title: Cost-effectiveness of community-based strategies to strengthen the continuum of HIV care in rural South Africa: a health economic modelling analysis.
abstract: BACKGROUND
  Home HIV counselling and testing (HTC) achieves high coverage of testing and linkage to care compared with existing facility-based approaches, particularly among asymptomatic individuals. In a modelling analysis we aimed to assess the effect on population-level health and cost-effectiveness of a community-based package of home HTC in KwaZulu-Natal, South Africa.
  
  
  METHODS
  We parameterised an individual-based model with data from home HTC and linkage field studies that achieved high coverage (91%) and linkage to antiretroviral therapy (80%) in rural KwaZulu-Natal, South Africa. Costs were derived from a linked microcosting study. The model simulated 10,000 individuals over 10 years and incremental cost-effectiveness ratios were calculated for the intervention relative to the existing status quo of facility-based testing, with costs discounted at 3% annually.
  
  
  RESULTS
  The model predicted implementation of home HTC in addition to current practice to decrease HIV-associated morbidity by 10–22% and HIV infections by 9–48% with increasing CD4 cell count thresholds for antiretroviral therapy initiation. Incremental programme costs were US$2·7 million to $4·4 million higher in the intervention scenarios than at baseline, and costs increased with higher CD4 cell count thresholds for antiretroviral therapy initiation; antiretroviral therapy accounted for 48–87% of total costs. Incremental cost-effectiveness ratios per disability-adjusted life-year averted were $1340 at an antiretroviral therapy threshold of CD4 count lower than 200 cells per μL, $1090 at lower than 350 cells per μL, $1150 at lower than 500 cells per μL, and $1360 at universal access to antiretroviral therapy.
  
  
  CONCLUSIONS
  Community-based HTC with enhanced linkage to care can result in increased HIV testing coverage and treatment uptake, decreasing the population burden of HIV-associated morbidity and mortality. The incremental cost-effectiveness ratios are less than 20% of South Africa's gross domestic product per person, and are therefore classed as very cost effective. Home HTC can be a viable means to achieve UNAIDS' ambitious new targets for HIV treatment coverage.
  
  
  BACKGROUND
  National Institutes of Health, Bill & Melinda Gates Foundation, Wellcome Trust.
authors.forename: Jennifer A
authors.initials: JA
authors.lastname: Smith
authors.forename: Monisha
authors.initials: M
authors.lastname: Sharma
authors.forename: Carol
authors.initials: C
authors.lastname: Levin
authors.forename: Jared M
authors.initials: JM
authors.lastname: Baeten
authors.forename: Heidi
authors.initials: H
authors.lastname: van Rooyen
authors.forename: Connie
authors.initials: C
authors.lastname: Celum
authors.forename: Timothy B
authors.initials: TB
authors.lastname: Hallett
authors.forename: Ruanne V
authors.initials: RV
authors.lastname: Barnabas
mesh_terms: D019380:Anti-HIV Agents / Q000191:economics* / Q000627:therapeutic use; D023241:Antiretroviral Therapy, Highly Active / Q000191:economics; D018791:CD4 Lymphocyte Count; D003153:Community Health Services / Q000191:economics* / Q000458:organization & administration; D003362:Cost-Benefit Analysis; D037001:Directive Counseling; D004608:Eligibility Determination; D015658:HIV Infections / Q000188:drug therapy / Q000191:economics* / Q000276:immunology / Q000517:prevention & control; D017048:Health Care Costs; D006801:Humans; D008403:Mass Screening / Q000191:economics* / Q000458:organization & administration; D018803:Models, Economic; D010865:Pilot Projects; D012424:Rural Population; D013019:South Africa / Q000453:epidemiology; D019562:Viral Load
chemical_list: D019380:Anti-HIV Agents
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