When cost-effective interventions are unaffordable: Integrating cost-effectiveness and budget impact in priority setting for global health programs

Scaling-up and scaling-out the Systems Analysis and Improvement Approach to optimize the hypertension diagnosis and care cascade for HIV infected individuals (SCALE SAIA-HTN): a stepped-wedge cluster randomized trial

BACKGROUND

Undiagnosed and untreated hypertension is a main driver of cardiovascular disease and disproportionately affects persons living with HIV (PLHIV) in low- and middle-income countries. Across sub-Saharan Africa, guideline application to screen and manage hypertension among PLHIV is inconsistent due to poor service readiness, low health worker motivation, and limited integration of hypertension screening and management within HIV care services. In Mozambique, where the adult HIV prevalence is over 13%, an estimated 39% of adults have hypertension. As the only scaled chronic care service in the county, the HIV treatment platform presents an opportunity to standardize and scale hypertension care services. Low-cost, multi-component systems-level strategies such as the Systems Analysis and Improvement Approach (SAIA) have been found effective at integrating hypertension and HIV services to improve the effectiveness of hypertension care delivery for PLHIV, reduce drop-offs in care, and improve service quality. To build off lessons learned from a recently completed cluster randomized trial (SAIA-HTN) and establish a robust evidence base on the effectiveness of SAIA at scale, we evaluated a scaled-delivery model of SAIA (SCALE SAIA-HTN) using existing district health management structures to facilitate SAIA across six districts of Maputo Province, Mozambique.

METHODS

This study employs a stepped-wedge design with randomization at the district level. The SAIA strategy will be "scaled up" with delivery by district health supervisors (rather than research staff) and will be "scaled out" via expansion to Southern Mozambique, to 18 facilities across six districts in Maputo Province. SCALE SAIA-HTN will be introduced over three, 9-month waves of intensive intervention, where technical support will be provided to facilities and district managers by study team members from the Mozambican National Institute of Health. Our evaluation of SCALE SAIA-HTN will be guided by the RE-AIM framework and will seek to estimate the budget impact from the payer's perspective.

DISCUSSION

SAIA packages user-friendly systems engineering tools to support decision-making by frontline health workers and to identify low-cost, contextually relevant improvement strategies. By integrating SAIA delivery into routine management structures, this pragmatic trial will determine an effective strategy for national scale-up and inform program planning.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05002322 (registered 02/15/2023).

Implementation costs of sugary drink policies in the United States

To support implementation of important public health policies, policymakers need information about implementation costs over time and across stakeholder groups. We assessed implementation costs of two federal sugar-sweetened beverage (SSB) policies of current policy interest and with evidence to support their effects: excise taxes and health warning labels. Our analysis encompassed the entire policy life cycle using the Exploration, Preparation, Implementation, and Sustainment framework. We identified implementation actions using key informant interviews and developed quantitative estimates of implementation costs using published literature and government documents. Results show that implementation costs vary over time and among stakeholders. Explicitly integrating implementation science theory and using mixed methods improved the comprehensiveness of our results. Although this work is specific to federal SSB policies, the process can inform how we understand the costs of many public health policies, providing crucial information for public health policy making.

Publicly Funded Cancer Care: Are Adjuvant Therapies Prioritized Over Treatment of Metastatic Cancer? The Israeli Experience

PURPOSE

In Israel, a public committee advises which new medications should be reimbursed subject to an annual budget allocation. The committee considers clinical trial outcomes, professional societies' preferences, projected budget impacts, and other social and ethical aspects. The Israeli oncologists' society places a strong emphasis on prioritizing adjuvant therapies because of their potential to advance cure. In 2023, several novel adjuvant therapies were suggested for national funding. Our objective was to ascertain whether Israeli decision makers have embraced the practice of prioritizing budgets for therapies with curative intent over late-disease therapy.

METHODS

We collected data on all proposed cancer therapies for the 2023 update: indications, treatment settings, European Society for Medical Oncology-Magnitude of Clinical Benefit Scale (ESMO-MCBS) score, and whether accepted for reimbursement. The rates of acceptance were compared between drugs in curative and noncurative settings. Data were extracted from the official Israeli Ministry of Health publications and ESMO-MCBS website.

RESULTS

Seven of the eight proposed therapies with curative intent received reimbursement approval (88%), in contrast to 11 of the 55 therapies for advanced/metastatic stages (20%). Among all advanced disease therapies with a high ESMO-MCBS score of 4, only four of 16 (25%) secured reimbursement approval.

CONCLUSION

Our analysis revealed that during the 2023 reimbursement deliberations, Israeli policymakers embraced the prioritization of potentially curative therapies over treatments for incurable cancers, including several interventions that have demonstrated significant improvements in overall survival and/or quality of life. Introducing objective cost-effectiveness measures as a guiding framework for comparing competing medications may offer some resolution to this complex challenge.

Framework for determining the optimal course of action when efficiency and affordability measures differ by perspective in cost-effectiveness analysis-with an illustrative case of HIV treatment in Mozambique

BACKGROUND

Cost-effectiveness analysis (CEA) is a standard tool for evaluating health programs and informing decisions about resource allocation and prioritization. Most CEAs evaluating health interventions in low- and middle-income countries adopt a health sector perspective, accounting for resources funded by international donors and country governments, while often excluding out-of-pocket expenditures and time costs borne by program beneficiaries. Even when patients' costs are included, a companion analysis focused on the patient perspective is rarely performed. We view this as a missed opportunity.

METHODS

We developed methods for assessing intervention affordability and evaluating whether optimal interventions from the health sector perspective also represent efficient and affordable options for patients. We mapped the five different patterns that a comparison of the perspective results can yield into a practical framework, and we provided guidance for researchers and decision-makers on how to use results from multiple perspectives. To illustrate the methodology, we conducted a CEA of six HIV treatment delivery models in Mozambique. We conducted a Monte Carlo microsimulation with probabilistic sensitivity analysis from both patient and health sector perspectives, generating incremental cost-effectiveness ratios for the treatment approaches. We also calculated annualized patient costs for the treatment approaches, comparing the costs with an affordability threshold. We then compared the cost-effectiveness and affordability results from the two perspectives using the framework we developed.

RESULTS

In this case, the two perspectives did not produce a shared optimal approach for HIV treatment at the willingness-to-pay threshold of 0.3 × Mozambique's annual GDP per capita per DALY averted. However, the clinical 6-month antiretroviral drug distribution strategy, which is optimal from the health sector perspective, is efficient and affordable from the patient perspective. All treatment approaches, except clinical 1-month distributions of antiretroviral drugs which were standard before Covid-19, had an annual cost to patients less than the country's annual average for out-of-pocket health expenditures.

CONCLUSION

Including a patient perspective in CEAs and explicitly considering affordability offers decision-makers additional insights either by confirming that the optimal strategy from the health sector perspective is also efficient and affordable from the patient perspective or by identifying incongruencies in value or affordability that could affect patient participation.

Health Technology Assessment-Informed Decision Making by the Federal Joint Committee/Institute for Quality and Efficiency in Health Care in Germany and the National Institute for Health and Care Excellence in England: The Role of Budget Impact

OBJECTIVES

This study aimed to test (official) evaluation criteria including the potential role of budget impact (BI) on health technology assessment (HTA) outcomes published by the Federal Joint Committee (Gemeinsamer Bundesausschuss [GBA]) and the Institute for Quality and Efficiency in Health Care (Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen [IQWiG]) in Germany as well as the National Institute for Health and Care Excellence (NICE) in England.

METHODS

Data were extracted from all publicly available GBA decisions and IQWiG assessments as well as NICE single technology appraisals between January 2011 and June 2018, and information with regard to evaluation criteria used by these agencies was collected. Data were analyzed using logistic regression to estimate the effect of the BI on the HTA outcomes while controlling for criteria used by GBA/IQWiG and NICE.

RESULTS

NICE recommendations are largely driven by the incremental cost-effectiveness ratio and, if applicable, by end-of-life criteria (P < .01). While IQWiG assessments are significantly affected by the availability of randomized controlled trials and patient-relevant endpoints (P < .01), GBA appraisals primarily focus on endpoints (P < .01). The BI correlated with NICE single technology appraisals (inverted-U relationship, P < .1) and IQWiG recommendations (increasing linear relationship, P < .05), but not with GBA decisions (P > .1). Nevertheless, given that IQWiG assessments seem to be more rigorous than GBA appraisals regarding the consideration of evidence-based evaluation criteria, decisions by GBA might be negatively associated with the BI.

CONCLUSIONS

Results reveal that GBA/IQWiG and NICE follow their official evaluation criteria consistently. After controlling for all significant variables, the BI seems to have an (independent) effect on HTA outcomes as well.

