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Thomas R, Probert WJM, Sauter R, Mwenge L, Singh S, Kanema S, Vanqa N, Harper A, Burger R, Cori A, Pickles M, Bell-Mandla N, Yang B, Bwalya J, Phiri M, Shanaube K, Floyd S, Donnell D, Bock P, Ayles H, Fidler S, Hayes RJ, Fraser C, Hauck K. Cost and cost-effectiveness of a universal HIV testing and treatment intervention in Zambia and South Africa: evidence and projections from the HPTN 071 (PopART) trial. Lancet Glob Health 2021; 9:e668-e680. [PMID: 33721566 PMCID: PMC8050197 DOI: 10.1016/s2214-109x(21)00034-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 12/15/2020] [Accepted: 01/21/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND The HPTN 071 (PopART) trial showed that a combination HIV prevention package including universal HIV testing and treatment (UTT) reduced population-level incidence of HIV compared with standard care. However, evidence is scarce on the costs and cost-effectiveness of such an intervention. METHODS Using an individual-based model, we simulated the PopART intervention and standard care with antiretroviral therapy (ART) provided according to national guidelines for the 21 trial communities in Zambia and South Africa (for all individuals aged >14 years), with model parameters and primary cost data collected during the PopART trial and from published sources. Two intervention scenarios were modelled: annual rounds of PopART from 2014 to 2030 (PopART 2014-30; as the UNAIDS Fast-Track target year) and three rounds of PopART throughout the trial intervention period (PopART 2014-17). For each country, we calculated incremental cost-effectiveness ratios (ICERs) as the cost per disability-adjusted life-year (DALY) and cost per HIV infection averted. Cost-effectiveness acceptability curves were used to indicate the probability of PopART being cost-effective compared with standard care at different thresholds of cost per DALY averted. We also assessed budget impact by projecting undiscounted costs of the intervention compared with standard care up to 2030. FINDINGS During 2014-17, the mean cost per person per year of delivering home-based HIV counselling and testing, linkage to care, promotion of ART adherence, and voluntary medical male circumcision via community HIV care providers for the simulated population was US$6·53 (SD 0·29) in Zambia and US$7·93 (0·16) in South Africa. In the PopART 2014-30 scenario, median ICERs for PopART delivered annually until 2030 were $2111 (95% credible interval [CrI] 1827-2462) per HIV infection averted in Zambia and $3248 (2472-3963) per HIV infection averted in South Africa; and $593 (95% CrI 526-674) per DALY averted in Zambia and $645 (538-757) per DALY averted in South Africa. In the PopART 2014-17 scenario, PopART averted one infection at a cost of $1318 (1098-1591) in Zambia and $2236 (1601-2916) in South Africa, and averted one DALY at $258 (225-298) in Zambia and $326 (266-391) in South Africa, when outcomes were projected until 2030. The intervention had almost 100% probability of being cost-effective at thresholds greater than $700 per DALY averted in Zambia, and greater than $800 per DALY averted in South Africa, in the PopART 2014-30 scenario. Incremental programme costs for annual rounds until 2030 were $46·12 million (for a mean of 341 323 people) in Zambia and $30·24 million (for a mean of 165 852 people) in South Africa. INTERPRETATION Combination prevention with universal home-based testing can be delivered at low annual cost per person but accumulates to a considerable amount when scaled for a growing population. Combination prevention including UTT is cost-effective at thresholds greater than $800 per DALY averted and can be an efficient strategy to reduce HIV incidence in high-prevalence settings. FUNDING US National Institutes of Health, President's Emergency Plan for AIDS Relief, International Initiative for Impact Evaluation, Bill & Melinda Gates Foundation.
