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A Review of the Cost-Effectiveness of Interventions to Prevent Sexual Transmission of HIV in the United States

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Abstract

Because resources to fund HIV prevention are limited, public health decision makers—such as health departments and HIV prevention community planning groups—need to know which prevention strategies are the most cost-effective. In the past several years, a number of studies have appeared in the literature that assess the cost-effectiveness of interventions to prevent the sexual transmission of HIV in the United States. Here, we comprehensively review 16 such studies and then outline an agenda for further research to advance the cost-effectiveness literature and to make the findings of these studies more useful for public health decision makers. The research summarized here provides compelling evidence that interventions to prevent sexual transmission of HIV can be highly cost-effective. Small-group, community-level, and outreach-based sexual risk reduction interventions, in particular, appear to be very efficient strategies for preventing the spread of HIV in moderate- to high-risk populations.

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REFERENCES

  • Allard, R. (1990a). A family of mathematical models to describe the risk of infection by a sexually transmitted agent. Epidemiology, 1, 30-33.

    Google Scholar 

  • Allard, R. (1990b). A mathematical model to describe the risk of infection from sharing injection equipment. Journal of Acquired Immune Deficiency Syndromes, 3, 1010-1016.

    Google Scholar 

  • Bedimo, A. L., Pinkerton, S. D., Cohen, D. A., Gray, B., and Farley, T. A. (in press). Cost-savings of a condom social marketing program. International Journal of STD and AIDS.

  • Brandeau, M. L., Owens, D. K., Sox, C. H., and Wachter, R. M. (1993). Screening women of childbearing age for human immunodeficiency virus:Amodel-based policy analysis. Management Science, 39, 72-92.

    Google Scholar 

  • Brown, B. S., and Beschner, G. M. (Eds.). (1993). Handbook of risk of AIDS: Injection drug users and sexual partners. Westport, CT: Greenwood.

    Google Scholar 

  • Centers for Disease Control. (1995). Case-control study of HIV seroconversion in health-care workers after percutaneous exposure to HIV-infected blood-France, United Kingdom, and United States, January 1988-August 1994. Morbidity and Mortality Weekly Report, 44, 929-933.

    Google Scholar 

  • Centers for Disease Control and Prevention. (1999). HIV/AIDS Surveillance Report, 11, 1-44.

    Google Scholar 

  • Choi, K. H., and Coates, T. J. (1994). Prevention of HIV infection. AIDS, 8, 1371-1389.

    Google Scholar 

  • Cohen, D. A., Farley, T. A., Bedimo-Etame, J. R., Scribner, R., Ward, W., Kendall, C., and Rice, J. (1999). Implementation of a condom social marketing program in Louisiana, 1993 to 1996. American Journal of Public Health, 89, 204-208.

    Google Scholar 

  • Coyle, S. L., Needle, R. H., and Normand, J. (1998). Outreach-based HIVprevention for injecting drug users:Areview of published outcome data. Public Health Reports, 113(Suppl. 1), 19-30.

    Google Scholar 

  • Drummond, M. F., O'Brien, B., Stoddart, G. L., and Torrance, G. W. (1997). Methods for the economic evaluation of health care programmes (2nd ed.). New York: Oxford University Press.

    Google Scholar 

  • Fabian, R. (1994). The QUALY approach. In G. Tolley, D. Kenkel, and R. Fabian (Eds.), Valuing health for policy: An economic approach (pp. 118-136). Chicago: University of Chicago Press.

    Google Scholar 

  • Farnham, P. G. (1998). Economic evaluation of HIV counseling and testing programs. The influence of program goals on evaluation. In D. R. Holtgrave (Ed.), Handbook of economic evaluation of HIV prevention programs (pp. 63-79). New York: Plenum.

    Google Scholar 

  • Farnham, P. G., Pinkerton, S. D., Holtgrave, D. R., and Johnson-Masotti, A. P. (2002). Cost-effectiveness of counseling and testing to prevent sexual transmission of HIV in the United States. AIDS and Behavior, 6, 33-43.