Optimizing next-generation RSV prevention in Mali: A cost-effectiveness analysis of pediatric vaccination, maternal vaccination, and extended half-life monoclonal antibody immunoprophylaxis

Respiratory syncytial virus (RSV) is the most common cause of early childhood lower respiratory tract infection (LRTI) in low- and middle-income countries (LMICs). Maternal vaccines, birth-dose extended half-life monoclonal antibodies (mAbs), and pediatric vaccines are under development for prevention of respiratory syncytial virus (RSV) lower respiratory tract infection (LRTI) in young children. We analyzed the health and economic impact of RSV interventions used alone or in combinations in Mali. We modeled age-specific and season-specific risks of RSV LRTI in children through three years, using WHO Preferred Product Characteristics and data generated in Mali. Health outcomes included RSV LRTI cases, hospitalizations, deaths, and disability-adjusted life-years (DALYs). We identified the optimal combination of products across a range of scenarios. We found that mAb delivered at birth could avert 878 DALYs per birth cohort at an incremental cost-effectiveness ratio (ICER) of $597 per DALY averted compared to no intervention if the product were available at $1 per dose. Combining mAb with pediatric vaccine administered at 10/14 weeks, 1947 DALYs would be prevented. The ICER of this combination strategy is $1514 per DALY averted compared to mAb alone. Incorporating parameter uncertainty, mAb alone is likely to be optimal from the societal perspective at efficacy against RSV LRTI above 66%. The optimal strategy was sensitive to economic considerations, including product prices and willingness-to-pay for DALYs. For example, the combination of mAb and pediatric vaccine would be optimal from the government perspective at a willingness-to-pay above $775 per DALY. Maternal vaccine alone or in combination with other interventions was never the optimal strategy, even for high vaccine efficacy. The same was true for pediatric vaccine administered at 6/7 months. At prices comparable to existing vaccine products, extended half-life RSV mAbs would be impactful and efficient components of prevention strategies in LMICs such as Mali.

A SMART Approach to Retention in HIV Care

The Joint United Nation Programme on HIV/AIDS (UNAIDS) has aims that, by 2025, 95% of people with HIV should know their HIV status, 95% of people who receive a diagnosis should be receiving antiretroviral therapy (ART), and 95% of people with HIV and receiving ART should be virally suppressed.1 The challenge and opportunity of the UNAIDS 95-95-95 goal are to reach people outside standard clinic-based services.2 However, after ART is initiated, retention in care is a challenge, with only 67% of persons continuing to receive ART after 5 years.3.

Budget impact analysis of two treatment approaches for hepatitis C in Malaysia through the use of voluntary and compulsory licensing options

Introduction

A scaled-up treatment cascade with direct-acting antiviral (DAA) therapy is necessary to achieve global WHO targets for hepatitis C virus (HCV) elimination in Malaysia. Recently, limited access to sofosbuvir/daclatasvir (SOF/DAC) is available through compulsory licensing, with access to sofosbuvir/velpatasvir (SOF/VEL) expected through voluntary licensing due to recent agreements. SOF/VEL has superior clinical outcomes but has higher drug acquisition costs compared to SOF/DAC. A stratified treatment cascade might be the most cost-efficient approach for Malaysia whereby all HCV patients are treated with SOF/DAC except for patients with cirrhosis who are treated with SOF/VEL.

Methods

This study aimed to conduct a 5-year budget impact analysis of the proposed stratified treatment cascade for HCV treatment in Malaysia. A disease progression model that was developed based on model-predicted HCV epidemiology data was used for the analysis, where all HCV patients in scenario A were treated with SOF/DAC for all disease stages while in scenario B, SOF/DAC was used only for non-cirrhotic patients and SOF/VEL was used for the cirrhotic patients. Healthcare costs associated with DAA therapy and disease stage monitoring were included to estimate the downstream cost implications.

Results

The stratified treatment cascade with 109 in Scenario B was found to be cost-saving compared to Scenario A. The cumulative savings for the stratified treatment cascade was USD 1.4 million over 5 years.

Discussion

A stratified treatment cascade with SOF/VEL was expected to be cost-saving and can result in a budget impact reduction in overall healthcare expenditure in Malaysia.

A symptomatic approach to tuberculosis screening for high-risk groups in Malaysia: Cost-effectiveness and budget impact analysis

BACKGROUND

One of the crucial areas of eliminating TB is the early detection of cases through the screening programme. This study's focal point is to measure the relative cost-effectiveness and budget impact of the symptomatic approach compared to the existing approach of TB screening (consisted of both symptomatic and asymptomatic screening) among high-risk groups in Malaysia.

METHOD

The Cost-Effectiveness Analysis (CEA) was measured using a decision tree model and the outcome is presented in terms of cost per TB case detected and the ICER. Analysis was conducted using secondary data collected from the Disease Control Division, Sabah and Sarawak State Health Departments. The robustness of the model is determined by Deterministic and Probabilistic Sensitivity Analysis. Subsequently, Budget impact over 5 years period, from 2018 to 2022 was estimated for both approaches.

RESULTS

The symptomatic approach was more cost-effective than the existing approach with ICER of MYR 424.71. The cost of conducting Sputum for Acid Fast Bacilli (SAFB) was found as the key driver for ICER. Budget Impact Analysis showed that switching from the existing approach towards the symptomatic approach would result in a cost-saving of MYR 65.5 million over 5 years. However, this would lead to 4473 TB cases being undetected over the same duration.

CONCLUSION

This study suggests that the policymakers have to weigh the trade-off between cost-saving and TB case detection. This cost-saving can be channelled to new TB intervention programme with a higher chance of TB case detection. Nevertheless, any decision made must be in concordance to the objectives of the country's TB programme.

What are the impacts of increasing cost-effectiveness Threshold? a protocol on an empirical study based on economic evaluations conducted in Thailand

Background

Economic evaluations have been widely used to inform and guide policy-making process in healthcare resources allocation as a part of an evidence package. An intervention is considered cost-effective if an ICER is less than a cost-effectiveness threshold (CET), where a CET represents the acceptable price for a unit of additional health gain which a decision-maker is willing to pay. There has been discussion to increase a CET in many settings such as the United Kingdom and Thailand. To the best of our knowledge, Thailand is the only country that has an explicit CET and has revised their CET, not once but twice. Hence, the situation in Thailand provides a unique opportunity for evaluating the impact of changing CET on healthcare expenditure and manufacturers’ behaviours in the real-world setting. Before we decide whether a CET should be increased, information on what happened after the CET was increased in the past could be informative and helpful.

Objectives

This study protocol describes a proposed plan to investigate the impact of increased cost-effectiveness threshold using Thailand as a case study. Specifically, we will examine the impact of increasing CET on the drug prices submitted by pharmaceutical companies to the National List of Essential Medicine (NLEM), the decision to include or exclude medications in the NLEM, and the overall budget impact.

Materials and designs

Retrospective data analysis of the impact of increased CET on national drug committee decisions in Thailand (an upper middle-income country) will be conducted and included data from various sources such as literature, local organizations (e.g. Thai Food and Drug Administration), and inputs from stakeholder consultation meetings. The outcomes include: (1) drug price submitted by the manufacturers and final drug price included in the NLEM if available; (2) decisions about whether the drug was included in the NLEM for reimbursement; and (3) budget impact. The independent variables include a CET, the variable of interest, which can take values of THB100,000, THB120,000, or THB160,000, and potential confounders such as whether this drug was for a chronic disease, market size, and primary endpoint. We will conduct separate multivariable regression analysis for each outcome specified above.

Discussion

Understanding the impact of increasing the CET would be helpful in assisting the decision to use and develop an appropriate threshold for one’s own setting. Due to the nature of the study design, the findings will be prone to confounding effect and biases; therefore, the analyses will be adjusted for potential confounders and statistical methods will be explored to minimize biases. Knowledge gained from the study will be conveyed to the public through various disseminations such as reports, policy briefs, academic journals, and presentations.

Determinants of prescribing decisions for off-patent biological medicines in Belgium: a qualitative study

BACKGROUND

A competitive market for off-patent biologicals leads to more affordable and high-quality healthcare. In recent years, Belgium has been characterized by its low use of biosimilars and by its shifts from off-patent biologicals toward new alternative therapies. Yet, the prescribing decisions involved in these observations are poorly understood. This study aims to better understand prescribing choices among Belgian physicians in the ambulatory care setting.

METHODS

This study consisted of two phases. First, a scoping literature review to identify determinants of prescribing choices was conducted. Scientific databases (Embase and PubMed) were searched until 4 November 2021. Second, the nominal group technique (NGT) was employed during focus group discussions with Belgian physicians to consider and validate these determinants for off-patent biologicals in the Belgian context. The qualitative data resulting from the literature review and focus group discussions were analyzed using the thematic framework method.

RESULTS

Fifty-three scientific articles that discussed elements that determine prescribing choices were identified. Out of these, 17 determinants of prescribing choices were found. These were divided into five categories: (1) product-related, (2) physicians' personal, (3) healthcare system-related, (4) patient-related, and (5) determinants related to the pharmaceutical company or brand. Nineteen Belgian physicians from different therapeutic areas that regularly prescribe biologicals then participated in focus group discussions. Using the NGT, the group discussions revealed that prescribing choices for off-patent biologicals are determined by a complex set of elements. Clinical data, geographical region, working environment, pharmaceutical marketing, patient profile, clinical guidelines, and preference of key opinion leaders (KOL) were considered most influential. Physicians indicated that the importance of these determinants differs depending on product classes or therapeutic domain.

CONCLUSIONS

Multiple elements determine the choice of an off-patent biological or biosimilar product. The importance of each of these determinants varies depending on the context in which the prescribing choice is made. To increase the prescription of best-value biologicals in the Belgian ambulatory care, a set of synergistic measures is required including information for healthcare providers (HCP) and patients, prescribing feedback, prescribing targets, tangible incentives, KOL involvement, guidelines regarding pharmaceutical promotion, and regular revision of reimbursement modalities.

