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What are the most cost-effective HIV/AIDS interventions?

May 26, 2011

What are the most cost-effective HIV/AIDS interventions?

John Stover

The cost-effectiveness of HIV interventions varies by epidemic so there is no single answer to this question. To further complicate matters we have relatively good cost and effectiveness information on key biomedical interventions such as ART, male circumcision, condoms and the prevention of mother-to-child transmission (PMTCT). Cost and impact are much harder to define for behavior change interventions such as behavior change communications, community mobilization, and school-based education because there are few standard definitions of what each intervention includes. More information is available for some behavior change interventions such as counseling and testing and outreach to key populations.

Accurate measurement of cost-effectiveness of prevention interventions requires randomized controlled trials to accurately measure impact and cost. But few such studies exist. Instead modeling is often used to estimate cost-effectiveness in certain epidemic settings. At Futures Institute we have developed the Goals model for such calculations and used it to estimate impact and cost-effectiveness for national strategic planning. When we look at the findings from applications across the world, some general conclusions do emerge.

For generalized epidemics male circumcision is very cost-effective in all countries in which current rates of male circumcision are low. PMTCT is generally cost-effective especially at high levels of HIV prevalence. Condoms promotion and outreach to sex workers and clients are also very cost-effective in most settings. Of course, ART is cost-effective in preventing AIDS deaths and can have a significant prevention impact as well.

For concentrated epidemics the picture is more varied depending on the main drivers of the epidemic. In those epidemics driven by transmission among injecting drug users, outreach to IDU and needle and syringe exchange programs are very cost-effective. Outreach to sex workers and clients, outreach to men who have sex with men, and condom promotion are also generally cost-effective prevention interventions. ART is cost-effective at preventing death.

UNAIDS has recently defined a set of "basic programs" that have demonstrated effectiveness and should be scaled-up in all countries. The set includes PMTCT; condom promotion and distribution; outreach to key populations (sex work, IDU, MSM); treatment, care and support for people living with HIV; male circumcision in generalized epidemics with low male circumcision rates; and social and behavioral change communications.

Other interventions may be cost-effective in specific settings but not in others. 

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