Cost-per-diagnosis as a metric for monitoring cost-effectiveness of HIV testing programmes in low-income settings in southern Africa: health economic and modelling analysis.
- Phillips AN Institute for Global Health, UCL, London, UK.
- Cambiano V Institute for Global Health, UCL, London, UK.
- Nakagawa F Institute for Global Health, UCL, London, UK.
- Bansi-Matharu L Institute for Global Health, UCL, London, UK.
- Wilson D Burnet Institute, Melbourne, Australia.
- Jani I National Institute of Health, Maputo, Mozambique.
- Apollo T Ministry of Health, Zimbabwe, Harare, Zimbabwe.
- Sculpher M Centre for Health Economics, University of York, York, UK.
- Hallett T Department of Infectious Disease Epidemiology, Imperial College London, London, UK.
- Kerr C Burnet Institute, Melbourne, Australia.
- van Oosterhout JJ Dignitas International, Zomba, Malawi.
- Eaton JW Department of Infectious Disease Epidemiology, Imperial College London, London, UK.
- Estill J Institute of Global Health, University of Geneva, Geneva, Switzerland.
- Williams B SACEMA, Stellenbosch University, Stellenbosch, South Africa.
- Doi N Clinton Health Access Initiative (CHAI), NY, USA.
- Cowan F CeSHHAR, Harare, Zimbabwe.
- Keiser O Institute of Global Health, University of Geneva, Geneva, Switzerland.
- Ford D MRC Clinical Trials Unit at UCL, UCL, London, UK.
- Hatzold K PSI, Harare, Zimbabwe.
- Barnabas R University of Washington, Seattle, WA, USA.
- Ayles H ZAMBART, Lusaka, Zambia.
- Meyer-Rath G Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
- Nelson L CDC Uganda, Kampala, Uganda.
- Johnson C World Health Organisation, Geneva, Switzerland.
- Baggaley R World Health Organisation, Geneva, Switzerland.
- Fakoya A The Global Fund, Geneva, Switzerland.
- Jahn A Ministry of Health, Lilongwe, Malawi.
- Revill P Centre for Health Economics, University of York, York, UK.
- 2019-07-10
Published in:
- Journal of the International AIDS Society. - 2019
HIV
cost-effectiveness
health systems
modelling
testing
Adult
Africa, Southern
Circumcision, Male
Cost-Benefit Analysis
Female
HIV Infections
HIV-1
Humans
Male
Mass Screening
Poverty
Pregnancy
Risk Factors
Sex Workers
Viral Load
English
INTRODUCTION
As prevalence of undiagnosed HIV declines, it is unclear whether testing programmes will be cost-effective. To guide their HIV testing programmes, countries require appropriate metrics that can be measured. The cost-per-diagnosis is potentially a useful metric.
METHODS
We simulated a series of setting-scenarios for adult HIV epidemics and ART programmes typical of settings in southern Africa using an individual-based model and projected forward from 2018 under two policies: (i) a minimum package of "core" testing (i.e. testing in pregnant women, for diagnosis of symptoms, in sex workers, and in men coming forward for circumcision) is conducted, and (ii) core-testing as above plus additional testing beyond this ("additional-testing"), for which we specify different rates of testing and various degrees to which those with HIV are more likely to test than those without HIV. We also considered a plausible range of unit test costs. The aim was to assess the relationship between cost-per-diagnosis and the incremental cost-effectiveness ratio (ICER) of the additional-testing policy. The discount rate used in the base case was 3% per annum (costs in 2018 U.S. dollars).
RESULTS
There was a strong graded relationship between the cost-per-diagnosis and the ICER. Overall, the ICER was below $500 per-DALY-averted (the cost-effectiveness threshold used in primary analysis) so long as the cost-per-diagnosis was below $315. This threshold cost-per-diagnosis was similar according to epidemic and programmatic features including the prevalence of undiagnosed HIV, the HIV incidence and a measure of HIV programme quality (the proportion of HIV diagnosed people having a viral load <1000 copies/mL). However, restricting to women, additional-testing did not appear cost-effective even at a cost-per-diagnosis of below $50, while restricting to men additional-testing was cost-effective up to a cost-per-diagnosis of $585. The threshold cost per diagnosis for testing in men to be cost-effective fell to $256 when the cost-effectiveness threshold was $300 instead of $500, and to $81 when considering a discount rate of 10% per annum.
CONCLUSIONS
For testing programmes in low-income settings in southern African there is an extremely strong relationship between the cost-per-diagnosis and the cost-per-DALY averted, indicating that the cost-per-diagnosis can be used to monitor the cost-effectiveness of testing programmes.
As prevalence of undiagnosed HIV declines, it is unclear whether testing programmes will be cost-effective. To guide their HIV testing programmes, countries require appropriate metrics that can be measured. The cost-per-diagnosis is potentially a useful metric.
METHODS
We simulated a series of setting-scenarios for adult HIV epidemics and ART programmes typical of settings in southern Africa using an individual-based model and projected forward from 2018 under two policies: (i) a minimum package of "core" testing (i.e. testing in pregnant women, for diagnosis of symptoms, in sex workers, and in men coming forward for circumcision) is conducted, and (ii) core-testing as above plus additional testing beyond this ("additional-testing"), for which we specify different rates of testing and various degrees to which those with HIV are more likely to test than those without HIV. We also considered a plausible range of unit test costs. The aim was to assess the relationship between cost-per-diagnosis and the incremental cost-effectiveness ratio (ICER) of the additional-testing policy. The discount rate used in the base case was 3% per annum (costs in 2018 U.S. dollars).
RESULTS
There was a strong graded relationship between the cost-per-diagnosis and the ICER. Overall, the ICER was below $500 per-DALY-averted (the cost-effectiveness threshold used in primary analysis) so long as the cost-per-diagnosis was below $315. This threshold cost-per-diagnosis was similar according to epidemic and programmatic features including the prevalence of undiagnosed HIV, the HIV incidence and a measure of HIV programme quality (the proportion of HIV diagnosed people having a viral load <1000 copies/mL). However, restricting to women, additional-testing did not appear cost-effective even at a cost-per-diagnosis of below $50, while restricting to men additional-testing was cost-effective up to a cost-per-diagnosis of $585. The threshold cost per diagnosis for testing in men to be cost-effective fell to $256 when the cost-effectiveness threshold was $300 instead of $500, and to $81 when considering a discount rate of 10% per annum.
CONCLUSIONS
For testing programmes in low-income settings in southern African there is an extremely strong relationship between the cost-per-diagnosis and the cost-per-DALY averted, indicating that the cost-per-diagnosis can be used to monitor the cost-effectiveness of testing programmes.
- Language
-
- English
- Open access status
- gold
- Identifiers
-
- DOI 10.1002/jia2.25325
- PMID 31287620
- Persistent URL
- https://sonar.ch/global/documents/319
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