Economic evaluation of psychological treatments for common mental disorders in low- and middle-income countries: a systematic review

Common mental disorders (CMDs) constitute a major public health and economic burden on low- and middle-income countries (LMICs). Systematic reviews of economic evaluations of psychological treatments for CMDs are limited. This systematic review examines methods, reports findings and appraises the quality of economic evaluations of psychological treatments for CMDs in LMICs. We searched a range of bibliographic databases (including PubMed, EconLit, APA-PsycINFO and Cochrane library) and the African Journals Online (AJoL) and Google Scholar platforms. We used a pre-populated template to extract data and the Drummond & Jefferson checklist for quality appraisal. We present results as a narrative synthesis. The review included 26 studies, mostly from Asia (12) and Africa (9). The majority were cost-effectiveness analyses (12), some were cost-utility analyses (5), with one cost-benefit analysis or combinations of economic evaluations (8). Most interventions were considered either cost-effective or potentially cost-effective (22), with 3 interventions being not cost-effective. Limitations were noted regarding appropriateness of conclusions drawn on cost-effectiveness, the use of cost-effectiveness thresholds and application of 'societal' incremental cost-effectiveness ratios to reflect value for money (VfM) of treatments. Non-specialist health workers (NSHWs) delivered most of the treatments (16) for low-cost delivery at scale, and costs should reflect the true opportunity cost of NSHWs' time to support the development of a sustainable cadre of health care providers. There is a 4-fold increase in economic evaluations of CMD psychological treatments in the last decade over the previous one. Yet, findings from this review highlight the need for better application of economic evaluation methodology to support resource allocation towards the World Health Organization recommended first-line treatments of CMDs. We suggest impact inventories to capture societal economic gains and propose a VfM assessment framework to guide researchers in evaluating cost-effectiveness.

Ensuring quality in contextualised cancer management guidelines for resource-constraint settings: using a systematic approach

To address the wide variation in access to cancer care in India requires strengthening of infrastructure, trained oncology workforce, and minimisation of out-of-pocket expenditures. However, even with major investments, it is unlikely to achieve the same level of infrastructure and expertise across the country. Therefore, a resource stratified approach driven by evidence-based and contextualised clinical guidelines is the need of the hour. The National Cancer Grid has been at the forefront of delivery of standardised cancer care through several of its initiatives, including the resource-stratified guidelines. Development of new guidelines is resource and time intensive, which may not be feasible and can delay the implementation. Adaptation of the existing standard guidelines using the transparent and well-documented methodology with involvement of all stakeholders can be one of the most reasonable pathways. However, the adaptation should be done keeping in mind the context, resource availability, budget impact, investment needed for implementation and acceptability by clinicians, patients, policymakers, and other stakeholders. The present paper provides the framework for systematically developing guidelines through adaptation and contextualisation. The process can be used for other health conditions in resource-constraint settings.

Comparing health gains, costs and cost-effectiveness of 100s of interventions in Australia and New Zealand: an online interactive league table

BACKGROUND

This study compares the health gains, costs, and cost-effectiveness of hundreds of Australian and New Zealand (NZ) health interventions conducted with comparable methods in an online interactive league table designed to inform policy.

METHODS

A literature review was conducted to identify peer-reviewed evaluations (2010 to 2018) arising from the Australia Cost-Effectiveness research and NZ Burden of Disease Epidemiology, Equity and Cost-Effectiveness Programmes, or using similar methodology, with: health gains quantified as health-adjusted life years (HALYs); net health system costs and/or incremental cost-effectiveness ratio; time horizon of at least 10 years; and 3% to 5% discount rates.

RESULTS

We identified 384 evaluations that met the inclusion criteria, covering 14 intervention domains: alcohol; cancer; cannabis; communicable disease; cardiovascular disease; diabetes; diet; injury; mental illness; other non-communicable diseases; overweight and obesity; physical inactivity; salt; and tobacco. There were large variations in health gain across evaluations: 33.9% gained less than 0.1 HALYs per 1000 people in the total population over the remainder of their lifespan, through to 13.0% gaining > 10 HALYs per 1000 people. Over a third (38.8%) of evaluations were cost-saving.

CONCLUSIONS

League tables of comparably conducted evaluations illustrate the large health gain (and cost) variations per capita between interventions, in addition to cost-effectiveness. Further work can test the utility of this league table with policy-makers and researchers.

Affordability and Value in Decision Rules for Cost-Effectiveness: A Survey of Health Economists

OBJECTIVES

New health technologies are often expensive, but may nevertheless meet standard thresholds for cost effectiveness, a situation exemplified by recent hepatitis C cures. Currently, cost-effectiveness analysis (CEA) does not supply practical means of weighing trade-offs between cost-effectiveness and affordability, particularly when costs and benefits are temporally separated and in health systems with multiple payers, such as the United States. We formally characterized disagreements in CEA theory and identified how these trade-offs are presently addressed in practice.

METHODS

We surveyed 170 health economics researchers.

RESULTS

When presented with a hypothetical cost-effective drug therapy in the United States that would require 20% of a state's Medicaid budget over 5 years, 34% of survey respondents recommended that policy makers fund the drug for all patients and 26% for a subset. By contrast, 26% recommended against funding the drug. We found additional disagreement regarding whether the willingness-to-pay threshold should be based on the budget (42%) or societal preferences (41%) and identified 4 approaches to weighing cost-effectiveness and affordability. A total of 61% of respondents did not believe that the threshold used in their last article (most often 1×-3× per capita gross domestic product) represented either the budget or societal willingness-to-pay threshold.

CONCLUSIONS

We use these findings to recommend metrics that can inform translation of CEA theory into practice. By contextualizing cost and value, researchers can provide more actionable policy recommendations.

Economic impact of generic antiretrovirals in France for HIV patients' care: a simulation between 2019 and 2023

Background

In a context where the economic burden of HIV is increasing as HIV patients now have a close to normal lifespan, the availability of generic antiretrovirals commonly prescribed in 2017 and the imminence of patent expiration are expected to provide substantial savings in the coming years. This article aims to assess the economic impact of these generic antiretrovirals in France and specifically over a five-year period.

Methods

An agent-based model was developed to simulate patient trajectories and treatment use over a five-year period. By comparing the results of costs for trajectories simulated under different predefined scenarios, a budget impact model can be created and sensitivity analyses performed on several parameters of importance.

Results

The potential economic savings from 2019 to 2023 generated by generic antiretrovirals range from €309 million when the penetration rate of generics is set at 10% to €1.5 billion at 70%. These savings range from €984 million to €993 million as the delay between patent and generic marketing authorisation varies from 10 to 15 years, and from €965 million to €993 million as the Negotiated Price per Unit (NPU) of generics at market-entry varies from 40 to 50% of the NPU for patents.

Discussion

This economic savings simulation could help decision makers to anticipate resource allocations for further innovation in antiretrovirals therapies as well as prevention, especially by funding the Pre-Exposure Prophylaxis (PrEP) or HIV screening.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07859-w.

Adoption of new therapies in the treatment of Hepatitis: a verification of the accuracy of budget impact analysis to guide investment decisions

OBJECTIVES

While there are good Budget Impact Analysis (BIA) guidelines, studies still register potential bias. To do this, we compared the results between theoretical and real-world evidence (RWE) expenditures for medicines for Hepatitis C: boceprevir (BOC) and telaprevir (TVR). While both are not currently recommended in treatment guidelines following recent developments, this is an emblematic case because for 4 years these medicines consumed considerable resources.

METHODS

Theoretical results and RWE expenditures were compared regarding the incorporation of BOC and TVR in 2013-2014 into the Brazilian Public Health System. Theoretical values were extracted from Commission for Technology Incorporation Report and RWE expenditures were extracted from the administrative data records using deterministic-probabilistic linkage.

RESULTS

The estimated number of patients treated (BOC+TVR) was 13,012 versus 7,641 (real). The estimated purchase price for BOC was US$6.20 versus US$11.07 (real) and for TVR was US$42.21 versus US$84.09 (average/real). The estimated budget impact was US$285.16 million versus US$128.58 million (real).

CONCLUSION

This study demonstrates appreciable divergence (US$156.58 million) between the theoretical budget impact and RWE expenditures due to underestimated purchase prices and overestimated populations. The greater the degree of accuracy the more reliable and usable BIAs become for decision-making.

The ethics of aggregation in cost-effectiveness analysis or, "on books, bookshelves, and budget impact"

In deciding how to allocate resources, healthcare priority-setters are increasingly paying attention to an intervention's budget impact alongside its cost-effectiveness. Some argue that approaches that use budget impact as a substantive consideration unfairly disadvantage individuals who belong to large patient groups. Others reject such claims of "numerical discrimination" on the grounds that consideration of the full budget impact of an intervention's adoption is necessary to properly estimate opportunity cost. This paper summarizes this debate and advances a new argument against modifying the cost-effectiveness threshold used for decision-making based on a technology's anticipated budget impact. In making this argument, the paper sets out how the apparent link between budget impact and opportunity cost is largely broken if the effects of a technology's adoption are disaggregated, while highlighting that the theoretical aggregation of effects during cost-effectiveness analysis likely only poorly reflects the operation of the health system in practice. As such, it identifies a need for healthcare priority-setters to be cognizant of the ethical implications associated with aggregating the effects of a technology's adoption for the purpose of decision-making. Throughout the paper, these arguments are illustrated with reference to a "bookshelf" analogy borrowed from previous work.

Cost-Effectiveness of a Culturally Adapted Manual-Assisted Brief Psychological Intervention for Self-Harm in Pakistan: A Secondary Analysis of the Culturally Adapted Manual-Assisted Brief Psychological Randomized Controlled Trial

OBJECTIVES

Self-harm is a serious public health problem. A culturally adapted manual-assisted problem-solving training (C-MAP) intervention improved and sustained a reduction in suicidal ideation, hopelessness, and depression compared with treatment as usual (TAU) alone. Here, we evaluate its cost-effectiveness.

