Cost-effectiveness of universal HIV testing and treatment: where next?
Authors: Jean B Nachega, Ethan D Borre, David W Dowdy, Pascalina Chanda-Kapata, Susan Cleary, Elvin H Geng
Journal: The Lancet Global Health (2021)

The HPTN 071 (PopART) trial and others have shown that a combination HIV prevention package, including universal testing and treatment (UTT), can reduce the population-level incidence of HIV compared with standard care.1Iwuji CC Orne-Gliemann J Larmarange J et al.Universal test and treat and the HIV epidemic in rural South Africa: a phase 4, open-label, community cluster randomised trial.Lancet HIV. 2018; 5: e116-e125Summary Full Text Full Text PDF PubMed Scopus (129) Google Scholar, 2Hayes RJ Donnell D Floyd S et al.Effect of universal testing and treatment on HIV incidence—HPTN 071 (PopART).N Engl J Med. 2019; 381: 207-218Crossref PubMed Scopus (118) Google Scholar However, evidence on the cost and cost-effectiveness of this strategy has been limited. In The Lancet Global Health, Ranjeeta Thomas and colleagues3Thomas R Probert WJM Sauter R et al.Cost and cost-effectiveness of a universal HIV testing and treatment intervention in Zambia and South Africa: evidence and projections from the HPTN 071 (PopART) trial.Lancet Glob Health. 2021; (published online March 12.)https://doi.org/10.1016/S2214-109X(21)00034-6Summary Full Text Full Text PDF Scopus (2) Google Scholar report on a cost-effectiveness analysis model, projecting that combination HIV prevention including UTT (ie, PopART) is cost-effective at thresholds greater than US$800 per disability-adjusted life year (DALY) averted in individuals older than 14 years. Their incremental cost-effectiveness ratios (ICERs) are lower than those in previous modelling studies, suggesting that population-level combination HIV prevention might be more cost-effective than initially suggested. In a 2018 study, country-level thresholds for cost per DALY averted, based on per-capita gross domestic product, were estimated at $2480–3334 in South Africa and $417–575 in Zambia (2015 US$).4Ochalek J Lomas J Claxton K Estimating health opportunity costs in low-income and middle-income countries: a novel approach and evidence from cross-country data.BMJ Glob Health. 2018; 3e000964Crossref PubMed Scopus (67) Google Scholar These estimates suggest that annual implementation of PopART until 2030, as modelled by Thomas and colleagues, would be cost-effective in South Africa ($645 [95% credible interval 538–757] per DALY averted), but not necessarily in Zambia ($593 [526–674] per DALY averted).3Thomas R Probert WJM Sauter R et al.Cost and cost-effectiveness of a universal HIV testing and treatment intervention in Zambia and South Africa: evidence and projections from the HPTN 071 (PopART) trial.Lancet Glob Health. 2021; (published online March 12.)https://doi.org/10.1016/S2214-109X(21)00034-6Summary Full Text Full Text PDF Scopus (2) Google Scholar In addition, the budget required to implement this intervention—at a mean cost of $6·53 (SD 0·29) per person per year in Zambia and $7·93 (0·16) per person per year in South Africa3Thomas R Probert WJM Sauter R et al.Cost and cost-effectiveness of a universal HIV testing and treatment intervention in Zambia and South Africa: evidence and projections from the HPTN 071 (PopART) trial.Lancet Glob Health. 2021; (published online March 12.)https://doi.org/10.1016/S2214-109X(21)00034-6Summary Full Text Full Text PDF Scopus (2) Google Scholar—would represent nearly 10% of total health expenditure in many low-income countries. These considerations are important. If not cost-effective, such investments might reduce population health and increase inequalities in settings such as Zambia. Some stakeholders might argue that international donors can or should implement higher cost-effectiveness thresholds than national governments, whereas others believe that donors should support programmes that are most beneficial to local communities.5Robinson LA Hammitt JK Chang AY Resch S Understanding and improving the one and three times GDP per capita cost-effectiveness thresholds.Health Policy Plan. 2017; 32: 141-145Crossref PubMed Scopus (80) Google Scholar Nevertheless, the findings of Thomas and colleagues, via a methodologically rigorous cost-effectiveness analysis, will assist policy makers in sub-Saharan Africa in identifying the most worthwhile investments towards achieving the UNAIDS 90-90-90 target of AIDS elimination by 2030. The analysis is specific to the high-prevalence, peri-urban communities in which PopART was studied; future research might aim to identify the minimum community HIV prevalence at which PopART is cost-effective. Additionally, the budgetary outlays required for PopART include the intervention itself and the costs of HIV treatment, laboratory monitoring, and other medical costs for people testing positive for HIV and their linkage to care. These additional costs approach or exceed the annual intervention-only costs in Zambia and South Africa.3Thomas R Probert WJM Sauter R et al.Cost and cost-effectiveness of a universal HIV testing and treatment intervention in Zambia and South Africa: evidence and projections from the HPTN 071 (PopART) trial.Lancet Glob Health. 