Elsevier

The Lancet

Volume 359, Issue 9318, 11 May 2002, Pages 1635-1642
The Lancet

Articles
Cost-effectiveness of HIV/AIDS interventions in Africa: a systematic review of the evidence

https://doi.org/10.1016/S0140-6736(02)08595-1Get rights and content

Summary

Background

Evidence for cost-effectiveness of interventions for HIV/AIDS in Africa is fragmentary. Cost-effectiveness is, however, highly relevant. African governments face difficult choices in striking the right balance between prevention, treatment, and care, all of which are necessary to deal comprehensively with the epidemic. Reductions in drug prices have raised the priority of treatment, though treatment access is restricted. We assessed the existing cost-effectiveness data and its implications for value-for-money strategies to combat HIV/AIDS in Africa.

Methods

We undertook a systematic review using databases and consultations with experts. We identified over 60 reports that measured both the cost and effectiveness of HIV/AIDS interventions in Africa. 24 studies met our inclusion criteria and were used to calculate standardised estimates of the cost (US$ for year 2000) per HIV infection prevented and per disability-adjusted life-year (DALY) gained for 31 interventions.

Findings

Cost-effectiveness varied greatly between interventions. A case of HIV/AIDS can be prevented for $11, and a DALY gained for $1, by selective blood safety measures, and by targeted condom distribution with treatment of sexually transmitted diseases. Single-dose nevirapine and short-course zidovudine for prevention of mother-to-child transmission, voluntary counselling and testing, and tuberculosis treatment, cost under $75 per DALY gained. Other interventions, such as formula feeding for infants, home care programmes, and antiretroviral therapy for adults, cost several thousand dollars per infection prevented, or several hundreds of dollars per DALY gained

Interpretation

A strong economic case exists for prioritisation of preventive interventions and tuberculosis treatment. Where potentially exclusive alternatives exist, cost-effectiveness analysis points to an intervention that offers the best value for money. Cost-effectiveness analysis is an essential component of informed debate about priority setting for HIV/AIDS.

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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