METHODS

Patients admitted after an episode of self-harm were randomized individually to either C-MAP plus TAU or TAU alone in Karachi. Improvement in health-related quality-adjusted life-years (QALYs) was measured using the EQ-5D with 3 levels instrument at baseline, 3 months, and 6 months after randomization. The primary economic outcome was health service cost per QALY gained as the incremental cost-effectiveness ratio, based on 2019 US$ and a 6-month time horizon. Nonparametric bootstrapping was used to assess uncertainties and sensitivity analysis to examine the impact of hospitalization costs.

RESULTS

A total of 108 and 113 participants were enrolled among the intervention and standard arms, respectively. The intervention resulted in 0.04 (95% confidence interval [CI] 0.00-0.08) more QALYs 6 months after enrolment. The mean cost per participant in the intervention arm was $1001 (95% CI 968-1031), resulting in an incremental cost of the intervention of $640 (95% CI 595-679). The incremental cost-effectiveness ratio for the C-MAP intervention versus TAU was $16 254 (95% CI 7116-99 057) per QALY gained. The probability that C-MAP is cost-effective was between 66% and 83% for cost-effective thresholds between $20 000 and $30 000. Cost-effectiveness results remained robust to sensitivity analyses.

CONCLUSIONS

C-MAP may be a valuable self-harm intervention. Further studies with longer follow-up and larger sample sizes are needed to draw reliable conclusions.

Systematic Literature Review of Guidelines on Budget Impact Analysis for Health Technology Assessment

OBJECTIVES

The objective of this systematic review was to review the recommendations for the conduct of a budget impact analysis in national or organisational guidelines globally.

METHODS

We searched several databases including MELDINE, EMBASE, The Cochrane Library, National Guideline Clearinghouse, HTA Database (International Network of Agencies for Health Technology Assessment), Econlit and IDEAS Database (RePEc, Research Papers in Economics). The OVID platform was used to run the search in all databases simultaneously. In addition, a search of the grey literature was also conducted. The timeframe was set from 2000 to 2020 with language of publication restricted to English.

RESULTS

A total of 13 publications were selected. All the countries where financing of health is predominantly tax funded with public provisioning recommend a healthcare payer (government) perspective. However, countries where a healthcare payer includes a mix of federal government, communities, hospital authorities and patient communities recommend a complementary analysis with a wider societal perspective. While four guidelines prefer a simple cost calculator for costing, the rest rely on a decision modelling approach. None of the guidelines recommend discounting except the Polish guidelines, which recommend discounting at 5%. Only two countries, Belgium and Poland, mention that indirect costs, if significant, should be included in addition to direct costs.

CONCLUSIONS

The comparative cross-country analysis shows that a standard set of recommendations cannot be directly useful for all as there are contextual differences. Thus, budget impact analysis guidelines must be carefully contextualised in the policy environment of a country so as to reflect the dynamics of health systems.

National Methodological Guidelines to Conduct Budget Impact Analysis for Health Technology Assessment in India

OBJECTIVE

Our paper aims to present Budget Impact Analysis (BIA) guidelines for health technology assessment (HTA) in India.

METHODOLOGY

A Systematic Literature Review (SLR) was conducted to retrieve information on existing BIA guidelines internationally. The initial set of principles for India were put together based on an interactive process between authors, taking into consideration the existing evidence on BIA and features of Indian healthcare system. These were reviewed by Technical Appraisal Committee (TAC) of Health Technology Assessment in India (HTAIn) for their inputs. Three rounds of consultations were held before finalising the guidelines. Finally, user feedback on the draft guidelines was obtained from the policy makers and programme managers involved in the budgeting decisions.

RESULTS

We recommend a payer's perspective, which will include both a multi-payer (depicting the current situation in India) and a single-payer scenario (which reflects a futuristic universal health care situation). A time horizon of 1-4 years is recommended. For estimation of eligible population, a top-down approach is considered appropriate. The future and current mix of interventions should be analysed for different utilisation and coverage patterns. We do not recommend discounting; however, inflation adjustments should be performed. The presentation of results should include total and disaggregated results, segregated year-wise throughout the chosen time horizon, as well as segregated by the type of resources. Deterministic sensitivity analysis and scenario analysis are recommended to address uncertainty.

CONCLUSION

Our recommendations, which are tailored for the Indian healthcare and financing context, aim to promote consistency and transparency in the conduct as well as reporting of the BIA. BIA should be used along with evidence from economic evaluation for decision making, and not as a substitute to evidence on value for money.

Integrating HIV services and other health services: A systematic review and meta-analysis

BACKGROUND

Integration of HIV services with other health services has been proposed as an important strategy to boost the sustainability of the global HIV response. We conducted a systematic and comprehensive synthesis of the existing scientific evidence on the impact of service integration on the HIV care cascade, health outcomes, and cost-effectiveness.

METHODS AND FINDINGS

We reviewed the global quantitative empirical evidence on integration published between 1 January 2010 and 10 September 2021. We included experimental and observational studies that featured both an integration intervention and a comparator in our review. Of the 7,118 unique peer-reviewed English-language studies that our search algorithm identified, 114 met all of our selection criteria for data extraction. Most of the studies (90) were conducted in sub-Saharan Africa, primarily in East Africa (55) and Southern Africa (24). The most common forms of integration were (i) HIV testing and counselling added to non-HIV services and (ii) non-HIV services added to antiretroviral therapy (ART). The most commonly integrated non-HIV services were maternal and child healthcare, tuberculosis testing and treatment, primary healthcare, family planning, and sexual and reproductive health services. Values for HIV care cascade outcomes tended to be better in integrated services: uptake of HIV testing and counselling (pooled risk ratio [RR] across 37 studies: 1.67 [95% CI 1.41-1.99], p < 0.001), ART initiation coverage (pooled RR across 19 studies: 1.42 [95% CI 1.16-1.75], p = 0.002), time until ART initiation (pooled RR across 5 studies: 0.45 [95% CI 0.20-1.00], p = 0.050), retention in HIV care (pooled RR across 19 studies: 1.68 [95% CI 1.05-2.69], p = 0.031), and viral suppression (pooled RR across 9 studies: 1.19 [95% CI 1.03-1.37], p = 0.025). Also, treatment success for non-HIV-related diseases and conditions and the uptake of non-HIV services were commonly higher in integrated services. We did not find any significant differences for the following outcomes in our meta-analyses: HIV testing yield, ART adherence, HIV-free survival among infants, and HIV and non-HIV mortality. We could not conduct meta-analyses for several outcomes (HIV infections averted, costs, and cost-effectiveness), because our systematic review did not identify sufficient poolable studies. Study limitations included possible publication bias of studies with significant or favourable findings and comparatively weak evidence from some world regions and on integration of services for key populations in the HIV response.

CONCLUSIONS

Integration of HIV services and other health services tends to improve health and health systems outcomes. Despite some scientific limitations, the global evidence shows that service integration can be a valuable strategy to boost the sustainability of the HIV response and contribute to the goal of 'ending AIDS by 2030', while simultaneously supporting progress towards universal health coverage.

Health Economics in the Field of Prosthetics and Orthotics: A Global Perspective

The rapid advancement of prosthetic and orthotic (P&O) technology raises the question how the industry can ensure that patients have access to the benefits and providers get paid properly and fairly by healthcare payers. This is a challenge that not only P&O but all areas of health technology face. In many areas of medicine and health products, such as drugs and medical devices, health-technology assessments (HTA) have become a standard procedure in the coverage and reimbursement process. In most countries, P&O is lagging behind that development, although some countries have already formalized HTA for prosthetic and orthotic products and may even use cost-effectiveness analyses to determine pricing and payment amounts. This article gives an overview on the coverage and reimbursement processes in the United States, Canada, Germany, France, Sweden, the United Kingdom, Poland, Japan, and China. This selection reflects the variety and diversity of coverage and reimbursement processes that the P&O industry faces globally. The paper continues with an overview on the necessary research and investment efforts that manufacturers will have to make in the future, and contemplates the likely consequences for the manufacturer community in the market place. Health economics may help support the transition from price-based to value-based coverage and reimbursement but will come at considerable costs to the industry.

An Introduction to the Main Types of Economic Evaluations Used for Informing Priority Setting and Resource Allocation in Healthcare: Key Features, Uses, and Limitations

Economic evidence is increasingly being used for informing health policies. However, the underlining principles of health economic analyses are not always fully understood by non-health economists, and inappropriate types of analyses, as well as inconsistent methodologies, may be being used for informing health policy decisions. In addition, there is a lack of open access information and methodological guidance targeted to public health professionals, particularly those based in low- and middle-income country (LMIC) settings. The objective of this review is to provide a comprehensive and accessible introduction to economic evaluations for public health professionals with a focus on LMIC settings. We cover the main principles underlining the most common types of full economic evaluations used in healthcare decision making in the context of priority setting (namely cost-effectiveness/cost-utility analyses, cost-benefit analyses), and outline their key features, strengths and weaknesses. It is envisioned that this will help those conducting such analyses, as well as stakeholders that need to interpret their output, gain a greater understanding of these methods and help them select/distinguish between the different approaches. In particular, we highlight the need for greater awareness of the methods used to place a monetary value on the health benefits of interventions, and the potential for such estimates to be misinterpreted. Specifically, the economic benefits reported are typically an approximation, summarising the health benefits experienced by a population monetarily in terms of individual preferences or potential productivity gains, rather than actual realisable or fiscal monetary benefits to payers or society.