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Affiliation(s)
- Ranjeeta Thomas
- Department of Health Policy, London School of Economics and Political Science, London, UK.
| | - William J M Probert
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Rafael Sauter
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Surya Singh
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Nosivuyile Vanqa
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Abigail Harper
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Ronelle Burger
- Department of Economics, Stellenbosch University, Cape Town, South Africa
| | - Anne Cori
- Medical Research Council Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Michael Pickles
- Medical Research Council Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Nomtha Bell-Mandla
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Blia Yang
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | | | | | | | - Sian Floyd
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Peter Bock
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Helen Ayles
- Zambart, University of Zambia, Lusaka, Zambia; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Sarah Fidler
- Department of Infectious Disease, Imperial College London, London, UK
| | - Richard J Hayes
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Christophe Fraser
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Katharina Hauck
- Medical Research Council Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK; Abdul Latif Jameel Institute for Disease and Emergency Analytics, School of Public Health, Imperial College London, London, UK
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Mangenah C, Mwenge L, Sande L, Ahmed N, d'Elbée M, Chiwawa P, Chigwenah T, Kanema S, Mutseta MN, Nalubamba M, Chilongosi R, Indravudh P, Sibanda EL, Neuman M, Ncube G, Ong JJ, Mugurungi O, Hatzold K, Johnson CC, Ayles H, Corbett EL, Cowan FM, Maheswaran H, Terris‐Prestholt F. Economic cost analysis of door-to-door community-based distribution of HIV self-test kits in Malawi, Zambia and Zimbabwe. J Int AIDS Soc 2019; 22 Suppl 1:e25255. [PMID: 30907499 PMCID: PMC6432106 DOI: 10.1002/jia2.25255] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 01/18/2019] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION HIV self-testing (HIVST) is recommended by the World Health Organization in addition to other testing modalities to increase uptake of HIV testing, particularly among harder-to-reach populations. This study provides the first empirical evidence of the costs of door-to-door community-based HIVST distribution in Malawi, Zambia and Zimbabwe. METHODS HIVST kits were distributed door-to-door in 71 sites across Malawi, Zambia and Zimbabwe from June 2016 to May 2017. Programme expenditures, supplemented by on-site observation and monitoring and evaluation data were used to estimate total economic and unit costs of HIVST distribution, by input and site. Inputs were categorized into start-up, capital and recurrent costs. Sensitivity and scenario analyses were performed to assess the impact of key parameters on unit costs. RESULTS In total, 152,671, 103,589 and 93,459 HIVST kits were distributed in Malawi, Zambia and Zimbabwe over 12, 11 and 10 months respectively. Across these countries, 43% to 51% of HIVST kits were distributed to men. The average cost per HIVST kit distributed was US$8.15, US$16.42 and US$13.84 in Malawi, Zambia and Zimbabwe, respectively, with pronounced intersite variation within countries driven largely by site-level fixed costs. Site-level recurrent costs were 70% to 92% of full costs and 20% to 62% higher than routine HIV testing services (HTS) costs. Personnel costs contributed from 26% to 52% of total costs across countries reflecting differences in remuneration approaches and country GDP. CONCLUSIONS These early door-to-door community HIVST distribution programmes show large potential, both for reaching untested populations and for substantial economies of scale as HIVST programmes scale-up and mature. From a societal perspective, the costs of HIVST appear similar to conventional HTS, with the higher providers' costs substantially offsetting user costs. Future approaches to minimizing cost and/or maximize testing coverage could include unpaid door-to-door community-led distribution to reach end-users and integrating HIVST into routine clinical services via direct or secondary distribution strategies with lower fixed costs.