2021; (published online March 12.)https://doi.org/10.1016/S2214-109X(21)00034-6Summary Full Text Full Text PDF Scopus (2) Google Scholar As a result, based on overall budgetary outlays and World Bank population estimates, the annual incremental cost of PopART could exceed $1 billion if scaled to the population of Zambia (for all individuals aged >14 years), and $7 billion to cover the population of South Africa. Although the analysis makes clear that the studied intervention could provide substantial health gains in populations similar to those studied in the HPTN 071 trial, policy makers are now faced with obtaining funding to implement the PopART intervention and other health interventions at a broader scale. Considering the available evidence, what should be the next steps for researchers and policy makers? Thomas and colleagues' analysis provides three considerations. First, health system and context-specific factors (eg, what would be needed to implement PopART within different health system platforms and in diverse populations) should be considered in cost-effectiveness analyses. Such analyses might also seek to evaluate quality metrics in scaling up complex models of care. For example, if a cadre of community-based health-care workers were trained in HIV prevention activities, management structures to monitor and maintain quality would be needed; the costs of these structures should not be ignored when compiling a realistic picture of the investments required. Second, components of organisational structure, such as morale, staffing, and performance feedback, are crucial to both implementation and incremental costs. In the USA, for example, a modelling study of the optimal package of HIV prevention activities suggested widely differing costs across six cities.6Nosyk B Zang X Krebs E et al.Ending the HIV epidemic in the USA: an economic modelling study in six cities.Lancet HIV. 2020; 7: e491-e503Summary Full Text Full Text PDF PubMed Scopus (17) Google Scholar In studies from eastern Africa and Zambia,7Geng EH Odeny TA Lyamuya RE et al.Estimation of mortality among HIV-infected people on antiretroviral treatment in east Africa: a sampling-based approach in an observational, multisite, cohort study.Lancet HIV. 2015; 2: e107-e116Summary Full Text Full Text PDF PubMed Scopus (60) Google Scholar, 8Holmes CB Sikazwe I Sikombe K et al.Estimated mortality on HIV treatment among active patients and patients lost to follow-up in 4 provinces of Zambia: findings from a multistage sampling-based survey.PLoS Med. 2018; 15e1002489Crossref PubMed Scopus (39) Google Scholar a 4-times difference was observed in HIV-related mortality among people on treatment in facilities with the lowest mortality versus facilities with the highest mortality, even across geographically comparable and similarly staffed facilities. These differences suggest that health system performance is uneven, and such heterogeneities (including epidemiological, cultural, and demographic factors) should be considered if the results of cost-effectiveness analyses are to translate into optimal evidence-based decisions in the real world. Finally, policy makers do not make decisions to buy a given strategy or policy, but rather seek to optimise population health via selection of the optimal bundle of practices and policies. This process involves not only comparing the cost-effectiveness of a range of interventions, but also considering the opportunity costs and the extent to which investments in particular resources can be leveraged across systems or disease areas. These considerations emerge at scale and are not easy to capture in any one study. For example, many countries have invested substantially in cadres of community health-care workers to improve maternal and child health and decrease mortality in children younger than 5 years.9Gilmore B McAuliffe E Effectiveness of community health workers delivering preventive interventions for maternal and child health in low- and middle-income countries: a systematic review.BMC Public Health. 2013; 13: 847Crossref PubMed Scopus (202) Google Scholar Could HIV prevention with PopART be incorporated into the existing cadres, thus reducing incremental costs while potentially expanding benefits? Or would PopART community health-care workers represent a competing model of service delivery that could undermine the value of investments in other community-based cadres, increasing inefficiencies? These questions are outside the scope of any one study, but as the HIV elimination agenda converges with growing momentum for universal health coverage and synergy across disease conditions,10Jamison DT Summers LH Alleyne G et al.Global health 2035: a world converging within a generation.Lancet. 2013; 382: 1898-1955Summary Full Text Full Text PDF PubMed Scopus (726) Google Scholar such integrated considerations demand urgent exploration by novel research methods. In summary, the PopART trial and Thomas and colleagues bring into focus three emerging considerations for cost-effectiveness analyses of health interventions in resource-limited settings. Such analyses should be systems-focused, context-specific, organisationally minded, and broad in their scope. By promoting economic evaluations in these directions, we can ensure that the results are relevant to health policy decision making in settings of limited resources. JBN is supported by the NIH Fogarty International Center ( grant 1R25TW011217–01 , awarded to the African Association for Health Professions Education and Research ; grant 1D43TW010937–01A1 , awarded to the University of Pittsburgh HIV Comorbidities Research Training Program in South Africa; and grant 1R21TW011706-01, awarded to the University of Pittsburgh). All other authors declare no competing interests. Cost and cost-effectiveness of a universal HIV testing and treatment intervention in Zambia and South Africa: evidence and projections from the HPTN 071 (PopART) trialCombination prevention with universal home-based testing can be delivered at low annual cost per person but accumulates to a considerable amount when scaled for a growing population. Combination prevention including UTT is cost-effective at thresholds greater than $800 per DALY averted and can be an efficient strategy to reduce HIV incidence in high-prevalence settings. Full-Text PDF Open Access