Considering potential solutions for limitations and challenges in the health economic evaluation of gene therapies

INTRODUCTION

The limited evidence in the clinical trials of gene therapies (GTs) posed substantial challenges for a reliable health technology assessment (HTA). This paper provides insights into the relationship between the background of diseases and the health economics assessment of GTs.Areas covered: The impacts of differentiated severity and unmet needs of genetic diseases, on the economic analysis of GTs, were discussed.Expert opinion: GTs offer a potential cure or significant clinical improvement, while limitations in clinical evidence constitute major obstacles for a robust assessment of clinical effectiveness and economic outcomes. This uncertainty may be balanced by the severity of the targeted condition and the associated unmet needs, thus leading to a relatively higher acceptance for GTs. Overtime, HTA agencies will become more demanding on comprehensive evidence of long-term effectiveness. With a growing number of GTs on the horizon, to what extent the unmet needs of previously devastating diseases will be fulfilled remain unclear. Nonetheless, comparative studies, either with a historical control group or existing treatments, will be necessary to demonstrate the additional benefits associated with GTs.

Cost-Effectiveness of a Culturally Adapted Manual-Assisted Brief Psychological Intervention for Self-Harm in Pakistan: A Secondary Analysis of the Culturally Adapted Manual-Assisted Problem-Solving Training Randomized Controlled Trial

OBJECTIVES

Self-harm is a serious public health problem. A culturally adapted manual-assisted problem-solving training (C-MAP) intervention improved and sustained the reduction in suicidal ideation, hopelessness, and depression compared with treatment as usual (TAU) alone. Here, we evaluate its cost-effectiveness.

METHODS

Patients admitted after an episode of self-harm were randomized individually to either C-MAP plus TAU or TAU alone in Karachi. Improvement in health-related quality-adjusted life years (QALYs) was measured using the Euro Qol-5D-3L instrument at baseline and at 3 months and 6 months after randomization. The primary economic outcome was health service cost per QALY gained as the incremental cost-effectiveness ratio, based on 2019 US dollars and a 6-month time horizon. Nonparametric bootstrapping was used to assess uncertainties, and sensitivity analysis to examine the impact of hospitalization costs.

RESULTS

A total of 108 and 113 participants were enrolled among the intervention and standard arms, respectively. The intervention resulted in 0.04 more QALYs (95% confidence interval [CI] 0.00-0.08) 6 months after enrolment. The mean cost per participant in the intervention arm was US $1001 (95% CI 968-1031), resulting in an incremental cost of the intervention of US $640 (95% CI 595-679). The incremental cost-effectiveness ratio for the C-MAP intervention versus TAU was US $16 254 (95% CI 7116-99 057) per QALY gained. The probability that C-MAP is cost-effective was between 66% and 83% for cost-effective thresholds between US $20 000 and US $30 000. Cost-effectiveness results remained robust to sensitivity analyses.

CONCLUSIONS

C-MAP may be a valuable self-harm intervention. Further studies with longer follow-up and larger sample sizes are needed to draw reliable conclusions.

Economic evaluation of point-of-care testing and treatment for sexually transmitted and genital infections in pregnancy in low- and middle-income countries: A systematic review

BACKGROUND

Sexually transmitted and genital infections in pregnancy are associated with adverse pregnancy and birth outcomes. Point-of-care tests for these infections facilitate testing and treatment in a single antenatal clinic visit and may reduce the risk of adverse outcomes. Successful implementation and scale-up depends on understanding comparative effectiveness of such programmes and their comparative costs and cost effectiveness. This systematic review synthesises and appraises evidence from economic evaluations of point-of-care testing and treatment for sexually transmitted and genital infections among pregnant women in low- and middle-income countries.

METHODS

Medline, Embase and Web of Science databases were comprehensively searched using pre-determined criteria. Additional literature was identified by searching Google Scholar and the bibliographies of all included studies. Economic evaluations were eligible if they were set in low- and middle-income countries and assessed antenatal point-of-care testing and treatment for syphilis, chlamydia, gonorrhoea, trichomoniasis, and/or bacterial vaginosis. Studies were analysed using narrative synthesis. Methodological and reporting standards were assessed using two published checklists.

RESULTS

Sixteen economic evaluations were included in this review; ten based in Africa, three in Latin and South America and three were cross-continent comparisons. Fifteen studies assessed point-of-care testing and treatment for syphilis, while one evaluated chlamydia. Key drivers of cost and cost-effectiveness included disease prevalence; test, treatment, and staff costs; test sensitivity and specificity; and screening and treatment coverage. All studies met 75% or more of the criteria of the Drummond Checklist and 60% of the Consolidated Health Economics Evaluation Reporting Standards.

CONCLUSIONS

Generally, point-of-care testing and treatment was cost-effective compared to no screening, syndromic management, and laboratory-based testing. Future economic evaluations should consider other common infections, and their lifetime impact on mothers and babies. Complementary affordability and equity analyses would strengthen the case for greater investment in antenatal point-of-care testing and treatment for sexually transmitted and genital infections.

Cost-Effectiveness of Improved Hypertension Management in India through Increased Treatment Coverage and Adherence: A Mathematical Modeling Study

Background:

Despite the availability of effective and affordable treatments, only 14% of hypertensive Indians have controlled blood pressure. Increased hypertension treatment coverage (the proportion of individuals initiated on treatment) and adherence (proportion of patients taking medicines as recommended) promise population health gains. However, governments and other payers will not invest in a large-scale hypertension control program unless it is both affordable and effective.

Objective:

To investigate if a national hypertension control intervention implemented across the private and public sector facilities in India could save overall costs of CVD prevention and treatment.

Methods:

We developed a discrete-time microsimulation model to assess the cost-effectiveness of population-level hypertension control intervention in India for combinations of treatment coverage and adherence targets. Input clinical parameters specific to India were obtained from large-scale surveys such as the Global Burden of Disease as well as local clinical trials. Input hypertensive medication cost parameters were based on government contracts. The model projected antihypertensive treatment costs, avoided CVD care costs, changes in disability-adjusted life year (DALYs) and incremental cost per DALY averted (represented as incremental cost-effectiveness ratio or ICER) over 20 years.

Results:

Over 20 years, at 70% coverage and adherence, the hypertension control intervention would avert 1.68% DALYs and be cost-saving overall. Increasing adherence (while keeping coverage constant) resulted in greater improvement in cost savings compared to increasing coverage (while keeping adherence constant). Results were most sensitive to the cost of antihypertensive medication, but the intervention remained highly cost-effective under all one-way sensitivity analyses.

Conclusion:

A national hypertension control intervention in India would most likely be budget neutral or cost-saving if the intervention can achieve and maintain high levels of both treatment coverage and adherence.

Do low-cost economic incentives motivate healthy behavior?

We conducted a field experiment to test the effectiveness of a conditional, low-cost, and recurring financial incentive in motivating recreation center visits. Results indicate that the financial incentive did not motivate students' recreation center visits. However, it was successful in increasing the frequency of recreation center visits for female students who had an established exercise habit. For a payout of $0.50, we estimate an increase of 0.4 visits per week for female students with established exercise habits. This provides modest evidence that the financial incentive structure was able to increase the behavioral response at the intensive margin. Our results show that the design of our financial incentive was not effective on the extensive margin. There was also no effect of the financial incentive on the recreation center visits for male students.

Cost-effectiveness of ribociclib plus letrozole versus palbociclib plus letrozole or letrozole as monotherapy in first-line treatment of postmenopausal women with HR+/HER2- locally advanced or metastatic breast cancer: a Brazilian private payer perspective

BACKGROUND

The global burden of breast cancer (BC) is high, especially in advanced stages. CDK 4/6 inhibitors represent a paradigm shift in the treatment of advanced BC HR+/HER2-, given the clinically and statistically significant gain in overall survival associated with this new class of medications. Nevertheless, as an innovation, the incorporation of these drugs impacts healthcare budgets, requiring cost-effectiveness analyses for decision-making. The aim of this study was to evaluate the cost-effectiveness of ribociclib plus letrozole compared with palbociclib plus letrozole or letrozole as monotherapy for first-line treatment of postmenopausal women with HR+/HER2- locally advanced or metastatic BC (aBC) from a Brazilian private healthcare system perspective.

METHODS

A model including progression-free survival (PFS), progressed disease, and death health states was used to simulate lifetime costs and outcomes. PFS and overall survival were derived from the MONALEESA-2 trial (lifetime horizon). Healthcare costs included drug acquisition and monitoring, subsequent therapies, adverse events, and end-of-life costs. Effectiveness was measured in quality-adjusted life-years (QALYs). Deterministic and probabilistic sensitivity analyses were performed.

RESULTS

The total cost of treatment with ribociclib plus letrozole was USD 72,091.82 versus USD 92,749.64 for palbociclib plus letrozole. Total QALYs were 3.30 and 3.16, respectively. Base-case analysis showed ribociclib as dominant over palbociclib in first-line treatment of women with HR+/HER2- aBC, associated with cost savings and QALY gains. The total cost of treatment with ribociclib plus letrozole was USD 83,058.73 versus USD 29,215.10 for letrozole. Total QALYs were 3.84 and 2.61, respectively. Compared with letrozole, ribociclib plus letrozole was associated with an incremental cost of USD 53,843.64 and an incremental QALY gain of 1.23, with incremental cost-effectiveness ratio of USD 43,826.91 per QALY gained.

