Cost Effectiveness Analysis of Strategies to Combat HIV/AIDS in Developing Countries

Published in the British Medical Journal, this 7-page paper assesses the effectiveness and costs of a variety of interventions for preventing and treating HIV/AIDS. The article is part of a series examining the cost effectiveness of strategies to achieve the Millennium Development Goals (MDGs) for health - in particular, MDG #6 (combat HIV/AIDS).

The authors provide data on the cost effectiveness of communication-centred strategies that were implemented in two regions with high HIV/AIDS burdens: countries in sub-Saharan Africa, and in South East Asia, with very high adult and high child mortality. Their analysis is based on an epidemiological model, and uses as an outcome measure the costs per disability adjusted life year (DALY) averted in year 2000 international dollars ($Int).

As reported here, the HIV/AIDS interventions considered in this analysis include:

• Mass media - e.g., television and radio episodes and inserts in key newspapers, repeated every two years
• Voluntary counselling and testing (VCT) - performed in primary care clinics for anyone requesting the services; includes training of health workers
• Peer education and treatment of sexually transmitted infections (STIs) for sex workers - training of selected sex workers by social workers to undertake peer education, as well as provision of condoms and referrals for testing and possible treatment of STIs
• School-based education - sessions provided during regular lessons to all students (aged 10-18 years) to promote prevention of HIV and other STIs; includes training of selected teachers
• Treatment of STIs (general population) - provided in primary care facilities to anyone who requests it
• Prevention of mother to child transmission (PMTCT) - information provided to women seeking antenatal care on benefits and risks of nevirapine for prophylaxis; pre-test counselling offered; single dose provided to women who accept, and single dose provided to child if delivered in a healthcare facility
• Highly active antiretroviral therapy (HAART) - monthly visits to healthcare providers, as well as more intensive monitoring that involves weekly contact

The evaluation found that the interventions which focused on mass media, education about and treatment of STIs for female sex workers, and treatment of STIs in the general population cost < $Int150 per DALY averted. VCT costs were < $Int350 per DALY averted in both regions, while PMTCT costs were < $Int50 per DALY averted in the African countries studied, but around $Int850 per DALY in the South East Asian countries. School-based education strategies and HAART strategies cost between $Int500 and $Int5000 per DALY averted. In both regions the largest number of DALYs are averted through education and treatment of STIs for sex workers, while the smallest gains are from school-based education.

The authors conclude that HIV transmission could be reduced most efficiently through a combination of the following strategies: mass media campaigns, interventions for sex workers and treatment of STIs where resources are most scarce. However, PMTCT, VCT, and school-based education would yield further health gains at higher budget levels and would be regarded as cost effective or highly cost effective based on standard international benchmarks. HAART is at least as cost effective in improving population health as some of these interventions.

In conclusion, "Our findings that a combination of prevention and treatment can be highly cost effective brings into sharper focus the importance of overcoming other constraints such as managerial needs, political commitment, infrastructure, and human resource requirements."

For more information, contact:

J. A. Salomon

Harvard School of Public Health

jsalomon@hsph.harvard.edu