title: Portfolios of biomedical HIV interventions in South Africa: a cost-effectiveness analysis.
abstract: BACKGROUND
  Recent clinical trials of male circumcision, oral pre-exposure prophylaxis (PrEP), and a vaginal microbicide gel have shown partial effectiveness at reducing HIV transmission, stimulating interest in implementing portfolios of biomedical prevention programs.
  
  
  OBJECTIVE
  To evaluate the effectiveness and cost-effectiveness of combination biomedical HIV prevention and treatment scale-up in South Africa, given uncertainty in program effectiveness.
  
  
  METHODS
  Dynamic HIV transmission and disease progression model with Monte Carlo simulation and cost-effectiveness analysis.
  
  
  METHODS
  Men and women aged 15 to 49 years in South Africa.
  
  
  METHODS
  HIV screening and counseling, antiretroviral therapy (ART), male circumcision, PrEP, microbicide, and select combinations.
  
  
  METHODS
  HIV incidence, prevalence, discounted costs, discounted quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios.
  
  
  RESULTS
  Providing half of all uninfected persons with PrEP averts 28 % of future HIV infections for $9,000/QALY gained, but the affordability of such a program is questionable. Given limited resources, annual HIV screening and ART utilization by 75 % of eligible infected persons could avert one-third of new HIV infections, for approximately $1,000/QALY gained. Male circumcision is more cost-effective, but disproportionately benefits men. A comprehensive portfolio of expanded screening, ART, male circumcision, microbicides, and PrEP could avert 62 % of new HIV infections, reducing HIV prevalence from a projected 14 % to 10 % after 10 years. This strategy doubles treatment initiation and adds 31 million QALYs to the population. Despite uncertainty in program effectiveness, a comprehensive portfolio costs less than $10,000/QALY gained in 33 % of simulation iterations and less than $30,000/QALY gained in 90 % of iterations, assuming an annual microbicide cost of $100.
  
  
  CONCLUSIONS
  A portfolio of modestly-effective biomedical HIV prevention programs, including male circumcision, vaginal microbicides, and oral PrEP, could substantially reduce HIV incidence and prevalence in South Africa and be likely cost-effective. Given limited resources, PrEP is the least cost-effective intervention of those considered.
authors.affiliation: Yale School of Management, 135 Prospect Street, New Haven, CT, 06520, USA, elisa.long@yale.edu.
authors.forename: Elisa F
authors.initials: EF
authors.lastname: Long
authors.forename: Robert R
authors.initials: RR
authors.lastname: Stavert
mesh_terms: D000284:Administration, Oral; D000293:Adolescent; D000328:Adult; D019380:Anti-HIV Agents / Q000008:administration & dosage / Q000191:economics / Q000627:therapeutic use; D002944:Circumcision, Male / Q000191:economics / Q000706:statistics & numerical data; D003362:Cost-Benefit Analysis; D018450:Disease Progression; D058872:Epidemics; D005260:Female; D015658:HIV Infections / Q000191:economics / Q000453:epidemiology / Q000517:prevention & control* / Q000635:transmission; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006801:Humans; D015994:Incidence; D008297:Male; D008403:Mass Screening / Q000191:economics; D008875:Middle Aged; D015995:Prevalence; D019057:Quality-Adjusted Life Years; D013019:South Africa / Q000453:epidemiology; D016896:Treatment Outcome; D014622:Vaginal Creams, Foams, and Jellies; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents; D014622:Vaginal Creams, Foams, and Jellies