title: Cost-effectiveness of HIV prevention for high-risk groups at scale: an economic evaluation of the Avahan programme in south India.
abstract: BACKGROUND
  Avahan is a large-scale, HIV preventive intervention, targeting high-risk populations in south India. We assessed the cost-effectiveness of Avahan to inform global and national funding institutions who are considering investing in worldwide HIV prevention in concentrated epidemics.
  
  
  METHODS
  We estimated cost effectiveness from a programme perspective in 22 districts in four high-prevalence states. We used the UNAIDS Costing Guidelines for HIV Prevention Strategies as the basis for our costing method, and calculated effect estimates using a dynamic transmission model of HIV and sexually transmitted disease transmission that was parameterised and fitted to locally observed behavioural and prevalence trends. We calculated incremental cost-effective ratios (ICERs), comparing the incremental cost of Avahan per disability-adjusted life-year (DALY) averted versus a no-Avahan counterfactual scenario. We also estimated incremental cost per HIV infection averted and incremental cost per person reached.
  
  
  RESULTS
  Avahan reached roughly 150 000 high-risk individuals between 2004 and 2008 in the 22 districts studied, at a mean cost per person reached of US$327 during the 4 years. This reach resulted in an estimated 61 000 HIV infections averted, with roughly 11 000 HIV infections averted in the general population, at a mean incremental cost per HIV infection averted of $785 (SD 166). We estimate that roughly 1 million DALYs were averted across the 22 districts, at a mean incremental cost per DALY averted of $46 (SD 10). Future antiretroviral treatment (ART) cost savings during the lifetime of the cohort exposed to HIV prevention were estimated to be more than $77 million (compared with the slightly more than $50 million spent on Avahan in the 22 districts during the 4 years of the study).
  
  
  CONCLUSIONS
  This study provides evidence that the investment in targeted HIV prevention programmes in south India has been cost effective, and is likely to be cost saving if a commitment is made to provide ART to all that can benefit from it. Policy makers should consider funding and sustaining large-scale targeted HIV prevention programmes in India and beyond.
  
  
  BACKGROUND
  Bill & Melinda Gates Foundation.
authors.affiliation: London School of Hygiene & Tropical Medicine, London, UK. Electronic address: Anna.Vassall@lshtm.ac.uk.
authors.forename: Anna
authors.initials: A
authors.lastname: Vassall
authors.affiliation: London School of Hygiene & Tropical Medicine, London, UK; Imperial College, London, UK.
authors.forename: Michael
authors.initials: M
authors.lastname: Pickles
authors.affiliation: London School of Hygiene & Tropical Medicine, London, UK; St John's Research Institute, Bangalore India.
authors.forename: Sudhashree
authors.initials: S
authors.lastname: Chandrashekar
authors.affiliation: Imperial College, London, UK.
authors.forename: Marie-Claude
authors.initials: MC
authors.lastname: Boily
authors.affiliation: Karnataka Health Promotion Trust, Bangalore, India.
authors.forename: Govindraj
authors.initials: G
authors.lastname: Shetty
authors.affiliation: London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Lorna
authors.initials: L
authors.lastname: Guinness
authors.affiliation: London School of Hygiene & Tropical Medicine, London, UK; Public Health England, London, UK.
authors.forename: Catherine M
authors.initials: CM
authors.lastname: Lowndes
authors.affiliation: Centre de Recherche du CHU Universitaire de Québec, QC, Canada.
authors.forename: Janet
authors.initials: J
authors.lastname: Bradley
authors.affiliation: Karnataka Health Promotion Trust, Bangalore, India; University of Manitoba, Winnipeg, MB, Canada.
authors.forename: Stephen
authors.initials: S
authors.lastname: Moses
authors.affiliation: Centre de Recherche du CHU Universitaire de Québec, QC, Canada; Département de Médecine Sociale et Préventive, Université Laval, Québec, QC, Canada.
authors.forename: Michel
authors.initials: M
authors.lastname: Alary
authors.affiliation: London School of Hygiene & Tropical Medicine, London, UK; Department of Social and Community Medicine, University of Bristol, Bristol, UK.
authors.forename: Peter
authors.initials: P
authors.lastname: Vickerman
mesh_terms: D044966:Anti-Retroviral Agents / Q000191:economics / Q000627:therapeutic use; D017280:Condoms; D003362:Cost-Benefit Analysis; D015658:HIV Infections / Q000188:drug therapy / Q000191:economics / Q000517:prevention & control*; D006266:Health Education / Q000191:economics / Q000458:organization & administration*; D006801:Humans; D007194:India; D008017:Life Expectancy; D015995:Prevalence; D012307:Risk Factors; D012749:Sexually Transmitted Diseases / Q000517:prevention & control
chemical_list: D044966:Anti-Retroviral Agents