CONCLUSIONS

As demonstrated by the cost-effectiveness dominance over palbociclib, ribociclib results in savings when used as first-line treatment in postmenopausal women with HR+/HER2- aBC, warranting incorporation in the private healthcare system.

Affordability of Adult Tuberculosis Vaccination in India and China: A Dynamic Transmission Model-Based Analysis

New tuberculosis vaccines have made substantial progress in the development pipeline. Previous modelling suggests that adolescent/adult mass vaccination may cost-effectively contribute towards achieving global tuberculosis control goals. These analyses have not considered the budgetary feasibility of vaccine programmes. We estimate the maximum total cost that the public health sectors in India and China should expect to pay to introduce a M72/AS01_E-like vaccine deemed cost-effective at country-specific willingness to pay thresholds for cost-effectiveness. To estimate the total disability adjusted life years (DALYs) averted by the vaccination programme, we simulated a 50% efficacy vaccine providing 10-years of protection in post-infection populations between 2027 and 2050 in India and China using a dynamic transmission model of M. tuberculosis. We investigated two mass vaccination strategies, both delivered every 10-years achieving 70% coverage: Vaccinating adults and adolescents (age ≥10y), or only the most efficient 10-year age subgroup (defined as greatest DALYs averted per vaccine given). We used country-specific thresholds for cost-effectiveness to estimate the maximum total cost (C_max) a government should be willing to pay for each vaccination strategy. Adult/adolescent vaccination resulted in a C_max of $21 billion (uncertainty interval [UI]: 16–27) in India, and $15B (UI:12–29) in China at willingness to pay thresholds of $264/DALY averted and $3650/DALY averted, respectively. Vaccinating the highest efficiency age group (India: 50–59y; China: 60–69y) resulted in a C_max of $5B (UI:4–6) in India and $6B (UI:4–7) in China. Mass vaccination against tuberculosis of all adults and adolescents, deemed cost-effective, will likely impose a substantial budgetary burden. Targeted tuberculosis vaccination, deemed cost-effective, may represent a more affordable approach.

The cost-effectiveness of computer navigation in primary total knee replacement: a scoping review

Despite additional costs associated with the use of computer navigation technology in total knee replacement (TKR), its impact on quality-adjusted life years following surgery has not been demonstrated. Cost-effectiveness evaluations require a balanced assessment of both quality and cost metrics.

This review sought to evaluate the cost-effectiveness of computer navigation, identify barriers to translation, and suggest directions for further investigation. A systematic search of the Cost-Effectiveness Analysis Registry, PubMed, and Embase was undertaken.

Cost-effectiveness analyses of computer navigation in primary total knee replacement were identified. Only primary studies of cost-effectiveness analyses published in the English language from the year 2000 onwards were included. Studies that reported secondary data were excluded from the analysis. Four publications met the inclusion criteria.

Estimated gains in quality-adjusted life years attributed to reductions in revision surgery were 0.0148 to 0.0164 over 10 years, and 0.0192 (95% CI –0.002 to 0.0473) over 15 years. Cost estimates ranged from 952 kr (US $90, 2020) per case at 250 TKRs/year, to $1,920 US per case at 25 TKRs/year.

The estimated probability of meeting local cost-effectiveness thresholds was 54% in the United States and 92% in the United Kingdom. These data were not available for Norway.

The cost-effectiveness of computer navigation in current practice settings remains uncertain, with the use of this technology associated with marginal increased quality-adjusted life years (QALYs) at additional cost. Existing analyses demonstrated a number of limitations which restrict the potential for translation to practice and policy settings. Further research evaluating the impact of computer navigation on QALYs following primary TKR is required to inform contemporary cost-effectiveness evaluations.

Cite this article: EFORT Open Rev 2021;6:173-180. DOI: 10.1302/2058-5241.6.200073

Real-World Evidence: Bridging Gaps in Evidence to Guide Payer Decisions

Randomized controlled trials (RCTs) are preferred by payers for health technology assessments and coverage decisions. However, the inclusion of a highly selective patient population and the rigorously controlled conditions in RCTs may not be reflective of real-world clinical practice. Real-world evidence (RWE) obtained from an analysis of real-world data (RWD) from observational studies can bridge gaps in evidence not addressed by RCTs and is thus valuable to public and private payers for decision-making. Through a broad literature search to obtain insights into payers' experience, we found that payers have concerns about real-world studies with respect to data quality, poor internal validity, potential bias, and lack of meaningful endpoints. However, they valued RWE to fill evidence gaps not addressed by RCTs, such as high-quality, real-world, long-term effectiveness and safety data; head-to-head drug comparisons; cost analyses for tiering formulary placement; medication use and adherence patterns; identification of relevant responder and non-responder patient subpopulations; and patient-reported outcomes (PROs). RWE can be used to assess clinically meaningful endpoints and gauge the impact of interventions on the quality of healthcare. Here, we review how payers use or can use RWD on the comparative effectiveness and safety of treatments, PROs, medication adherence and persistence, prescribing patterns, healthcare resource utilization, and patient characteristics and/or biomarkers associated with treatment response when making health technology assessments and payer coverage decisions across therapeutic areas.

Cryptococcal Meningitis Screening and Community-based Early Adherence Support in People With Advanced Human Immunodeficiency Virus Infection Starting Antiretroviral Therapy in Tanzania and Zambia: A Cost-effectiveness Analysis

Background

A randomized trial demonstrated that among people living with late-stage human immunodeficiency virus (HIV) infection initiating antiretroviral therapy, screening serum for cryptococcal antigen (CrAg) combined with adherence support reduced all-cause mortality by 28%, compared with standard clinic-based care. Here, we present the cost-effectiveness.

Methods

HIV-infected adults with CD4 count <200 cells/μL were randomized to either CrAg screening plus 4 weekly home visits to provide adherence support or to standard clinic-based care in Dar es Salaam and Lusaka. The primary economic outcome was health service care cost per life-year saved as the incremental cost-effectiveness ratio (ICER), based on 2017 US dollars. We used nonparametric bootstrapping to assess uncertainties and univariate deterministic sensitivity analysis to examine the impact of individual parameters on the ICER.

Results

Among the intervention and standard arms, 1001 and 998 participants, respectively, were enrolled. The annual mean cost per participant in the intervention arm was US$339 (95% confidence interval [CI], $331–$347), resulting in an incremental cost of the intervention of US$77 (95% CI, $66–$88). The incremental cost was similar when analysis was restricted to persons with CD4 count <100 cells/μL. The ICER for the intervention vs standard care, per life-year saved, was US$70 (95% CI, $43–$211) for all participants with CD4 count up to 200 cells/μL and US$91 (95% CI, $49–$443) among those with CD4 counts <100 cells /μL. Cost-effectveness was most sensitive to mortality estimates.

Conclusions

Screening for cryptococcal antigen combined with a short period of adherence support, is cost-effective in resource-limited settings.

Optimizing infant HIV diagnosis with additional screening at immunization clinics in three sub-Saharan African settings: a cost-effectiveness analysis

INTRODUCTION

Uptake of early infant HIV diagnosis (EID) varies widely across sub-Saharan African settings. We evaluated the potential clinical impact and cost-effectiveness of universal maternal HIV screening at infant immunization visits, with referral to EID and maternal antiretroviral therapy (ART) initiation.

METHODS

Using the CEPAC-Pediatric model, we compared two strategies for infants born in 2017 in Côte d'Ivoire (CI), South Africa (SA), and Zimbabwe: (1) existing EID programmes offering six-week nucleic acid testing (NAT) for infants with known HIV exposure (EID), and (2) EID plus universal maternal HIV screening at six-week infant immunization visits, leading to referral for infant NAT and maternal ART initiation (screen-and-test). Model inputs included published Ivoirian/South African/Zimbabwean data: maternal HIV prevalence (4.8/30.8/16.1%), current uptake of EID (40/95/65%) and six-week immunization attendance (99/74/94%). Referral rates for infant NAT and maternal ART initiation after screen-and-test were 80%. Costs included NAT ($24/infant), maternal screening ($10/mother-infant pair), ART ($5 to 31/month) and HIV care ($15 to 190/month). Model outcomes included mother-to-child transmission of HIV (MTCT) among HIV-exposed infants, and life expectancy (LE) and mean lifetime per-person costs for children with HIV (CWH) and all children born in 2017. We calculated incremental cost-effectiveness ratios (ICERs) using discounted (3%/year) lifetime costs and LE for all children. We considered two cost-effectiveness thresholds in each country: (1) the per-capita GDP ($1720/6380/2150) per year-of-life saved (YLS), and (2) the CEPAC-generated ICER of offering 2 versus 1 lifetime ART regimens (e.g. offering second-line ART; $520/500/580/YLS).

RESULTS

With EID, projected six-week MTCT was 9.3% (CI), 4.2% (SA) and 5.2% (Zimbabwe). Screen-and-test decreased total MTCT by 0.2% to 0.5%, improved LE by 2.0 to 3.5 years for CWH and 0.03 to 0.07 years for all children, and increased discounted costs by $17 to 22/child (all children). The ICER of screen-and-test compared to EID was $1340/YLS (CI), $650/YLS (SA) and $670/YLS (Zimbabwe), below the per-capita GDP but above the ICER of 2 versus 1 lifetime ART regimens in all countries.

CONCLUSIONS

Universal maternal HIV screening at immunization visits with referral to EID and maternal ART initiation may reduce MTCT, improve paediatric LE, and be of comparable value to current HIV-related interventions in high maternal HIV prevalence settings like SA and Zimbabwe.

What next after GDP-based cost-effectiveness thresholds?

