Cost-effectiveness of community-based strategies for HIV
Authors: Laith J Abu-Raddad
Journal: The Lancet HIV (2015)

In 2013, 2·1 million people became infected with HIV, 1·5 million died from AIDS, and 35 million continued to live with HIV infection,1UNAIDSThe Gap Report.http://www.unaids.org/sites/default/files/en/media/unaids/contentassets/documents/unaidspublication/2014/UNAIDS_Gap_report_en.pdfGoogle Scholar despite the existence of highly effective interventions (eg, antiretroviral therapy) that can reduce HIV transmission by 96%.2Cohen MS Chen YQ McCauley M et al.Prevention of HIV-1 infection with early antiretroviral therapy.N Engl J Med. 2011; 365: 493-505Crossref PubMed Scopus (5469) Google Scholar An AIDS-free generation is no longer a theoretical conjecture, but it is not the reality either. In The Lancet HIV, Jennifer Smith and colleagues3Smith JA Sharma M Levin C et al.Cost-effectiveness of community-based strategies to strengthen the continuum of HIV care in rural South Africa: a health economic modelling analysis.Lancet HIV. 2015; (published online Feb 24.)http://dx.doi.org/10.1016/S2352-3018(15)00016-8Google Scholar provide an insightful analysis into how this goal might be achieved. Clinical trials of HIV prevention strategies are designed to be shielded from many factors; one possible cause for the failure to eliminate HIV is underappreciation that these factors can affect the implementation of such strategies in non-trial contexts, undermining the ability of trials to predict effectiveness in the real world. A successful trial therefore is just an initial step in a process to build a scientific understanding of how an intervention can be implemented in real contexts to alleviate HIV burden. Through a series of studies culminating in this analysis, Smith and colleagues' research team has filled a major knowledge gap by translating the measured efficacy of antiretroviral therapy (the most promising HIV intervention) into a viable and cost-effective community-based strategy to control HIV and its disease burden. The line of evidence started with observational studies establishing that community-based home HIV testing and counselling (HTC) is feasible to achieve high coverage of HIV testing, point-of-care CD4 count testing, linkage to care, antiretroviral therapy initiation, and viral suppression.4Barnabas RV van Rooyen H Tumwesigye E et al.Initiation of antiretroviral therapy and viral suppression after home HIV testing and counselling in KwaZulu-Natal, South Africa, and Mbarara district, Uganda: a prospective, observational intervention study.Lancet HIV. 2014; 1: e68-e76Summary Full Text Full Text PDF PubMed Scopus (73) Google Scholar, 5van Rooyen H Barnabas RV Baeten JM et al.High HIV testing uptake and linkage to care in a novel program of home-based HIV counseling and testing with facilitated referral in KwaZulu-Natal, South Africa.J Acquir Immune Defic Syndr. 2013; 64: e1-e8Crossref PubMed Scopus (120) Google Scholar Detailed field work allowed the investigators to collect data about demographic characteristics, behaviour, CD4 cell count distribution, care before initiation of antiretroviral therapy, and treatment uptake. Although these observational studies established the feasibility of this approach, they raised questions about cost-effectiveness and cost implications of community-based HTC. The team proceeded to do a microcosting study from a provider perspective, and collected comprehensive real-world costing data. With this accumulation of community-based evidence, they were in position to build an individual-based mathematical model grounded in realism to assess the population-level effect and cost-effectiveness of this intervention strategy. The investigators used population-level viral suppression after the intervention as a biomarker for adherence to antiretroviral therapy, and were able to estimate the effect of the intervention on HIV incidence. Their findings are remarkable: the intervention was very cost-effective at all eligibility criteria for antiretroviral therapy, and the model's findings suggested that it could help to achieve ambitious targets for incidence reduction and treatment, thereby reducing morbidity, mortality, and onwards transmission of HIV. The costs were driven mainly by drug prices; through reduction of these prices, which are higher in South Africa than in the rest of Africa, the intervention would be more cost effective. These results are encouraging, but the public health effect might actually have been underestimated. Smith and colleagues used a short time horizon (a decade), with most of the effect tilted towards incidence reduction rather than prevention of morbidity and mortality. The long-term effects of the intervention are thus likely to be more favourable than this analysis suggests. In short, community-based HTC is a viable and cost-effective strategy. The UNAIDS 90-90-90 treatment targets by 20206UNAIDS90-90-90 An ambitious treatment target to help end the AIDS epidemic.http://www.unaids.org/sites/default/files/media_asset/90-90-90_en_0.pdfGoogle Scholar are ambitious, but probably not far from what could be achieved in actual communities in at least parts of Africa. This line of studies provided an excellent example of implementation science that takes a new intervention and uses it in communities. The relevance of this approach could go beyond HIV to other global health challenges.7El-Sadr WM Philip NM Justman J Letting HIV transform academia—embracing implementation science.N Engl J Med. 2014; 370: 1679-1681Crossref PubMed Scopus (21) Google Scholar Such analyses might reduce the need for costly longitudinal assessments of the effects of interventions and provide estimates earlier than would be possible with field studies. The results of Smith and colleagues' analysis might be applicable in other settings in Africa, particularly those with comparable HIV prevalence, but lower antiretroviral therapy cost. Yet, this approach needs to be replicated in other settings beyond South Africa, to have a better picture of what can be achieved in the near and intermediate terms. The rollout of this strategy should also factor in the spatial structure of infection distribution, and prioritise regions with high density of HIV infection.8Jones A Cremin I Abdullah F et al.Transformation of HIV from pandemic to low-endemic levels: a public health approach to combination prevention.Lancet. 2014; 384: 272-279Summary Full Text Full Text PDF PubMed Scopus (99) Google Scholar, 9Cuadros DF Awad SF Abu-Raddad LJ Mapping HIV clustering: a strategy for identifying populations at high risk of HIV infection in sub-Saharan Africa.Int J Health Geogr. 2013; 12: 28Crossref PubMed Scopus (68) Google Scholar Cost-effectiveness in small communities with high HIV prevalence might not translate into cost-effectiveness across larger geographic areas that encompass various epidemics. Voluntary programmes and provider-initiated services cannot achieve the coverage needed to make a decisive effect on the epidemic. Social and community engagement, for example through community-based HTC, is an essential ingredient to achieve HIV elimination. With its low infrastructure demands, community-based HTC and linkage to care can be easily and rapidly scaled up. Evidence also points to the acceptability of community-based HTC in diverse settings.10Sabapathy K Van den Bergh R Fidler S Hayes R Ford N Uptake of home-based voluntary HIV testing in sub-Saharan Africa: a systematic review and meta-analysis.PLoS Med. 2012; 9: e1001351Crossref PubMed Scopus (160) Google Scholar, 11Suthar AB Ford N Bachanas PJ et al.Towards universal voluntary HIV testing and counselling: a systematic review and meta-analysis of community-based approaches.PLoS Med. 2013; 10: e1001496Crossref PubMed Scopus (280) Google Scholar The drawbacks for community public health programmes are often their cost and logistics, but these factors might not be as much of a concern in the HIV hyperepidemics of sub-Saharan Africa. The scale of epidemics is large and justifies a proportionate investment of resources, and evidence from Smith and colleagues' study shows that the investment will be very cost-effective. The diffusion of a community culture of health-seeking behaviour might also affect other health outcomes. I declare no competing interests. This publication was made possible by NPRP 5-752-3-177 from the Qatar National Research Fund (a member of Qatar Foundation). The statements made herein are solely the responsibility of the author. Cost-effectiveness of community-based strategies to strengthen the continuum of HIV care in rural South Africa: a health economic modelling analysisCommunity-based HTC with enhanced linkage to care can result in increased HIV testing coverage and treatment uptake, decreasing the population burden of HIV-associated morbidity and mortality. The incremental cost-effectiveness ratios are less than 20% of South Africa's gross domestic product per person, and are therefore classed as very cost effective. Home HTC can be a viable means to achieve UNAIDS' ambitious new targets for HIV treatment coverage. Full-Text PDF Open Access