Anna Vassall1, Michael Pickles2, Sudhashree Chandrashekar3, Marie-Claude Boily4, Govindraj Shetty5, Lorna Guinness6, Catherine M Lowndes7, Janet Bradley8, Stephen Moses9, Michel Alary10, Peter Vickerman11. 1. London School of Hygiene & Tropical Medicine, London, UK. Electronic address: Anna.Vassall@lshtm.ac.uk. 2. London School of Hygiene & Tropical Medicine, London, UK; Imperial College, London, UK. 3. London School of Hygiene & Tropical Medicine, London, UK; St John's Research Institute, Bangalore India. 4. Imperial College, London, UK. 5. Karnataka Health Promotion Trust, Bangalore, India. 6. London School of Hygiene & Tropical Medicine, London, UK. 7. London School of Hygiene & Tropical Medicine, London, UK; Public Health England, London, UK. 8. Centre de Recherche du CHU Universitaire de Québec, QC, Canada. 9. Karnataka Health Promotion Trust, Bangalore, India; University of Manitoba, Winnipeg, MB, Canada. 10. Centre de Recherche du CHU Universitaire de Québec, QC, Canada; Département de Médecine Sociale et Préventive, Université Laval, Québec, QC, Canada. 11. London School of Hygiene & Tropical Medicine, London, UK; Department of Social and Community Medicine, University of Bristol, Bristol, UK.
Abstract
BACKGROUND: Avahan is a large-scale, HIV preventive intervention, targeting high-risk populations in south India. We assessed the cost-effectiveness of Avahan to inform global and national funding institutions who are considering investing in worldwide HIV prevention in concentrated epidemics. METHODS: We estimated cost effectiveness from a programme perspective in 22 districts in four high-prevalence states. We used the UNAIDS Costing Guidelines for HIV Prevention Strategies as the basis for our costing method, and calculated effect estimates using a dynamic transmission model of HIV and sexually transmitted disease transmission that was parameterised and fitted to locally observed behavioural and prevalence trends. We calculated incremental cost-effective ratios (ICERs), comparing the incremental cost of Avahan per disability-adjusted life-year (DALY) averted versus a no-Avahan counterfactual scenario. We also estimated incremental cost per HIV infection averted and incremental cost per person reached. FINDINGS: Avahan reached roughly 150 000 high-risk individuals between 2004 and 2008 in the 22 districts studied, at a mean cost per person reached of US$327 during the 4 years. This reach resulted in an estimated 61 000 HIV infections averted, with roughly 11 000 HIV infections averted in the general population, at a mean incremental cost per HIV infection averted of $785 (SD 166). We estimate that roughly 1 million DALYs were averted across the 22 districts, at a mean incremental cost per DALY averted of $46 (SD 10). Future antiretroviral treatment (ART) cost savings during the lifetime of the cohort exposed to HIV prevention were estimated to be more than $77 million (compared with the slightly more than $50 million spent on Avahan in the 22 districts during the 4 years of the study). INTERPRETATION: This study provides evidence that the investment in targeted HIV prevention programmes in south India has been cost effective, and is likely to be cost saving if a commitment is made to provide ART to all that can benefit from it. Policy makers should consider funding and sustaining large-scale targeted HIV prevention programmes in India and beyond. FUNDING: Bill & Melinda Gates Foundation.
BACKGROUND:Avahan is a large-scale, HIV preventive intervention, targeting high-risk populations in south India. We assessed the cost-effectiveness of Avahan to inform global and national funding institutions who are considering investing in worldwide HIV prevention in concentrated epidemics. METHODS: We estimated cost effectiveness from a programme perspective in 22 districts in four high-prevalence states. We used the UNAIDS Costing Guidelines for HIV Prevention Strategies as the basis for our costing method, and calculated effect estimates using a dynamic transmission model of HIV and sexually transmitted disease transmission that was parameterised and fitted to locally observed behavioural and prevalence trends. We calculated incremental cost-effective ratios (ICERs), comparing the incremental cost of Avahan per disability-adjusted life-year (DALY) averted versus a no-Avahan counterfactual scenario. We also estimated incremental cost per HIV infection averted and incremental cost per person reached. FINDINGS:Avahan reached roughly 150 000 high-risk individuals between 2004 and 2008 in the 22 districts studied, at a mean cost per person reached of US$327 during the 4 years. This reach resulted in an estimated 61 000 HIV infections averted, with roughly 11 000 HIV infections averted in the general population, at a mean incremental cost per HIV infection averted of $785 (SD 166). We estimate that roughly 1 million DALYs were averted across the 22 districts, at a mean incremental cost per DALY averted of $46 (SD 10). Future antiretroviral treatment (ART) cost savings during the lifetime of the cohort exposed to HIV prevention were estimated to be more than $77 million (compared with the slightly more than $50 million spent on Avahan in the 22 districts during the 4 years of the study). INTERPRETATION: This study provides evidence that the investment in targeted HIV prevention programmes in south India has been cost effective, and is likely to be cost saving if a commitment is made to provide ART to all that can benefit from it. Policy makers should consider funding and sustaining large-scale targeted HIV prevention programmes in India and beyond. FUNDING: Bill & Melinda Gates Foundation.
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