ArticlesCost-effectiveness of HIV/AIDS interventions in Africa: a systematic review of the evidence
Introduction
HIV/AIDS accounts for about 20% of all deaths and disability-adjusted life-years (DALYs) lost in Africa, which makes it the biggest single component of the continent's disease burden.1 The epidemic has reduced life expectancy in the worst affected countries by more than 10 years, and its social and economic consequences have been devastating2
Substantial new resources are becoming available for prevention, care, and support. The European Commission is committed to a major increase in spending on the diseases of poverty, including HIV/AIDS3. A global fund to fight AIDS, tuberculosis, and malaria became operational in January, 2002; so far pledges are in the region of US$2 billion (www.globalfundatm.org).
To ensure that any new resources have the maximum possible effect on the epidemic, cost-effectiveness should be considered in the design of strategies for prevention, care, and support. As Kahn and Marseille have pointed out4, the scale of the HIV/AIDS epidemic combined with scarcity of resources makes cost-effectiveness especially important in developing countries. Up to now, however, cost-effectiveness has been well documented only for industrialised countries5, 6. For low-income and middle-income countries, we could identify only one detailed review, which addressed interventions to reduce mother-to-child transmission7. For Africa, investigators focused on individual HIV/AIDS-related interventions. We could not identify any published report that brought together the evidence base in a standardised way that allowed comparison among interventions.
We report a critical assessment of studies of the cost-effectiveness of HIV/AIDS interventions in Africa, and present their results in a standard form.
Section snippets
Review of published work
We searched Medline, Popline, and EconLit databases for 1984–2000 using the key words HIV, AIDS, and HIV/AIDS in combination with each of the terms: costs; cost-effectiveness; cost-benefit analysis; economics; and Africa. Citations and reference lists were then reviewed to identify any additional relevant studies. Abstracts from international conferences were searched but were not included because they provided insufficient detail. Unpublished data were obtained through contact with experts in
Results
For information about the costs included in each study and the principal assumptions used in measuring effectiveness see webtable 1 (http://image.thelancet.com/extras/01art9117webtable1.pdf) and webtable 2 (http://image.thelancet.com/extras/01art9117webtable2.pdf). Table 3, Table 4 show the HIV prevalence rates that applied to the study populations, and unit costs and unit effectiveness for prevention (table 3) and treatment and care (table 4).
Discussion
Our results show that there are few studies of the cost-effectiveness of HIV/AIDS prevention, treatment, and care interventions in Africa, and there is considerable variability in the cost-effectiveness of such interventions. The most cost-effective interventions are for prevention of HIV/AIDS and treatment of tuberculosis, whereas HAART for adults, and home based care organised from health facilities, are the least cost effective. For some interventions, such as prevention of mother-to-child
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