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Affiliation(s)
| | | | - Linda Sande
- Malawi‐Liverpool‐Wellcome Trust Clinical Research ProgrammeBlantyreMalawi
- Faculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Nurilign Ahmed
- Faculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Marc d'Elbée
- Faculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | | | | | | | | | | | | | - Pitchaya Indravudh
- Malawi‐Liverpool‐Wellcome Trust Clinical Research ProgrammeBlantyreMalawi
- Faculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Euphemia L Sibanda
- Centre for Sexual HealthHIV and AIDS ResearchHarareZimbabwe
- Liverpool School of Tropical MedicineLiverpoolUK
| | | | | | - Jason J Ong
- Faculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
- Faculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUK
| | | | | | - Cheryl C Johnson
- Faculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUK
- Department of HIV/AIDSWorld Health OrganizationGenevaSwitzerland
| | - Helen Ayles
- ZambartLusakaZambia
- Faculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUK
| | - Elizabeth L Corbett
- Malawi‐Liverpool‐Wellcome Trust Clinical Research ProgrammeBlantyreMalawi
- Faculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUK
| | - Frances M Cowan
- Centre for Sexual HealthHIV and AIDS ResearchHarareZimbabwe
- Liverpool School of Tropical MedicineLiverpoolUK
| | | | - Fern Terris‐Prestholt
- Faculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
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Mwenge L, Sande L, Mangenah C, Ahmed N, Kanema S, d’Elbée M, Sibanda E, Kalua T, Ncube G, Johnson CC, Hatzold K, Cowan FM, Corbett EL, Ayles H, Maheswaran H, Terris-Prestholt F. Costs of facility-based HIV testing in Malawi, Zambia and Zimbabwe. PLoS One 2017; 12:e0185740. [PMID: 29036171 PMCID: PMC5642898 DOI: 10.1371/journal.pone.0185740] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 09/14/2017] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Providing HIV testing at health facilities remains the most common approach to ensuring access to HIV treatment and prevention services for the millions of undiagnosed HIV-infected individuals in sub-Saharan Africa. We sought to explore the costs of providing these services across three southern African countries with high HIV burden. METHODS Primary costing studies were undertaken in 54 health facilities providing HIV testing services (HTS) in Malawi, Zambia and Zimbabwe. Routinely collected monitoring and evaluation data for the health facilities were extracted to estimate the costs per individual tested and costs per HIV-positive individual identified. Costs are presented in 2016 US dollars. Sensitivity analysis explored key drivers of costs. RESULTS Health facilities were testing on average 2290 individuals annually, albeit with wide variations. The mean cost per individual tested was US$5.03.9 in Malawi, US$4.24 in Zambia and US$8.79 in Zimbabwe. The mean cost per HIV-positive individual identified was US$79.58, US$73.63 and US$178.92 in Malawi, Zambia and Zimbabwe respectively. Both cost estimates were sensitive to scale of testing, facility staffing levels and the costs of HIV test kits. CONCLUSIONS Health facility based HIV testing remains an essential service to meet HIV universal access goals. The low costs and potential for economies of scale suggests an opportunity for further scale-up. However low uptake in many settings suggests that demand creation or alternative testing models may be needed to achieve economies of scale and reach populations less willing to attend facility based services.
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Affiliation(s)
| | - Linda Sande
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Collin Mangenah
- Centre for Sexual Health and HIV AIDS Research, Harare, Zimbabwe
| | - Nurilign Ahmed
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Marc d’Elbée
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Euphemia Sibanda
- Centre for Sexual Health and HIV AIDS Research, Harare, Zimbabwe
| | - Thokozani Kalua
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | | | - Cheryl C. Johnson
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | | | - Frances M. Cowan
- Centre for Sexual Health and HIV AIDS Research, Harare, Zimbabwe
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Elizabeth L. Corbett
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Helen Ayles
- Zambart, Lusaka, Zambia
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Fern Terris-Prestholt