    Google Scholar 

  • Ganiats, T. G., and Wong, A. F. (1991). Evaluation of costeffectiveness research:Asurvey of recent publications. Family Medicine, 23, 457-462.

    Google Scholar 

  • Gold, M. R., Siegel, J. E., Russell, L.B., and Weinstein, M. C. (Eds.). (1996). Cost-effectiveness in health and medicine. New York: Oxford University Press.

    Google Scholar 

  • Gorsky, R. D., Haddix, A. C., and Shaffer, P. A. (1996). Cost of an intervention. In A. C. Haddix, S. M. Teutsch, P. A. Shaffer, and D. O. Duñet (Eds.), Prevention effectiveness: A guide to decision analysis and economic evaluation (pp. 57-75). New York: Oxford University Press.

    Google Scholar 

  • Guinan, M. E., Farnham, P. G., and Holtgrave, D. R. (1994). Estimating the value of preventing a human immunodeficiency virus infection. American Journal of Preventive Medicine, 10, 1-4.

    Google Scholar 

  • Haddix, A. C., Teutsch, S. M., Shaffer, P. A., and Duñet, D. O. (Eds.). (1996). Prevention effectiveness: A guide to decision analysis and economic evaluation. New York: Oxford University Press.

    Google Scholar 

  • Higgins, D. L., Galavotti, C., O'Reilly, K. R., Schnell, D. J., Moore, M., Rugg, D. L., and Johnson, R. (1991). Evidence for the effects of HIV antibody counseling and testing on risk behaviors. Journal of the American Medical Association, 266, 2419-2429.

    Google Scholar 

  • Holtgrave, D. R. (1994a). Cost analysis and HIV prevention programs. American Psychologist, 49, 1088-1089.

    Google Scholar 

  • Holtgrave, D. R. (1994b). Setting priorities and community planning for HIV-prevention programs. AIDS & Public Policy Journal, 9, 145-151.

    Google Scholar 

  • Holtgrave, D. R. (1998). The cost-effectiveness of the components of a comprehensive HIV prevention program. In D. R. Holtgrave (Ed.), Handbook of economic evaluation of HIV prevention programs (pp. 127-134). New York: Plenum.

    Google Scholar 

  • Holtgrave, D. R., and Kelly, J. A. (1996). Preventing HIV/AIDS among high-risk urban women: The cost-effectiveness of a behavioral group intervention. American Journal of Public Health, 86, 1442-1445.

    Google Scholar 

  • Holtgrave, D. R., and Kelly, J. A. (1997). Cost-effectiveness of an HIV/AIDS prevention intervention for gay men. AIDS and Behavior, 1, 173-180.

    Google Scholar 

  • Holtgrave, D. R., and Pinkerton, S. D. (1997). Updates of cost of illness and quality of life estimates for use in economic evaluations of HIV prevention programs. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, 16, 54-62.

    Google Scholar 

  • Holtgrave, D. R., and Pinkerton, S. D. (1998). The cost-effectiveness of small group and community-level interventions. In D. R. Holtgrave (Ed.), Handbook of economic evaluation of HIV prevention programs (pp. 120-127). New York: Plenum.

    Google Scholar 

  • Holtgrave, D. R., and Pinkerton, S. D. (2001). Implications of economic evaluations for national HIV prevention policy makers. In E. H. Kaplan and R. Brookmeyer (Eds.), Quantitative evaluation of HIV prevention programs (pp. 32-54). New York: Oxford University Press.

    Google Scholar 

  • Holtgrave, D. R., and Qualls, N. L. (1995). Threshold analysis and programs for prevention of HIV infection. Medical Decision Making, 15, 311-317.

    Google Scholar 

  • Holtgrave, D. R., Qualls, N. L., Curran, J. W., Valdiserri, R. O., Guinan, M. E., and Parra, W. C. (1995). An overview of the effectiveness and efficiency of HIV prevention programs. Public Health Reports, 110, 134-146.