Public payers around the world are increasingly using cost-effectiveness thresholds (CETs) to assess the value-for-money of an intervention and make coverage decisions. However, there is still much confusion about the meaning and uses of the CET, how it should be calculated, and what constitutes an adequate evidence base for its formulation. One widely referenced and used threshold in the last decade has been the 1-3 GDP per capita, which is often attributed to the Commission on Macroeconomics and  WHO guidelines on Choosing Interventions that are Cost Effective (WHO-CHOICE). For many reasons, however, this threshold has been widely criticised; which has led experts across the world, including the WHO, to discourage its use. This has left a vacuum for policy-makers and technical staff at a time when countries are wanting to move towards Universal Health Coverage .

This article seeks to address this gap by offering five practical options for decision-makers in low- and middle-income countries that can be used instead of the 1-3 GDP rule, to combine existing evidence with fair decision-rules or develop locally relevant CETs. It builds on existing literature as well as an engagement with a group of experts and decision-makers working in low, middle and high income countries.

Determining if Telehealth Can Reduce Health System Costs: Scoping Review

BACKGROUND

Telehealth represents an opportunity for Australia to harness the power of technology to redesign the way health care is delivered. The potential benefits of telehealth include increased accessibility to care, productivity gains for health providers and patients through reduced travel, potential for cost savings, and an opportunity to develop culturally appropriate services that are more sensitive to the needs of special populations. The uptake of telehealth has been hindered at times by clinician reluctance and policies that preclude metropolitan populations from accessing telehealth services.

OBJECTIVE

This study aims to investigate if telehealth reduces health system costs compared with traditional service models and to identify the scenarios in which cost savings can be realized.

METHODS

A scoping review was undertaken to meet the study aims. Initially, literature searches were conducted using broad terms for telehealth and economics to identify economic evaluation literature in telehealth. The investigators then conducted an expert focus group to identify domains where telehealth could reduce health system costs, followed by targeted literature searches for corresponding evidence.

RESULTS

The cost analyses reviewed provided evidence that telehealth reduced costs when health system-funded travel was prevented and when telehealth mitigated the need for expensive procedural or specialist follow-up by providing competent care in a more efficient way. The expert focus group identified 4 areas of potential savings from telehealth: productivity gains, reductions in secondary care, alternate funding models, and telementoring. Telehealth demonstrated great potential for productivity gains arising from health system redesign; however, under the Australian activity-based funding, it is unlikely that these gains will result in cost savings. Secondary care use mitigation is an area of promise for telehealth; however, many studies have not demonstrated overall cost savings due to the cost of administering and monitoring telehealth systems. Alternate funding models from telehealth systems have the potential to save the health system money in situations where the consumers pay out of pocket to receive services. Telementoring has had minimal economic evaluation; however, in the long term it is likely to result in inadvertent cost savings through the upskilling of generalist and allied health clinicians.

CONCLUSIONS

Health services considering implementing telehealth should be motivated by benefits other than cost reduction. The available evidence has indicated that although telehealth provides overwhelmingly positive patient benefits and increases productivity for many services, current evidence suggests that it does not routinely reduce the cost of care delivery for the health system.

Increasing Human Papillomavirus Vaccination and Cervical Cancer Screening in Nigeria: An Assessment of Community-Based Educational Interventions

We explored the impact of two community-based educational interventions on Nigerian adults' knowledge and intention to take or encourage human papillomavirus (HPV) vaccine and cervical screenings. Face-to-face presentation and printed pamphlet intervention were delivered to 266 men and women aged 18 to 65 years in 12 locations in urban setting. At baseline, the majority (80%) had poor knowledge of HPV, and less than 12% had ever received or have a family member who had received HPV vaccine or cervical screening. Postintervention, there was significant increase (>70%) in the participants knowledge and intention to take or encourage HPV vaccination and cervical screening. In addition, more than half were willing to pay for HPV vaccine and screening even when expensive. Gender-focused and context-specific low-cost community-based educational interventions are effective in increasing HPV vaccine and cervical screening in sub-Saharan Africa.

A situation analysis of the state of supply of in vitro diagnostics in Low-Income Countries

In vitro diagnostics (IVDs) are medical devices and accessories used to test bodily samples for causative agents of disease. IVDs play a central role in the diagnosis of individuals, in the rationale use of medicines, in burden of disease estimates, as well as in public health surveillance; especially for detection of emerging epidemics, the identification and monitoring of antimicrobial resistance, and the documentation of infection rates in populations. This article examines how the state of (a) product quality, (b) pricing, and (c) development country manufacturing capacity, are affecting the supply of IVDs in Low-Income Countries (LICs). Data informing this work is derived from interviews with representatives of leading stakeholder organisations working in this space, and analysis of secondary literature. The findings of this analysis are that the supply of IVDs in LICs is undermined by (i) significant variation in product quality; (ii) inconsistent market demand from governments; (iii) limited opportunities for pooled procurement; (iv) a lack of transparency and consistency in product pricing; and (v) insufficient competition among producers capable of innovating for populations with limited purchasing power and low-resource settings. The article then examines four strategies for how these challenges can be overcome.

How do decision-makers use evidence in community health policy and financing decisions? A qualitative study and conceptual framework in four African countries

Various investments could help countries deliver on the universal health coverage (UHC) goals set by the global community; community health is a pillar of many national strategies towards UHC. Yet despite resource mobilization towards this end, little is known about the potential costs and value of these investments, as well as how evidence on the same would be used in related decisions. This qualitative study was conducted to understand the use of evidence in policy and financing decisions for large-scale community health programmes in low- and middle-income countries. Through key informant interviews with 43 respondents in countries with community health embedded in national UHC strategies (Ethiopia, Kenya, Malawi, Mozambique) and at global institutions, we investigated evidence use in community health financing and policy decision-making, as well as evidentiary needs related to community health data for decision-making. We found that evidence use is limited at all levels, in part due to a perceived lack of high-quality, relevant evidence. This perception stems from two main areas: first, desire for local evidence that reflects the context, and second, much existing economic evidence does not deal with what decision-makers value when it comes to community health systems-i.e. coverage and (to a lesser extent) quality. Beyond the evidence gap, there is limited capacity to assess and use the evidence. Elected officials also face political challenges to disinvestment as well as structural obstacles to evidence use, including the outsized influence of donor priorities. Evaluation data must to speak to decision-maker interests and constraints more directly, alongside financiers of community health providing explicit guidance and support on the role of evidence use in decision-making, empowering national decision-makers. Improved data quality, increased relevance of evidence and capacity for evidence use can drive improved efficiency of financing and evidence-based policymaking.

Healthcare Costs and Life-years Gained From Treatments Within the Advancing Cryptococcal Meningitis Treatment for Africa (ACTA) Trial on Cryptococcal Meningitis: A Comparison of Antifungal Induction Strategies in Sub-Saharan Africa

Background

Mortality from cryptoccocal meningitis remains high. The ACTA trial demonstrated that, compared with 2 weeks of amphotericin B (AmB) plus flucystosine (5FC), 1 week of AmB and 5FC was associated with lower mortality and 2 weeks of oral flucanozole (FLU) plus 5FC was non-inferior. Here, we assess the cost-effectiveness of these different treatment courses.

Methods

Participants were randomized in a ratio of 2:1:1:1:1 to 2 weeks of oral 5FC and FLU, 1 week of AmB and FLU, 1 week of AmB and 5FC, 2 weeks of AmB and FLU, or 2 weeks of AmB and 5FC in Malawi, Zambia, Cameroon, and Tanzania. Data on individual resource use and health outcomes were collected. Cost-effectiveness was measured as incremental costs per life-year saved, and non-parametric bootstrapping was done.

Results

Total costs per patient were US $1442 for 2 weeks of oral FLU and 5FC, $1763 for 1 week of AmB and FLU, $1861 for 1 week of AmB and 5FC, $2125 for 2 weeks of AmB and FLU, and $2285 for 2 weeks of AmB and 5FC. Compared to 2 weeks of AmB and 5FC, 1 week of AmB and 5FC was less costly and more effective and 2 weeks of oral FLU and 5FC was less costly and as effective. The incremental cost-effectiveness ratio for 1 week of AmB and 5FC versus oral FLU and 5FC was US $208 (95% confidence interval $91–1210) per life-year saved.

Clinical Trials Registration

ISRCTN45035509.

Conclusions

Both 1 week of AmB and 5FC and 2 weeks of Oral FLU and 5FC are cost-effective treatments.

Effectiveness of embedding a specialist preventive care clinician in a community mental health service in increasing preventive care provision: A randomised controlled trial

OBJECTIVE

Clinical practice guidelines recommend that community mental health services provide preventive care for clients' chronic disease risk behaviours; however, such care is often not routinely provided. This study aimed to assess the effectiveness of offering clients an additional consultation with a specialist clinician embedded within a community mental health service, in increasing client-reported receipt of, and satisfaction with, preventive care.

METHOD

A randomised controlled trial was undertaken in one Australian community mental health service. Participants (N = 811) were randomised to receive usual care (preventive care in routine consultations; n = 405) or usual care plus the offer of an additional consultation with a specialist preventive care clinician (n = 406). Blinded interviewers assessed at baseline and 1-month follow-up the client-reported receipt of preventive care (assessment, advice and referral) for four key risk behaviours individually (smoking, poor nutrition, alcohol overconsumption and physical inactivity) and all applicable risks combined, acceptance of referrals and satisfaction with preventive care received.

