Cost-effectiveness of voluntary HIV-1 counselling and testing in reducing sexual transmission of HIV-1 in Kenya and Tanzania.
BACKGROUND
Access to HIV-1 voluntary counselling and testing (VCT) is severely limited in less-developed countries. We undertook a multisite trial of HIV-1 VCT to assess its impact, cost, and cost-effectiveness in less-developed country settings.


METHODS
The cost-effectiveness of HIV-1 VCT was estimated for a hypothetical cohort of 10000 people seeking VCT in urban east Africa. Outcomes were modelled based on results from a randomised controlled trial of HIV-1 VCT in Tanzania and Kenya. Our main outcome measures included programme cost, number of HIV-1 infections averted, cost per HIV-1 infection averted, and cost per disability-adjusted life-year (DALY) saved. We also modelled the impact of targeting VCT by HIV-1 prevalence of the client population, and the proportion of clients who receive VCT as a couple compared with as individuals. Sensitivity analysis was done on all model parameters.


RESULTS
HIV-1 VCT was estimated to avert 1104 HIV-1 infections in Kenya and 895 in Tanzania during the subsequent year. The cost per HIV-1 infection averted was US$249 and $346, respectively, and the cost per DALY saved was $12.77 and $17.78. The intervention was most cost-effective for HIV-1-infected people and those who received VCT as a couple. The cost-effectiveness of VCT was robust, with a range for the average cost per DALY saved of $5.16-27.36 in Kenya, and $6.58-45.03 in Tanzania. Analysis of targeting showed that increasing the proportion of couples to 70% reduces the cost per DALY saved to $10.71 in Kenya and $13.39 in Tanzania, and that targeting a population with HIV-1 prevalence of 45% decreased the cost per DALY saved to $8.36 in Kenya and $11.74 in Tanzania.


CONCLUSIONS
HIV-1 VCT is highly cost-effective in urban east African settings, but slightly less so than interventions such as improvement of sexually transmitted disease services and universal provision of nevirapine to pregnant women in high-prevalence settings. With the targeting of VCT to populations with high HIV-1 prevalence and couples the cost-effectiveness of VCT is improved significantly.
Sweat
M
M
School of Hygiene and Public Health, Johns Hopkins University, Baltimore, MD 21205, USA. MSWEAT@JHSPH.EDU
Gregorich
S
S
Sangiwa
G
G
Furlonge
C
C
Balmer
D
D
Kamenga
C
C
Grinstead
O
O
Coates
T
T
D015492:AIDS Serodiagnosis / Q000191:economics*; D000328:Adult; D003376:Counseling / Q000191:economics*; D003906:Developing Countries; D006233:Persons with Disabilities / Q000706:statistics & numerical data; D005260:Female; D015658:HIV Infections / Q000175:diagnosis* / Q000191:economics / Q000453:epidemiology / Q000517:prevention & control* / Q000635:transmission; D015528:HIV Seroprevalence; D015497:HIV-1; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007630:Kenya / Q000453:epidemiology; D008297:Male; D011247:Pregnancy; D015397:Program Evaluation; D012725:Sexual Behavior / Q000523:psychology / Q000706:statistics & numerical data*; D013636:Tanzania / Q000453:epidemiology; D016896:Treatment Outcome; D014504:Urban Health / Q000706:statistics & numerical data