    Google Scholar 

  • Holtgrave, D. R., Qualls, N. L., and Graham, J. D. (1996). Economic evaluation of HIV prevention programs. Annual Review of Public Health, 17, 467-488.

    Google Scholar 

  • Hughes, D., and Morris, S. (1996). The cost-effectiveness of condoms in the prevention of HIV infection in England and Wales: Should condoms be available on prescription? Journal of Health Services Research and Policy, 1, 205-211.

    Google Scholar 

  • Ickovics, J., Morrill, A., Beren, S., Walsh, U., and Rodin, J. (1994). Limited effects of HIV counseling and testing for women. Journal of the American Medical Association, 272, 443-448.

    Google Scholar 

  • Institute of Medicine Committee on HIV Prevention Strategies in the United States. (2000). No time to lose-getting more from HIV prevention. Washington, DC: National Academy Press.

    Google Scholar 

  • Jemmott, J. B. III, Jemmott, L. S., and Fong, G. T. (1992). Reductions in HIV risk-associated sexual behaviors among black male adolescents: Effects of an AIDS prevention intervention. American Journal of Public Health, 82, 372-377.

    Google Scholar 

  • Johnson-Masotti, A. P., Pinkerton, S. D., and Holtgrave, D. R. (2000a). Prioritization methods for HIV prevention community planning. Journal of Public Health Management and Practice, 6, 72-85.

    Google Scholar 

  • Johnson-Masotti, A. P., Pinkerton, S. D., Kelly, J. A., and Stevenson, L. Y. (2000b). Cost-effectiveness of an HIV risk reduction intervention for adults with severe mental illness. AIDS Care, 12, 321-332.

    Google Scholar 

  • Kahn, J. G. (1996). The cost-effectiveness of HIV prevention targeting: How much more bang for the buck? American Journal of Public Health, 86, 1709-1712.

    Google Scholar 

  • Kahn, J. G., and Haynes-Sanstad, K. C. (1997). The role of costeffectiveness analysis in assessing HIV-prevention interventions. AIDS and Public Policy Journal, 12, 21-30.

    Google Scholar 

  • Kahn, J. G., Washington, A. E., Showstack, J. A., Berlin, M., Phillips, K., and Watson, S. (1992). Updated estimates of the impact and cost of HIVprevention in injection drug users (Report prepared for the Centers for Disease Control). San Francisco: Institute for Health Policy Studies, University of California.

    Google Scholar 

  • Kaplan, E. H. (1989a). What are the risks of risky sex? Modeling the AIDS epidemic. Operations Research, 37, 198-209.

    Google Scholar 

  • Kaplan, E. H. (1989b). Needles that kill: Modeling human immunodeficiency virus transmission via shared drug injection equipment in shooting galleries. Reviews of Infectious Diseases, 11, 289-298.

    Google Scholar 

  • Kaplan, R. M., and Bush, J. W. (1982). Health-related quality of life measurement for evaluation research and policy analysis. Health Psychology, 1, 61-80.

    Google Scholar 

  • Katz, M. H., and Gerberding, J. L. (1997). Postexposure treatment of people exposed to the human immunodeficiency virus through sexual contact or injection-drug use. New England Journal of Medicine, 336, 1097-1100.

    Google Scholar 

  • Katz, M. H., and Gerberding, J. L. (1998a). Guidelines for postexposure prophylaxis (PEP) after sexual and drug exposures to HIV. San Francisco: San Francisco Department of Health/San Francisco General Hospital.

    Google Scholar 

  • Katz, M. H., and Gerberding, J. L. (1998b). The care of persons with recent sexual exposure to HIV. Annals of Internal Medicine, 128, 306-312.

    Google Scholar 

  • Kelly, J. A., McAuliffe, T. L., Sikkema, K. J., Murphy, D. A., Somlai, A. M., Mulry, G., Miller, J. G., Stevenson, L. Y., and Fernandez, M. I. (1997). Reduction in risk behavior among adults with severe mental illness who learn to advocate for HIV prevention. Psychiatric Services, 48, 1283-12188.

