HIV PREVENTION CASE MANAGEMENT IS NOT COST-EFFECTIVE

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The report “Get Connected: An HIV Prevention Case Management Program for Men and Women Leaving California Prisons”1 provides important data for assessing the cost-effectiveness of HIV-prevention case management. The authors state that HIV-negative individuals released from prison who completed their 10-week assessments after receiving an average of 39 case management hours reported an average increase in consistent condom use or abstinence from 33% to 59% and fewer sexual partners. We calculated the cost-effectiveness of this intervention with a Bernoulli formula that has been used in many evaluations of HIV-prevention cost-effectiveness.2–4 We assumed that the cost of case management was between $30 and $50 per hour (a conservative estimate for the salary of a social worker plus fringe benefits and overhead); that the prevalence of HIV infection among their sexual partners was 0.016 for men and 0.006 for women; that the average number of sexual partners was reduced from 3 to 2; and that the frequency of sex was similar to that in the general population (81 times per year5). We estimate that the intervention prevented only .02 cases of HIV infection (formula available from the corresponding author). The cost of the intervention ranged from $1140 to $1950 per enrolled inmate, making the cost per infection prevented between $3 600 000 and $5 900 000. This may be a low-end estimate, however, considering that, of the 127 inmates enrolled, only 75 completed the initial evaluation, and that the 51 inmates who completed the program likely would have used more case management hours than the average hours used by the enrolled group. If we include the 24 additional inmates who completed the initial evaluation and assume they did not change their behavior, as is normally assumed for dropouts, the cost per HIV infection prevented rises from $5 300 000 to $8 800 000. On the basis of any of these figures, prevention case management should not be touted as a cost-effective use of resources for HIV prevention. Other effective HIV-prevention interventions, such as needle exchange in high-prevalence communities ($13 000 per HIV infection prevented), condom distribution ($47 000 per HIV infection prevented), or outreach to men who have sex with men ($12 000 per HIV infection prevented) could prevent considerably more cases at a lower cost.6,7