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

Ranjeeta Thomas,Blia Yang,Christophe Fraser,Sian Floyd,Mwelwa Phiri,Sarah Fidler,Abigail Harper,Sarah Kanema,Rafael Sauter,Lawrence Mwenge,Surya Singh,Nosivuyile Vanqa,Michael Pickles,Deborah Donnell,Kwame Shanaube,Justin Bwalya,Helen Ayles,Anne Cori,Katharina Hauck,Ronelle Burger,Peter Böck ,Richard Hayes ,Nomtha Bell‐Mandla ,William J M Probert

doi:10.1016/s2214-109x(21)00034-6

Abstract

SummaryBackgroundThe 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.MethodsUsing 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.FindingsDuring 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.InterpretationCombination 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.FundingUS National Institutes of Health, President's Emergency Plan for AIDS Relief, International Initiative for Impact Evaluation, Bill & Melinda Gates Foundation.

Highlights

In 2018, approximately 38 million people were living with HIV infection worldwide, with 1·7 million new infections that year.[1]
In the PopART 2014–30 scenario, median incremental cost-effectiveness ratios (ICERs) for PopART delivered annually until 2030 were $2111 (95% credible interval [credible intervals (CrIs)] 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 disability-adjusted life-year (DALY) averted in Zambia and $645 (538–757) per DALY averted in South Africa
The intervention had almost 100% probability of being costeffective 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

Summary

Introduction

In 2018, approximately 38 million people were living with HIV infection worldwide, with 1·7 million new infections that year.[1]. Evidence before this study We searched PubMed and Embase on Nov 20, 2019, for health economic analyses of home-based HIV counselling and testing (HBCT) and linkage to care published between Jan 1, 2000, and Sept 13, 2019, with the terms “HIV” AND “Africa South of the Sahara” AND (“home” OR “community” OR “mass screening” OR “testing” OR “screen” OR “diagnosis” OR “counselling”) AND (“cost” OR “cost-effectiveness” OR “cost-utility” OR “cost-benefit”). We excluded studies that compared universal HIV testing and treatment (UTT) against standard care with antiretroviral therapy (ART) conditional on CD4 eligibility criteria. These studies would not be comparable with our study incorporating universal provision of ART as standard care for most years of the projection horizon. In modelling projections of various combination interventions, estimates of costeffectiveness varied widely, at US$860–1710 per QALY gained or DALY averted, $8639–22 000 per infection averted, $474–3400 per life-year saved, and cost-effectiveness thresholds greater than $1690 per DALY averted

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