    Google Scholar 

  • Kelly, J. A., Murphy, D. A., Sikkema, K. J., and Kalichman, S. C. (1993). Psychological interventions to prevent HIV infection are urgently needed: New priorities for behavioral research in the second decade of AIDS. American Psychologist, 48, 1023-1034.

    Google Scholar 

  • Kelly, J. A., Murphy, D. A., Washington, C. D., Wilson, T. S., Koob, J. J., Davis, D. R., Ledezma, G., and Davantes, B. (1994). The effect of HIV/AIDS intervention groups for high-risk women in urban clinics. American Journal of Public Health, 84, 1918-1922.

    Google Scholar 

  • Kelly, J. A., St. Lawrence, J. S., Diaz, Y. E., Stevenson, L. Y., Hauth, A. C., Brasfield, T. L., Kalichman, S. C., Smith, J. E., and Andrew, M. E. (1991). HIV risk behavior reduction following intervention with key opinion leaders of population: An experimental analysis. American Journal of Public Health, 81, 168-171.

    Google Scholar 

  • Kelly, J. A., St. Lawrence, J. S., Hood, H. V., and Brasfield, T. L. (1989). Behavioral intervention to reduce AIDS risk activities. Journal of Consulting and Clinical Psychology, 57, 60-67.

    Google Scholar 

  • Lurie, P., Miller, S., Hecht, F., Chesney, M., and Lo, B. (1998). Postexposure prophylaxis after nonoccupational HIV exposure. Journal of the American Medical Association, 280, 1769-1773.

    Google Scholar 

  • National Institutes of Health. (1997). Consensus development conference statement on interventions to prevent HIV risk behavior. Bethesda, MD: NIH Office on Medical Applications of Research.

    Google Scholar 

  • NIMH Multisite HIV Prevention Trial. (1997a). Methodological overview of a multisite HIV prevention trial for populations at risk for HIV. AIDS, 11(Suppl. 2), S1-S11.

    Google Scholar 

  • NIMH Multisite HIV Prevention Trial. (1997b). Conceptual basis and procedures for the intervention in a multisite HIV prevention trial. AIDS, 11(Suppl. 2), S29-S35.

    Google Scholar 

  • NIMH Multisite HIV Prevention Trial Group. (1998). The NIMH Multisite HIV Prevention Trial: Reducing HIV sexual risk behavior. Science, 280, 1889-1894.

    Google Scholar 

  • Norton, E. C., Martin, R. F., and Wechsberg, W. M. (1998). Threshold analysis of AIDS outreach and intervention. In D. R. Holtgrave (Ed.), Handbook of economic evaluation of HIV prevention programs (pp. 195-209). New York: Plenum.

    Google Scholar 

  • Otto-Salaj, L. L., Kelly, J. A., Stevenson, L. Y., Hoffmann, R., and Kalichman, S. C. (2000). Outcomes of a randomized smallgroup HIV prevention intervention trial for people with serious mental illness. Community Mental Health Journal, 37, 123-144.

    Google Scholar 

  • Owens, D. K. (1998). Interpretation of cost-effectiveness analyses. Journal of General Internal Medicine, 13, 716-717.

    Google Scholar 

  • Paltiel, A. D., and Stinnett, A. A. (1998). Resource allocation and the funding of HIV prevention. D. R. Holtgrave (Ed.), Handbook of economic evaluation of HIV prevention programs(pp. 135-152). New York: Plenum.

    Google Scholar 

  • Patrick, D. L., and Erikson,P. (1993). Health status and health policy: Allocating resources to health care. New York: Oxford University Press.

    Google Scholar 

  • Peterson, J. L., and DiClemente, R. J. (2000). Handbook of HIV prevention. New York: Kluwer Academic.

    Google Scholar 

  • Pinkerton, S. D., and Abramson, P. R. (1998).The Bernoulli-process model of HIV transmission: Applications and implications. In D. R. Holtgrave (Ed.), Handbook of economic evaluation of HIV prevention programs (pp. 13-32). New York: Plenum.

