Cost and efficiency of HIV voluntary counselling and testing centres in Andhra Pradesh, India.

BACKGROUND: [corrected] As part of the effort to control HIV/AIDS, the number of HlV voluntarycounselling and testingcentres (VCTCs) is increasing rapidly in the public health system of the Indian state of Andhra Pradesh, which is estimated to have one of the highest rates of HIV infection in India. However, systematic data on the cost and efficiency of providing VCT services in India are not available to help guide efficient use of resources for these services. METHODS: We used standardized methods to obtain detailed cost and output data for the 2002-03 fiscal year from written records and interviews in 17 VCTCs in the public health system in Andhra Pradesh. We calculated the economic cost per client receiving VCT services, and analysed the variation and determinants of total and unit costs across VCTCs. We used multivariate regression techniques to estimate incremental unit costs. We assessed hurdles towards serving an optimal number of clients by VCTCs. RESULTS: In the 2002-03 fiscal year, 32 413 clients received the complete sequence of services at the 17 VCTCs, including post-HIV test counselling. The number of clients served by each VCTC ranged from 334 to 7802 (median 979). The overall HIV-positive rate in post-test counselled clients was 20.5% (range 5.4%-52.6%). The cost per client for the complete VCT sequence varied 6-fold between VCTCs (range Rs 141.5-829.6 [US 2.92-17.14 dollars], median Rs 363.5 [US 7.51 dollars]). The cost per client was significantly lower at VCTCs with more clients (p < 0.001, R2 = 0.83; power function) due to substantial fixed costs. Personnel made up the largest component of cost (53.7%). The cost per client had a significant direct relation with percent personnel cost for VCTCs (p < 0.001, R2 = 0.58; exponential function). A multiple regression model revealed that the incremental cost of providing complete VCT services to each HIV-positive and -negative client was Rs 123.5 (US 2.54 dollars) and Rs 59.2 (US 1.22 dollars), respectively. Fourteen VCTCs (82.4%) reported that they could serve more clients with the available personnel and infrastructure, and that inadequate demand for their services was the main hurdle towards achieving this. CONCLUSION: These data suggest that the efforts of the National AIDS Control Organisation of India and the Andhra Pradesh State AIDS Control Society in increasing VCTCs could yield even higher benefit if the demand for these services was enhanced, as this would increase the number of clients served and reduce the cost per client. Ongoing systematic cost-efficiency analysis is necessary to help guide efficient use of HIV-control resources in India.

Cost-effectiveness of the female condom in preventing HIV and STDs in commercial sex workers in rural South Africa.

We assessed the cost-effectiveness of the female condom (FC) in preventing HIV infection and other STDs among commercial sex workers (CSWs) and their clients in the Mpumulanga Province of South Africa. The health and economic outcomes of current levels of male condom (MC) use in 1000 CSWs who average 25 partners per year and have an HIV prevalence of 50.3% was compared with the expected outcomes resulting from the additional provision of FCs to these CSWs. A simulation model calculated health and public sector cost outcomes assuming 5 years of HIV infectivity, 1 month of syphilis and gonorrhea infectivity, and FC use in 12% of episodes of vaginal intercourse. Delayed infections and interactions between STDs and HIV were modeled. The simulation was extended to non-CSWs with as few as one casual partner per year. We conducted multiple sensitivity analyses. The program would distribute 6000 FCs annually at a cost of $4002 and would avert 5.9 HIV, 38 syphilis, and 33 gonorrhea cases. This would save the public sector health payer $12,090 in averted HIV/AIDS treatment costs, and $1,074 in averted syphilis and gonorrhea treatment costs for a net saving of $9163. Sensitivity analyses indicate that the economic findings are robust across a wide range of values for key inputs. The program generates net savings of $5421 if HIV prevalence in CSWs is 25% rather than 50.3% and savings of S3591 if each CSW has an average of 10 clients per year rather than 25. A program focusing on non-CSWs with only one casual partner would save $199. We conclude that a well-designed FC program oriented to CSWs and other women with casual partners is likely to be highly cost-effective and can save public sector health funds in rural South Africa.

