Avahan and the cost-effectiveness of “prevention as prevention”
Authors: Elliot Marseille, James G Kahn
Journal: The Lancet Global Health (2014)

Avahan, the India AIDS Initiative funded by the Bill & Melinda Gates Foundation, is one of the largest HIV prevention programmes targeted to populations at high risk of infection. The initiative operated across 22 districts and committed US$258 million from 2004 to 2009, reaching 154 425 individuals. Through work with non-governmental organisations (NGOs), and a focus on peer-led interventions, it offered a package of services that included risk-reduction education, access to condoms, screening and treatment for sexually transmitted infection, and referral to clinical services as appropriate. Avahan was a full-scale, real-world test of the generally accepted principle that focused prevention in high-risk groups, particularly in the context of a concentrated epidemic, can substantially and efficiently reduce the incidence of HIV infection.1Wegbreit J Bertozzi S DeMaria LM Padian NS Effectiveness of HIV prevention strategies in resource-poor countries: tailoring the intervention to the context.Aids. 2006; 20: 1217-1235Crossref PubMed Scopus (49) Google Scholar Although these findings are not novel, showing them in the context of a programme of this scale is important and should increase the confidence of global health decision makers that investments in thoughtfully designed, scaled-up prevention programmes can yield large effects on health. Much of the focus of expert and public attention has been on HIV treatment, including test and treat (ie, treatment as prevention) strategies. This is understandable. Treatment for HIV has become extraordinarily effective, costs have dropped substantially during the past two decades, and the potential for antiretroviral therapy to reduce community viral load and transmission was shown in the groundbreaking HPTN 052 trial2Cohen 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, 3Granich R Kahn JG Bennett R et al.Expanding ART for treatment and prevention of HIV in South Africa: estimated cost and cost-effectiveness 2011–2050.PloS One. 2012; 7: e30216Crossref PubMed Scopus (113) Google Scholar in 2011. Against this background, the publication of these important and positive findings on the benefits and economic attractiveness of Avahan serves as a welcome reminder that so-called prevention as prevention can be extremely cost-effective. Treatment programmes designed to reach the general population might be politically more palatable than those targeted at individuals at high risk of infection, including sex workers, intravenous drug users, and men who have sex with men. The evaluation of Avahan reinforces previous understanding that serving the health-care needs of these marginalised groups is often the most direct and efficient way to curb the HIV epidemic. Prevention of HIV transmission among groups at high risk of infection can be very cost effective. The most important finding of this study is that the package of preventive services delivered by Avahan yields an incremental cost of $46 per disability-adjusted life-year (DALY) averted. This cost-effectiveness study indicates that Avahan-style interventions are an extraordinarily good use of public health funds, roughly on par with the provision of insecticide-treated bednets to prevent malaria; diarrhoeal disease prevention with the promotion of hygiene practices; volunteer paramedic training in emergency care; and the provision of childhood immunisation against tuberculosis, diphtheria, polio, and measles;4World Bank Jamison DT Breman JG Disease control priorities in developing countries. 2nd edn. Oxford University Press, New York2006Crossref Google Scholar and cost far less than the $597–833 per DALY averted or life-year gained cost-effectiveness of other HIV treatment programmes in low-income countries.5Marseille E Giganti MJ Mwango A et al.Taking ART to scale: determinants of the cost and cost-effectiveness of antiretroviral therapy in 45 clinical sites in Zambia.PloS One. 2012; 7: e51993Crossref PubMed Scopus (37) Google Scholar, 6Marseille E Kahn JG Pitter C et al.The cost effectiveness of home-based provision of antiretroviral therapy in rural Uganda.Appl Health Econ Health Policy. 2009; 7: 229-243Crossref PubMed Google Scholar, 7Goldie SJ Yazdanpanah Y Losina E et al.Cost-effectiveness of HIV treatment in resource-poor settings—the case of Cote d'Ivoire.N Engl J Med. 2006; 355: 1141-1153Crossref PubMed Scopus (223) Google Scholar Particularly encouraging is the fact that the study included a comprehensive account of the costs involved. Rather than being confined to the level of service delivery, the study analysis included Avahan programme costs at the state and national levels, such as for programme management, capacity building, and community supply costs. One of the most important findings of this study is that these programme costs often ignored in cost-effectiveness analyses exceeded those of service delivery by a wide margin. Avahan cost $109 per person at the NGO level compared with a programme cost of $327 per person. The importance of costs above the service delivery level have been noted in other studies.5Marseille E Giganti MJ Mwango A et al.Taking ART to scale: determinants of the cost and cost-effectiveness of antiretroviral therapy in 45 clinical sites in Zambia.PloS One. 2012; 7: e51993Crossref PubMed Scopus (37) Google Scholar Although this type of data collection takes more effort, because the programme costs are such a large part of the total, the estimation of these programme management level costs, should become standard practice in cost-effectiveness analyses. This study showed a substantial economy of scale in the delivery of HIV prevention. Although unsurprising, this result provides assurance that preventive HIV transmission programmes, when implemented on a sufficiently large scale, can have an effect on the epidemic that will yield greater, not reduced, returns. Another striking finding in this study is the wide variation in unit costs of $24–594 per person among the different service delivery sites and districts. These large variations in unit cost have been seen elsewhere.8Marseille E Dandona L Marshall N et al.HIV prevention costs and program scale: data from the PANCEA project in five low and middle-income countries.BMC Health Services Res. 2007; 7: 108Crossref PubMed Scopus (58) Google Scholar, 9Bautista-Arredondo S Gadsden P Harris JE Bertozzi SM Optimizing resource allocation for HIV/AIDS prevention programmes: an analytical framework.Aids. 2008; 22: S67-S74Crossref PubMed Google Scholar An important question that this study was not designed to address pertains to the portion of this variation that is due to unavoidable differences in costs incurred at the different sites, and what portion can be attributed to the differences in personnel management, procurement practices, and other factors that could be addressed by programme administrators. To understand the drivers of this variation in unit costs and identify strategies to address such avoidable inefficiencies is the cutting edge of global health economics inquiry. Irrespective of how cost effective an intervention is overall, improved efficiency (without sacrificing quality) means more money is available to save more lives. An unavoidable, but relevant, shortcoming of the study design is the absence of concurrent control groups. The Avahan study, instead, compared results from the 22 districts evaluated with a no-Avahan counterfactual scenario under the assumption of continued trends in condom use and other risk behaviours previously seen in these districts. However, with an incremental cost of $46 per DALY averted, there is much room for error in cost estimation before the positive economic outcomes predicted by this study can be called into question. In an era of either level spending or decreased real global spending on HIV therapy, the Avahan experience argues powerfully for commitment to so-called prevention as prevention even as strategies of treatment as prevention are being formulated. We declare no competing interests. Cost-effectiveness of HIV prevention for high-risk groups at scale: an economic evaluation of the Avahan programme in south IndiaThis study provides evidence that the investment in targeted HIV prevention programmes in south India has been cost effective, and is likely to be cost saving if a commitment is made to provide ART to all that can benefit from it. Policy makers should consider funding and sustaining large-scale targeted HIV prevention programmes in India and beyond. Full-Text PDF Open Access