    Google Scholar 

  • Pinkerton, S. D., Abramson, P. R., and Holtgrave, D. R. (1999). What is a condom worth? AIDS and Behavior, 3, 301-312.

    Google Scholar 

  • Pinkerton, S. D., and Holtgrave, D. R. (1998a). A method for evaluating the economic efficiency of HIV behavioral risk reduction interventions. AIDS and Behavior, 2, 189-201.

    Google Scholar 

  • Pinkerton, S. D., and Holtgrave, D. R. (1998b). Assessing the cost-effectiveness of HIV prevention interventions. In D. R. Holtgrave (Ed.), Handbook of economic evaluation of HIV prevention programs (pp. 34-44). New York: Plenum.

    Google Scholar 

  • Pinkerton, S. D., and Holtgrave, D. R. (2000). How HIV treatment advances affect the cost-effectiveness of prevention. Medical Decision Making, 20, 89-94.

    Google Scholar 

  • Pinkerton, S. D., Holtgrave, D. R., and Bloom, F. R. (1997b). Postexposure treatment of HIV. New England Journal of Medicine, 337, 500-501.

    Google Scholar 

  • Pinkerton, S. D., Holtgrave, D. R., and Bloom, F. R. (1998e). Costeffectiveness of postexposure prophylaxis following sexual exposure to HIV. AIDS, 12, 1067-1078.

    Google Scholar 

  • Pinkerton, S. D., Holtgrave, D. R., DiFranceisco, W., Semaan, S., Coyle, S. L., and Johnson-Masotti, A. P. (2000a). Cost-threshold analyses of the National AIDS Demonstration Research HIV prevention interventions. AIDS, 14, 1257-1268.

    Google Scholar 

  • Pinkerton, S. D., Holtgrave, D. R., DiFranceisco, W. J., Stevenson, L. Y., and Kelly, J. A. (1998c). Cost-effectiveness of a community-level HIV risk reduction intervention. American Journal of Public Health, 88, 1239-1242.

    Google Scholar 

  • Pinkerton, S. D., Holtgrave, D. R., DiFranceisco, W. J., Stevenson, L. Y., and Kelly, J. A. (1998d). Cost-effectiveness of a community-level HIV prevention intervention research trial. In D. R. Holtgrave (Ed.), Handbook of economic evaluation of HIV prevention programs (pp. 243-260). New York: Plenum.

    Google Scholar 

  • Pinkerton, S. D., Holtgrave, D. R., and Jemmott, J. B. (2000b). Economic analysis of an HIV risk reduction intervention for male African American adolescents. Journal of Acquired Immune Deficiency Syndromes, 25, 164-172.

    Google Scholar 

  • Pinkerton, S. D., Holtgrave, D. R., Johnson-Masotti, A. P., Turk, M. E., Hackl, K. L., DiFranceisco, W., and the NIMH Multisite HIV Prevention Trial Group. (2002). Cost-effectiveness of the NIMH Multisite HIV Prevention Intervention. AIDS and Behavior, 6, 83-96.

    Google Scholar 

  • Pinkerton, S. D., Holtgrave, D. R., Leviton, L. C., Wagstaff, D. A., and Abramson, P. R. (1998b). Model-based evaluation of HIV prevention interventions. Evaluation Review, 22, 155-174.

    Google Scholar 

  • Pinkerton, S. D., Holtgrave, D. R., and Valdiserri, R. O. (1997a). Cost-effectiveness of HIV-prevention skills training for men who have sex with men. AIDS, 11, 347-357.

    Google Scholar 

  • Pinkerton, S. D., Holtgrave, D. R., Willingham, M., and Goldstein, E. (1998a). Cost-effectiveness analysis and HIV prevention community planning. AIDSand PublicPolicy Journal, 13, 115-127.

