Universal testing and treatment for HIV in southern Africa is an economically efficient strategy to help control the HIV epidemic, suggests new analysis

Our results provide crucial evidence on the costs and cost-effectiveness of this strategy for countries looking to control the HIV epidemic.

Dr Ranjeeta Thomas

An economic evaluation of the largest ever HIV prevention trial (HPTN 071 PopART) suggests a package of HIV prevention interventions, including community wide home-based counselling and testing can be delivered at low annual cost per person and is an efficient strategy to control the HIV epidemic in southern Africa.

The study published in Lancet Global Health and authored by researchers from the London School of Economics and Political Science (LSE), Imperial College London, Oxford University and London School of Hygiene & Tropical Medicine, evaluates the costs and cost-effectiveness of the intervention delivered in the HPTN 071 (PopART)community randomised trial. The trial examined the impact of a package of HIV prevention interventions on community-level HIV incidence amongst around one million people living in Zambia and South Africa.

In 2019, approximately 38 million people were living with human immunodeficiency virus (HIV) worldwide, with 1.7 million new infections that year. HIV incidence is declining worldwide but is unlikely to reach the UNAIDS Fast Track target of under 200,000 new infections in 2030. Steep reductions in incidence are needed to curb the HIV epidemic, especially in southern Africa where the prevalence of HIV is higher than anywhere else in the world.

The study shows it is possible for a package of HIV prevention methods to be delivered through community health workers at scale for a low-cost per person per year: USD 6.53 in Zambia and USD 7.93 in South Africa. These include door-to-door home-based counselling and testing; linkage-to-care; promotion of antiretroviral therapy (ART) adherence; and voluntary medical male circumcision. However, it is important to evaluate the cost-effectiveness and affordability of such large-scale, integrated prevention strategies because costs can accumulate to a considerable amount when projected for total country populations and sustained for a prolonged period.

Dr Ranjeeta Thomas, Assistant Professor of Health Economics at LSE and lead author of the study, said: “These results show that a population level combination HIV prevention strategy that includes home-based HIV testing can be delivered at low unit cost. Universal test and treat generates substantial health gains compared to standard health facility-based provision. Our results provide crucial evidence on the costs and cost-effectiveness of this strategy for countries looking to control the HIV epidemic.”

Richard Hayes, Professor of Epidemiology and International Health at LSHTM, and principal investigator of the HPTN 071 (PopART) trial said: "The trial results, published in the New England Journal of Medicine in July 2019, showed that the PopART combination prevention package reduced HIV incidence in the general population by around 20%. This is a substantial effect that would build up over time if the intervention were sustained. These new data, quantifying the cost of the intervention and its cost-effectiveness, are very important and will be of great value to health policy makers considering how to substantially reduce HIV incidence during the coming decade to achieve the UNAIDS targets for elimination.”

To date, there is limited and conflicting evidence on the cost-effectiveness of combination prevention interventions including universal HIV testing and treatment. The findings of this study provide urgently needed evidence on the benefits and costs of UTT in high-prevalence communities. Existing studies are problematic to compare because of differences across studies – including scale and features of the intervention, country settings and target population. This study used a state-of-the-art individual-based simulation model specifically developed to model this population level trial and was informed extensively by data collected during the trial.

Study projections indicate a sustained reduction in HIV incidence with universal testing and treatment delivered over 17 years. But while UTT as delivered under PopART generates significant health benefits, it is not a cost saving strategy. Delivered in annual rounds over 17 years, PopART is certain to be cost-effective at thresholds over 800 USD /DALY averted. Such a threshold being the decision criteria for when benefits from a new intervention might be considered sufficient in comparison with its costs by a policy maker.

The findings from this study are therefore critical for national policy makers to determine whether the package of HIV prevention interventions delivered under PopART is cost-effective and affordable for their setting.


Behind the article

The study was carried out by researchers from LSHTM, Imperial College London and LSE in collaboration with the HIV Prevention Trials Network (HPTN)Zambart (Zambia), the Desmond Tutu TB Centre (South Africa), and Oxford University, and funded by PEPFARthe National Institutes of Health, and the International Initiative for Impact Evaluation with support from the Bill & Melinda Gates Foundation. The study was sponsored by the National Institute of Allergy and Infectious Diseases, part of NIH.