Cost effectiveness of single-dose nevirapine regimen for mothers and babies to decrease vertical HIV-1 transmission in sub-Saharan Africa.

BACKGROUND: Identification of economical interventions to decrease HIV-1 transmission to children is an urgent public-health priority in sub-Saharan Africa. We assessed the cost effectiveness of the HIVNET 012 nevirapine regimen. METHODS: We assessed cost effectiveness in a hypothetical cohort of 20,000 pregnant women in sub-Saharan Africa. Our main outcome measures were programme cost, paediatric HIV-1 cases averted, cost per case averted, and cost per disability-adjusted life-year (DALY). We compared HIVNET 012 with other short-course antiretroviral regimens. We also compared two implementation strategies: counselling and HIV-1 testing before treatment (targeted treatment), or nevirapine for all pregnant women (universal treatment, no counselling and testing). We did univariate and multivariate sensitivity analyses. FINDINGS: For universal treatment with 30% HIV-1 seroprevalence, the HIVNET 012 regimen would avert 603 cases of HIV-1 in babies, cost US$83,333, and generate 15,862 DALYs. The associated cost-effectiveness ratios were $138 per case averted or $5.25 per DALY. At 15% seroprevalence, the universal treatment option would cost $83,333 and avert 302 cases at $276 per case averted or $10.51 per DALY. For targeted treatment at 30% seroprevalence, HIVNET 012 would cost $141,922 and avert 476 cases at $298 per case averted or $11.29 per DALY. With seroprevalence higher than 3.0% for universal and 4.5% for targeted treatment, the HIVNET 012 regimen was likely to be as cost effective as other public-health interventions. The cost effectiveness of HIVNET 012 was robust under a wide range of parameters in the sensitivity analysis. INTERPRETATION: The HIVNET 012 regimen can be highly cost-effective in high seroprevalence settings. In lower seroprevalence areas, when multidose regimens are not cost effective, nevirapine therapy could have a major public-health impact at a reasonable cost.

PIP: The cost effectiveness of HIVNET 012 nevirapine regimen for treatment of HIV-1-positive mothers was assessed in a hypothetical cohort of 20,000 pregnant women in sub-Saharan Africa. The program cost, pediatric HIV-1 cases averted, and cost per disability-adjusted life-year (DALY) were the main outcome measures. Univariate and multivariate analyses were used. Results showed that the nevirapine program would avert from 603 pediatric HIV-1 cases (universal treatment at 30% seroprevalence) to 246 cases (targeted treatment at 15% seroprevalence). At 30% seroprevalence, the universal treatment would cost $83,333 with 15,862 DALY. At 15% seroprevalence, it would cost $83,333 and avert 302 cases at $276 per case averted. The HIVNET 012 regimen was more effective and less costly than other regimens. The HIVNET 012 regimen would retain cost effectiveness at seroprevalence as low as 10.7% under the universal treatment option and 22% under the targeted treatment option. Furthermore, the HIVNET 012 regimen can be highly cost-effective in high seroprevalence settings. On the other hand, in areas with low seroprevalence, nevirapine therapy could have an important public health impact at a reasonable cost.

Cost-effectiveness of antiviral drug therapy to reduce mother-to-child HIV transmission in sub-Saharan Africa.