    Google Scholar 

  • Pinkerton, S. D., Johnson-Masotti, A. P., Otto-Salaj, L. L., Stevenson, L. Y., and Hoffmann, R. G. (2001b). Cost-effectiveness of an HIV risk reduction intervention for mentally ill adults. Mental Health Services Research, 3, 45-55.

    Google Scholar 

  • Pinkerton, S. D., Johnson-Masotti, A. P., Holtgrave, D. R., and Farnham, P. G. (2001a). Using cost-effectiveness league tables to compare interventions to prevent sexual transmission of HIV. AIDS, 15, 917-928.

    Google Scholar 

  • Pinkerton, S. D., Kahn, J. G., and Holtgrave, D. R. (in press). Cost-effectiveness of community-level approaches to HIV prevention: A review. Journal of Primary Prevention.

  • Rehle, T. M., Saidel, T. J., Hassig, S. E., Bouey, P. D., Gaillard, E. M., and Sokal, D. C. (1998). AVERT: A user-friendly model to estimate the impact of HIV/sexually transmitted disease prevention programs on HIV transmission. AIDS, 12(Suppl. 2), S27-S35.

    Google Scholar 

  • Remafedi, G. (1994). Cognitive and behavioral adaptation to HIV/AIDS among gay and bisexual adolescents. Journal of Adolescent Health, 15, 142-148.

    Google Scholar 

  • Schrappe, M., and Lauterbach, K. (1998). Systematic review on the cost-effectiveness of public health interventions for HIV prevention in industrialized countries. AIDS, 12(Suppl. A), S231-S238.

    Google Scholar 

  • Shriver, M. (1998). Postexposure prophylaxis: A community member's perspective. In D. O. Ostrow and S. C. Kalichman (Eds.), Psychosocial and public health impacts of new HIV therapies (pp. 171-182). New York: Plenum.

    Google Scholar 

  • Tao, G., and Remafedi, G. (1998). Economic evaluation of an HIV prevention intervention for gay and bisexual male adolescents. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, 17, 83-90.

    Google Scholar 

  • Tengs, T. O., Adams, M. E., Pliskin, J. S., Safran, D. G., Siegel, J. E., Weinstein, M. C., and Graham, J. D. (1995). Five-hundred life-saving interventions and their cost-effectiveness. Risk Analysis, 15, 369-390.

    Google Scholar 

  • Valdiserri, R. O., Aultman, T. V., and Curaan, J. W. (1995). Community Planning: A national strategy to improve HIV prevention programs. Journal of Community Health, 20, 87-99.

    Google Scholar 

  • Valdiserri, R. O., Lyter, D. W., Leviton, L. C., Callahan, C. M., Kingsley, L. A., and Rinaldo, C. R. (1989). AIDS prevention in homosexual and bisexual men: Results of a randomized trial evaluating two risk reduction interventions. AIDS, 3, 21-26.

    Google Scholar 

  • Weinhardt, L. S., Carey, M. P., Johnson, B. T., and Bickham, N. L. (1999). Effect of HIV counseling and testing on sexual risk behavior:Ameta-analytic review of published research, 1985-1997. American Journal of Public Health, 89, 1397-1405.

    Google Scholar 

  • Weinstein, M. C., Graham, J. D., Siegel, J. E., and Fineberg, H. V. (1989). Cost-effectiveness analysis of AIDS prevention programs: Concepts, complications, and illustrations. In C. F. Turner, H. G. Miller, and L. E. Moses (Eds.), AIDS: Sexual behavior and intravenous drug use (pp. 471-499). Washington, DC: National Academy Press.

    Google Scholar 

  • Winkler, M. A. (1999). The need for concrete improvement in abstract quality. Journal of the American Medical Association, 281, 1129-1130.

    Google Scholar 

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Pinkerton, S.D., Johnson-Masotti, A.P., Holtgrave, D.R. et al. A Review of the Cost-Effectiveness of Interventions to Prevent Sexual Transmission of HIV in the United States. AIDS Behav 6, 15–31 (2002). https://doi.org/10.1023/A:1014572427706

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