Cost-effectiveness analyses in HIV prevention can provide

HIV prevention cost-effectiveness: a systematic review.

Galárraga O, Colchero MA, Wamai RG, Bertozzi SM. BMC Public Health. 2009. 9 Suppl 1:S5.

After more than 25 years, public health programs have not been able to sufficiently reduce the number of new HIV infections. Over 7,000 people become infected with HIV every day. Lack of convincing evidence of cost-effectiveness may be one of the reasons why implementation of effective programs is not occurring at sufficient scale. This paper identifies, summarizes and critiques the cost-effectiveness literature related to HIV-prevention interventions in low- and middle-income countries during 2005-2008. Systematic identification of publications was conducted through several methods: electronic databases, internet search of international organizations and major funding/implementing agencies, and journal browsing. Inclusion criteria included: HIV prevention intervention, year for publication (2005-2008), setting (low- and middle-income countries), and cost-effectiveness estimation (empirical or modeling) using outcomes in terms of cost per HIV infection averted and/or cost per disability-adjusted life year(DALY) or quality-adjusted life year (QALY). The authors found 21 distinct studies analyzing the cost-effectiveness of HIV-prevention interventions published in the past four years (2005-2008). Seventeen cost-effectiveness studies analyzed biomedical interventions; only a few dealt with behavioural and environmental/structural interventions. Sixteen studies focused on sub-Saharan Africa, and only a handful on Asia, Latin America and Eastern Europe. Many HIV-prevention interventions are very cost effective in absolute terms (using costs per DALY averted), and also in country-specific relative terms (in cost per DALY measured as percentage of GDP per capita). There are several types of interventions for which cost-effectiveness studies are still not available or are insufficient, including surveillance, abstinence, school-based education, universal precautions, prevention for positives and most structural interventions. The sparse cost-effectiveness evidence available is not easily comparable; thus, not very useful for decision making. More than 25 years into the HIV epidemic and billions of dollars of spending later, there is still much work to be done both on costs and effectiveness to adequately inform HIV prevention planning.

Cost-effectiveness analyses in HIV prevention can provide

part of the information that decision-makers use to decide on the optimal mix of interventions to tailor to their epidemic context. Although available cost-effectiveness data show that many HIV prevention interventions are cost-effective, there are huge gaps in our knowledge. For example, there are no cost-effectiveness studies on prevention for and with positive people, for key populations at higher risk of HIV exposure in concentrated epidemics around the world, and for inmates or other captive populations. We lack cost-effectiveness data by epidemic type and scale-up scenario, as well as for a number of HIV prevention interventions that are considered standard components of national strategies. Cost-effectiveness analysis has several limitations and is not the ‘be all, end all’ in decision-making but it can usefully inform difficult choices.