OBJECTIVE: To assess the potential cost-effectiveness of short-course antiviral regimens to prevent mother-to-child transmission (MCT) of HIV in sub-Saharan Africa. DESIGN: Cost-effectiveness analysis. METHODS: No intervention was compared with three regimens of twice daily zidovudine and lamivudine: regimen A, starting at 36 weeks of gestation and continuing to 1 week postpartum; regimen B, from intrapartum through 1 week postpartum; and regimen C, intrapartum only. Model inputs were estimated from published and unpublished data. Absolute percentage reductions in HIV transmission extrapolated from zidovudine monotherapy trials were estimated at 12.4, 8.6 and 4.3% for regimens A, B, and C, respectively. Outcome measures were net costs to the public sector health-care system, cost per infection averted, and cost per disability-adjusted life-year (DALY) gained. Multiple sensitivity analyses were conducted. RESULTS: Based on the hypothetical efficacy estimates, regimen C was the most cost-effective. For a cohort of 100 women with 15% HIV prevalence, net costs to the public sector health-care systems were estimated at US$3617 for regimen A, US$ 1667 for regimen B, and US$351 for regimen C. Regimen C had a cost of US$ 1129 per HIV infection averted and a cost of US$60 per DALY. Regimens B and A cost US$2680 and 5134 per infection averted and US$143 and 274 per DALY, respectively. Cost-effectiveness declined rapidly at efficacy below 10% or HIV prevalence below 7%. Results were very sensitive to antiviral drug costs. For example, at 20% of current prices, the cost per DALY for regimen A fell to US$64, and to about US$42 for regimens B and C. CONCLUSION: Antiviral therapy may be cost-effective compared with other health interventions if HIV prevalence is high, if clinical trials confirm estimated efficacies, and if drug prices are reduced.

The distribution of cataract surgery services in a public health eye care program in Nepal.

The cost-effectiveness of public health cataract programs in low-income countries has been well documented. Equity, another important dimension of program quality which has received less attention is analyzed here by comparisons of surgical coverage rates for major sub-groups within the intended beneficiary population of the Nepal blindness program (NBP). Substantial differences in surgical coverage were found between males and females and between different age groups of the same gender. Among the cataract blind, the surgical coverage of males was 70% higher than that of females. For both genders, the cataract blind over 55 received proportionately fewer services than younger people blind from cataract. Blind males aged 45-54 had a 500% higher rate of surgical coverage than blind males over 65. Blind females aged 35-44 had nearly a 600% higher rate of surgical coverage than blind females over 65. There was wide variation in overall surgical coverage between geographic zones, but little variation by terrain type, an indicator of the logistical difficulties in delivery of services. Members of the two highest caste groupings had somewhat lower surgical coverage than members of lower castes. Program managers should consider developing methods to increase services to women and to those over 65. Reaching these populations will become increasingly important as those most readily served receive surgery and members of the under-served groups form a growing portion of the remaining cataract backlog.

The cost of cataract surgery in a public health eye care program in Nepal.

Using data from the Lumbini Zonal Eye Care Program in Nepal, the authors estimated marginal costs, capital costs, and average recurring costs for a public health cataract program with and without donor agency overhead expenditures. Each estimate is useful for guiding decisions under certain conditions. Marginal costs are appropriate for short-term planning. Average in-country recurring cost figures are needed to project budgets for longer term program costs or major program expansion. A portion of donor agency overhead costs should be included if expansion requires more donor agency contributions. Marginal costs are estimated at US$3.01 per case. In country recurring costs are about $13.91. Capital costs excluding hospital construction are an additional $2.42. Seva's USA administrative expenditures in support of the cataract component of the program add about another $5.38. Total costs were about $21.71 per case.

Cost-effectiveness of cataract surgery in a public health eye care programme in Nepal.

Presented is an assessment of the cost-effectiveness of cataract surgery using cost and services data from the Lumbini Zonal Eye Care Programme in Nepal. The analysis suggests that cataract surgery may be even more cost-effective than previously reported. Under a "best estimate" scenario, cataract surgery had a cost of US$5.06 per disability-adjusted life year (DALY). This places it among the most cost-effective of public health interventions. Sensitivity analysis indicates that cataract surgery remains highly cost-effective even under a very pessimistic set of assumptions. The estimated mortality rates of those who receive surgery and of those who do not are among the variables that most influence the cost per DALY.