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2013;380(9859):2071–2094.CrossRefGoogle Scholar
  4. 4.
    Joint United Nations Programme on HIV/AIDS (UNAIDS). Report on the global AIDS epidemic. Geneva 2010.Google Scholar
  5. 5.
    Kates J, Boortz K, Lief E, Avila C, Bobet G. Financing the Response to AIDS in Low- and Middle-Income Countries: International Assistance from the G8, European Commission and Other Donor Governments in 2009, Washington, DC: Kaiser Family Foundation and UNAIDS; 2010.Google Scholar
  6. 6.
    Joint United Nations Programme on HIV/AIDS (UNAIDS). World AIDS Day Report. Geneva 2011.Google Scholar
  7. 7.
    Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med. 2005;2(11):e298.PubMedCrossRefGoogle Scholar
  8. 8.
    Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet. 2007;369(9562):643–656.PubMedCrossRefGoogle Scholar
  9. 9.
    Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet. 2007;369(9562):657–666.PubMedCrossRefGoogle Scholar
  10. 10.
    Siegfried N, Muller M, Deeks JJ, Volmink J. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane database of systematic reviews (Online). 2009(2):CD003362.Google Scholar
  11. 11.
    Abdool Karim Q, Abdool Karim SS, Frohlich JA, et al. Effectiveness and safety of tenofovir gel, an antiretroviral microbicide, for the prevention of HIV infection in women. Science. 2010;329(5996):1168–1174.PubMedCrossRefGoogle Scholar
  12. 12.
    Grant RM, Lama JR, Anderson PL, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med. 2010;363(27):2587–2599.PubMedCrossRefGoogle Scholar
  13. 13.
    Van Damme L, Corneli A, Ahmed K, et al. Preexposure prophylaxis for HIV infection among African women. N Engl J Med. 2012;367(5):411–422.PubMedCrossRefGoogle Scholar
  14. 14.
    Baeten JM, Donnell D, Ndase P, et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med. 2012;367(5):399–410.PubMedCrossRefGoogle Scholar
  15. 15.
    Thigpen MC, Kebaabetswe PM, Paxton LA, et al. Antiretroviral preexposure prophylaxis for heterosexual HIV transmission in Botswana. N Engl J Med. 2012;367(5):423–434.PubMedCrossRefGoogle Scholar
  16. 16.
    Hankins CA, de Zalduondo BO. Combination prevention: a deeper understanding of effective HIV prevention. AIDS. 2010;24(Suppl 4):S70–80.PubMedCrossRefGoogle Scholar
  17. 17.
    Kurth AE, Celum C, Baeten JM, Vermund SH, Wasserheit JN. Combination HIV prevention: significance, challenges, and opportunities. Curr HIV/AIDS Rep. 2011;8(1):62–72.PubMedCrossRefGoogle Scholar
  18. 18.
    Folkers GK, Fauci AS. Controlling and ultimately ending the HIV/AIDS pandemic: a feasible goal. JAMA. 2010;304(3):350–351.PubMedCrossRefGoogle Scholar
  19. 19.
    National Institute of Allergy and Infectious Diseases (NIAID). HIV Study Named 2011 Breakthrough of the Year by Science. 2011; Accessed January 25, 2013.
  20. 20.
    Excler JL, Rida W, Priddy F, et al. AIDS vaccines and preexposure prophylaxis: is synergy possible? AIDS Res Hum Retroviruses. 2011;27(6):669–680.PubMedCrossRefGoogle Scholar
  21. 21.
    Stover J, Bertozzi S, Gutierrez JP, et al. The global impact of scaling up HIV/AIDS prevention programs in low- and middle-income countries. Science. 2006;311(5766):1474–1476.PubMedCrossRefGoogle Scholar
  22. 22.
    Hogan DR, Baltussen R, Hayashi C, Lauer JA, Salomon JA. Cost effectiveness analysis of strategies to combat HIV/AIDS in developing countries. BMJ. 2005;331(7530):1431–1437.PubMedCrossRefGoogle Scholar
  23. 23.
    Salomon JA, Hogan DR, Stover J, et al. Integrating HIV prevention and treatment: from slogans to impact. PLoS Med. 2005;2(1):e16.PubMedCrossRefGoogle Scholar
  24. 24.
    Long EF, Brandeau ML, Owens DK. The cost-effectiveness and population outcomes of expanded HIV screening and antiretroviral treatment in the United States. Ann Intern Med. 2010;153:778–789.PubMedCrossRefGoogle Scholar
  25. 25.
    Hallett TB, Baeten JM, Heffron R, et al. Optimal Uses of Antiretrovirals for Prevention in HIV-1 Serodiscordant Heterosexual Couples in South Africa: A Modelling Study. PLoS Med. 2011;8(11):e1001123.PubMedCrossRefGoogle Scholar
  26. 26.
    Long EF, Brandeau ML, Owens DK. Potential population health outcomes and expenditures of HIV vaccination strategies in the United States. Vaccine. 2009;27(39):5402–5410.PubMedCrossRefGoogle Scholar
  27. 27.
    Gold MR, Siegel JE, Russell LB, Weinstein MC, eds. Cost-Effectiveness in Health and Medicine. New York: Oxford University Press; 1996.Google Scholar
  28. 28.
    Shisana O, Rehle T, Simbayi L, et al. South African national HIV prevalence, HIV incidence, behaviour and communication survey, 2008: A turning tide among teenagers? Cape Town: HSRC Press; 2009.Google Scholar
  29. 29.
    South Africa Department of Health. Country progress report on the Declaration of Commitment on HIV/AIDS. Pretoria: Department of Health; 2010.Google Scholar
  30. 30.
    World Health Organization Commission on Macroeconomics and Health. Macroeconomics and Health: Investing in Health for Economic Development. Geneva 2001.Google Scholar
  31. 31.
    Freedberg KA, Losina E, Weinstein MC, et al. The cost effectiveness of combination antiretroviral therapy for HIV disease. N Engl J Med. 2001;344(11):824–831.PubMedCrossRefGoogle Scholar
  32. 32.
    Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365(6):493–505.PubMedCrossRefGoogle Scholar
  33. 33.
    Cohen MS, Baden LR. Preexposure prophylaxis for HIV–where do we go from here? N Engl J Med. 2012;367(5):459–461.PubMedCrossRefGoogle Scholar
  34. 34.
    Shisana O, Rehle T, Simbayi L, et al. South African national HIV prevalence, HIV incidence, behaviour and communication survey, 2005. Cape Town: HSRC Press; 2005.Google Scholar
  35. 35.
    South Africa Department of Health, Medical Research Council. South Africa demographic and health survey 2003. Pretoria: Department of Health; 2007.Google Scholar

Copyright information

© Society of General Internal Medicine 2013

Authors and Affiliations

  1. 1.Yale School of ManagementNew HavenUSA
  2. 2.Yale School of MedicineNew HavenUSA

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