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Thomas R, Burger R, Harper A, Kanema S, Mwenge L, Vanqa N, Bell-Mandla N, Smith PC, Floyd S, Bock P, Ayles H, Beyers N, Donnell D, Fidler S, Hayes R, Hauck K. Differences in health-related quality of life between HIV-positive and HIV-negative people in Zambia and South Africa: a cross-sectional baseline survey of the HPTN 071 (PopART) trial. Lancet Glob Health 2017; 5:e1133-e1141. [PMID: 28964756 PMCID: PMC5640509 DOI: 10.1016/s2214-109x(17)30367-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 06/14/2017] [Accepted: 08/25/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND The life expectancy of HIV-positive individuals receiving antiretroviral therapy (ART) is approaching that of HIV-negative people. However, little is known about how these populations compare in terms of health-related quality of life (HRQoL). We aimed to compare HRQoL between HIV-positive and HIV-negative people in Zambia and South Africa. METHODS As part of the HPTN 071 (PopART) study, data from adults aged 18-44 years were gathered between Nov 28, 2013, and March 31, 2015, in large cross-sectional surveys of random samples of the general population in 21 communities in Zambia and South Africa. HRQoL data were collected with a standardised generic measure of health across five domains. We used β-distributed multivariable models to analyse differences in HRQoL scores between HIV-negative and HIV-positive individuals who were unaware of their status; aware, but not in HIV care; in HIV care, but who had not initiated ART; on ART for less than 5 years; and on ART for 5 years or more. We included controls for sociodemographic variables, herpes simplex virus type-2 status, and recreational drug use. FINDINGS We obtained data for 19 750 respondents in Zambia and 18 941 respondents in South Africa. Laboratory-confirmed HIV status was available for 19 330 respondents in Zambia and 18 004 respondents in South Africa; 4128 (21%) of these 19 330 respondents in Zambia and 4012 (22%) of 18 004 respondents in South Africa had laboratory-confirmed HIV. We obtained complete HRQoL information for 19 637 respondents in Zambia and 18 429 respondents in South Africa. HRQoL scores did not differ significantly between individuals who had initiated ART more than 5 years previously and HIV-negative individuals, neither in Zambia (change in mean score -0·002, 95% CI -0·01 to 0·001; p=0·219) nor in South Africa (0·000, -0·002 to 0·003; p=0·939). However, scores did differ between HIV-positive individuals who had initiated ART less than 5 years previously and HIV-negative individuals in Zambia (-0·006, 95% CI -0·008 to -0·003; p<0·0001). A large proportion of people with clinically confirmed HIV were unaware of being HIV-positive (1768 [43%] of 4128 people in Zambia and 2026 [50%] of 4012 people in South Africa) and reported good HRQoL, with no significant differences from that of HIV-negative people (change in mean HRQoL score -0·001, 95% CI -0·003 to 0·001, p=0·216; and 0·001, -0·001 to 0·001, p=0·997, respectively). In South Africa, HRQoL scores were lower in HIV-positive individuals who were aware of their status but not enrolled in HIV care (change in mean HRQoL -0·004, 95% CI -0·01 to -0·001; p=0·010) and those in HIV care but not on ART (-0·008, -0·01 to -0·004; p=0·001) than in HIV-negative people, but the magnitudes of difference were small. INTERPRETATION ART is successful in helping to reduce inequalities in HRQoL between HIV-positive and HIV-negative individuals in this general population sample. These findings highlight the importance of improving awareness of HIV status and expanding ART to prevent losses in HRQoL that occur with untreated HIV progression. The gains in HRQoL after individuals initiate ART could be substantial when scaled up to the population level. FUNDING National Institute of Allergy and Infectious Diseases, National Institute on Drug Abuse, National Institute of Mental Health, President's Emergency Plan for AIDS Relief, International Initiative for Impact Evaluation, the Bill & Melinda Gates Foundation.
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Affiliation(s)
- Ranjeeta Thomas
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK.
| | - Ronelle Burger
- Department of Economics, Stellenbosch University, Stellenbosch, South Africa
| | - Abigail Harper
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Sarah Kanema
- ZAMBART Project, Ridgeway Campus, University of Zambia, Lusaka, Zambia
| | - Lawrence Mwenge
- ZAMBART Project, Ridgeway Campus, University of Zambia, Lusaka, Zambia
| | - Nosivuyile Vanqa
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Nomtha Bell-Mandla
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Peter C Smith
- Imperial College Business School, Imperial College London, London, UK
| | - Sian Floyd
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Peter Bock
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Helen Ayles
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Nulda Beyers
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Deborah Donnell
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Sarah Fidler
- Department of Medicine, Imperial College London, London, UK
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Katharina Hauck
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
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