RESULTS

Analyses indicated significantly greater increases in 12 of the 18 preventive care delivery outcomes in the intervention compared to the usual care condition from baseline to follow-up, including assessment for all risks combined (risk ratio = 4.00; 95% confidence interval = [1.57, 10.22]), advice for all applicable risks combined (risk ratio = 2.40; 95% confidence interval = [1.89, 6.47]) and offer of referral to applicable telephone services combined (risk ratio = 20.13; 95% confidence interval = [2.56, 158.04]). For each component of care, there was a significant intervention effect for at least one of the individual risk behaviours. Participants reported high levels of satisfaction with preventive care received, ranging from 77% (assessment) to 87% (referral), with no significant differences between conditions.

CONCLUSION

The intervention had a significant effect on the provision of the majority of recommended elements of preventive care. Further research is needed to maximise its impact, including identifying strategies to increase client uptake.

Japanese encephalitis vaccination in the Philippines: A cost-effectiveness analysis comparing alternative delivery strategies

INTRODUCTION

Japanese encephalitis (JE) is a mosquito-borne viral infection of the brain that can cause permanent brain damage and death. In the Philippines, efforts are underway to deliver a live attenuated JE vaccine (CD-JEV) to children under five years of age (YOA), who are disproportionately infected. Multiple vaccination strategies are being considered.

METHODS

We conducted a cost-effectiveness analysis comparing three vaccination strategies to the current state of no vaccination from the societal and government perspectives: (1) national routine vaccination only, (2) sub-national campaign followed by national routine, and (3) national campaign followed by national routine. We developed a Markov model to estimate impact of vaccination or no vaccination over the child's lifetime horizon, assuming an annual incidence of 10.6 cases per 100,000. Costs of illness ($859/case), vaccine ($0.50/dose), routine vaccination ($0.95/dose), and campaign vaccination ($0.98/dose) were based on hospital financial records, expert opinion and literature. The societal perspective included transportation and opportunity costs of caregiver time, in addition to costs incurred by the health system.

RESULTS

JE vaccination via national campaign followed by national routine delivery was the most cost-effective strategy modeled with a cost per disability adjusted life year (DALY) averted of $233 and $29 from the government and societal perspectives, respectively. Results were similar for other delivery strategies with cost/DALY ranging from $233 to $265 from the government perspective and $29-$57 from the societal perspective. JE vaccination was projected to prevent 27,856-37,277 cases, 5571-7455 deaths, and 173,233-230,704 DALYs among children under five over 20 consecutive birth cohorts. Total incremental costs of vaccination versus no vaccination over 20 birth cohorts were $6.6-$9.8 million from the societal perspective ($230 K-$440 K annually) and $45.9-$53.9 million ($2.2 M-$2.7 M annually) from the governmental perspective.

CONCLUSION

Vaccination with CD-JEV in the Philippines is projected to be cost-effective, reducing long-term costs associated with JE illness and improving health outcomes compared to no vaccination.

Conducting Value for Money Analyses for Non-randomised Interventional Studies Including Service Evaluations: An Educational Review with Recommendations

This article provides an educational review covering the consideration of conducting ‘value for money’ analyses as part of non-randomised study designs including service evaluations. These evaluations represent a vehicle for producing evidence such as value for money of a care intervention or service delivery model. Decision makers including charities and local and national governing bodies often rely on evidence from non-randomised data and service evaluations to inform their resource allocation decision-making. However, as randomised data obtained from randomised controlled trials are considered the ‘gold standard’ for assessing causation, the use of this alternative vehicle for producing an evidence base requires careful consideration. We refer to value for money analyses, but reflect on methods associated with economic evaluations as a form of analysis used to inform resource allocation decision-making alongside a finite budget. Not all forms of value for money analysis are considered a full economic evaluation with implications for the information provided to decision makers. The type of value for money analysis to be conducted requires considerations such as the outcome(s) of interest, study design, statistical methods to control for confounding and bias, and how to quantify and describe uncertainty and opportunity costs to decision makers in any resulting value for money estimates. Service evaluations as vehicles for producing evidence present different challenges to analysts than what is commonly associated with research, randomised controlled trials and health technology appraisals, requiring specific study design and analytic considerations. This educational review describes and discusses these considerations, as overlooking them could affect the information provided to decision makers who may make an ‘ill-informed’ decision based on ‘poor’ or ‘inaccurate’ information with long-term implications. We make direct comparisons between randomised controlled trials relative to non-randomised data as vehicles for assessing causation; given ‘gold standard’ randomised controlled trials have limitations. Although we use UK-based decision makers as examples, we reflect on the needs of decision makers internationally for evidence-based decision-making specific to resource allocation. We make recommendations based on the experiences of the authors in the UK, reflecting on the wide variety of methods available, used as documented in the empirical literature. These methods may not have been fully considered relevant to non-randomised study designs and/or service evaluations, but could improve and aid the analysis conducted to inform the relevant value for money decision problem.

Interpreting social determinants: Emergent properties and adolescent risk behaviour

A link between adversity, including low socio-economic status, and behaviours which carry health risks, such as alcohol consumption, has often been observed. The causes of this link are, however, poorly understood, making it difficult to explain why the association is often not linear and why there is so much variability between groups and individuals facing similar adversity. We investigate the use of the concept of emergent properties in explaining the link and its non-linear nature. `Emergent properties’ arise from the interaction of factors or items in a high-level system which, as a result, has qualities possessed by none of the individual factors. We apply a mixed methods approach to examine the association of an example emergent property, hope, and alcohol consumption among adolescents in a rural South African site. We found that among adolescents living in similar contexts, there was enough variance in reported levels of hope, that an association with alcohol use could be identified. This result is cause for optimism regarding the potential use of emergent properties in explaining variations in risk behaviour. Improving our measurement of emergent properties is perhaps the biggest challenge facing this approach. More work is needed to take further the task of identifying emergent properties capable of distilling the influence of lower level variables into single measures useful for analysis and policy purposes.

Comparative Approaches to Drug Pricing

The United States relies primarily on market forces to determine prices for drugs, whereas most other industrialized countries use a variety of approaches to determine drug prices. Branded drug companies have patents and market exclusivity periods in most industrialized countries. During this period, pharmaceutical companies are allowed to set their list price as high as they prefer in the United States owing to the absence of government price control mechanisms that exist in other countries. Insured patients often pay a percentage of the list price, and cost sharing creates some pressure to lower the list price. Pharmacy benefit managers negotiate with drug companies for lower prices by offering the drug company favorable formulary placement and fewer utilization controls. However, these approaches appear to be less effective, compared with other countries' approaches to containing branded drug prices, because prices are substantially higher in the United States. Other industrialized countries employ various forms of rate setting and price regulation, such as external reference pricing, therapeutic valuation, and health technology assessment to determine the appropriate price.

Added Value of Comprehensive Program to Provide Universal Access to Care for Sputum Smear-Negative Drug-Resistant Tuberculosis, China

The increase in drug-resistant tuberculosis in China calls for scaling up rapid diagnosis. We evaluated introduction of rapid resistance testing by line-probe assay for all patients with a diagnosis of pulmonary tuberculosis in 2 prefectures in middle and eastern China. We analyzed sputum samples for smear-positive patients and cultures for smear-negative patients. We used a before–after comparison of baseline and intervention periods (12 months each) and analyzed data for 5,222 baseline period patients and 4,364 intervention period patients. The number of patients with rifampin resistance increased from 30 in the baseline period to 97 in the intervention period for smear-positive patients and from 0 to 13 for smear-negative patients, reflecting a low proportion of positive cultures (410/2,844, 14.4%). Expanding rapid testing for drug resistance for smear-positive patients resulted in a 3-fold increase in patients with diagnoses of rifampin-resistant tuberculosis. However, testing smear-negative patients had limited added value because of a low culture-positive rate.

Cost-Effectiveness of Accelerated HIV Response Scenarios in Côte d'Ivoire

BACKGROUND

Despite Côte d'Ivoire epidemic being labeled as "generalized," key populations (KPs) are important to overall transmission. Using a dynamic model of HIV transmission, we previously estimated the impact of several treatment-as-prevention strategies that reached-or missed-the UNAIDS 90-90-90 targets in different populations groups, including KP and clients of female sex workers (CFSWs). To inform program planning and resources allocation, we assessed the cost-effectiveness of these scenarios.

METHODS

Costing was performed from the provider's perspective. Unit costs were obtained from the Ivorian Programme national de lutte contre le Sida (USD 2015) and discounted at 3%. Net incremental cost-effectiveness ratios (ICER) per adult HIV infection prevented and per disability-adjusted life-years (DALY) averted were estimated over 2015-2030.

RESULTS

The 3 most cost-effective and affordable scenarios were the ones that projected current programmatic trends [ICER = $210; 90% uncertainty interval (90% UI): $150-$300], attaining the 90-90-90 objectives among KP and CFSW (ICER = $220; 90% UI: $80-$510), and among KP only (ICER = $290; 90% UI: $90-$660). The least cost-effective scenario was the one that reached the UNAIDS 90-90-90 target accompanied by a 25% point drop in condom use in KP (ICER = $710; 90% UI: $450-$1270). In comparison, the UNAIDS scenario had a net ICER of $570 (90% UI: $390-$900) per DALY averted.

CONCLUSIONS

According to commonly used thresholds, accelerating the HIV response can be considered very cost-effective for all scenarios. However, when balancing epidemiological impact, cost-effectiveness, and affordability, scenarios that sustain both high condom use and rates of viral suppression among KP and CFSW seem most promising in Côte d'Ivoire.