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

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Title: 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
Authors: Phillips, AN
Cambiano, V
Nakagawa, F
Bansi-Matharu, L
Wilson, D
Jani, I
Apollo, T
Sculpher, M
Hallett, T
Kerr, C
Van Oosterhout, JJ
Eaton, J
Estill, J
Williams, B
Doi, N
Cowan, F
Keiser, O
Ford, D
Hatzold, K
Barnabas, R
Ayles, H
Meyer-Rath, G
Nelson, L
Johnson, CC
Baggaley, R
Fakoya, A
Jahn, A
Revill, P
Item Type: Journal Article
Abstract: 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 appropriatemetrics that can be measured. The cost-per-diagnosisis 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”, for which we specify different rates of testing and various degrees to which those with HIV are more likely to test than thosewithout HIV. We also considered a plausible range of unit test costs. The aim was to assess the relationship between cost-per-diagnosisand the incremental cost-effectiveness ratio(ICER) of the additional-testingpolicy. Discount rate 3%; costs in 2018 $US. Results:There was a strong graded relationship between the cost-per-diagnosisand the ICER. Overall, the ICERwas below $500 per-DALY-averted (the cost effectiveness threshold used in primary analysis) so long as thecost-per-diagnosiswas below $315. This thresholdcost-per-diagnosiswas 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, restrictingto women, additional-testingdid not appear cost-effective even at acost-per-diagnosisof below $50, while restrictingto men additional-testingwas cost effective up to a cost-per-diagnosisof $585. Thethreshold cost for testing in men fell to $256 when the cost effectiveness threshold was $300instead of $500, and to $81 when considering a discount rate of 10% perannum.Conclusions:For testing programmesin low income settings in southern African there is an extremely strong relationship between the cost-per-diagnosisand the cost per DALY averted, indicating that the cost-per-diagnosiscan be used to monitor the cost effectiveness of testing programmes.
Issue Date: Jul-2019
Date of Acceptance: 22-May-2019
DOI: 10.1002/jia2.25325
ISSN: 1758-2652
Publisher: International AIDS Society
Start Page: 1
End Page: 10
Journal / Book Title: Journal of the International AIDS Society
Volume: 22
Issue: 7
Copyright Statement: © 2019 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited (
Sponsor/Funder: Bill & Melinda Gates Foundation
Funder's Grant Number: OPP1084364
Keywords: Science & Technology
Life Sciences & Biomedicine
Infectious Diseases
health systems
health systems
1199 Other Medical and Health Sciences
Publication Status: Published
Online Publication Date: 2019-07-09
Appears in Collections:School of Public Health

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