Brian Weir Johns Hopkins University Cost-effectiveness analyses for integrating health services for HIV and other health conditions in Kenya, Nigeria, and India Brian Weir Johns Hopkins University

Background Economic evaluation essential Caveat emptor: Estimate resource requirements Determine whether interventions are cost-saving, cost-effective or not cost-effective Compare across prevention packages Inform policy-makers Caveat emptor: Also need to consider feasibility, affordability, acceptability, and equity of integrated services Few integration scenarios have good cost and impact data Unclear when integration leads to economies of scope

Methods Economic evaluation based on estimating for status quo and integrated services scenarios. For each scenario: Resources required to deliver interventions Impact on healthcare utilization Impact on death and disability expressed as disability-adjusted life years (DALYs) Reporting 10-year time horizon for most costs and impacts Lifetime time horizon for diabetes and hypertension medical costs and DALYs Values reported in 2016 USD 3% discount rate Incremental cost-effectiveness ratio (ICER), defined as cost per DALY averted per capita GDP used as cost-effectiveness threshold

Integrated community-based HIV and NCD screening in Kenya: Costs, DALYs averted, and ICER (2018 – 2028) HIV Community mobilisation and HIV testing cost 625.6m USD Antiretroviral therapy cost 854.3m USD Total HIV healthcare cost 1480.0m USD HIV-related DALYs averted 6.5m Incremental cost-effectiveness ratio (cost per DALY averted) 227 USD Hypertension Supplemental screening for hypertension and diabetes 35.4m USD Hypertension lifetime treatment costs 374.4m USD Total hypertension healthcare cost 409.8m USD Hypertension-related DALYs averted 1.8m 232 USD Diabetes Untreated diabetics identified 686,000 Cost per untreated diabetic identified 54 USD Per capita gross domestic product (2016) 3155 USD

Scaling-up PMTCT and family planning in Nigeria: Costs, DALYs averted, and ICER (2018 – 2028) Prevention of mother-to-child transmission (PMTCT) HIV screening cost 881.0m USD PMTCT treatment cost 588.4m USD Total HIV healthcare costs 1469.4m USD HIV-related DALYs averted 8.6m Incremental cost-effectiveness ratio (cost per DALY averted) 169 USD Family Planning Family planning costs 230.3m USD Healthcare costs averted 208.6m USD Net cost 21.7m USD DALYs averted 22.9m 0.95 USD Per capita gross domestic product (2016) 5861 USD

Integrated HIV/STI management for female sex workers and men who have sex with men in India: Costs, DALYs averted, and ICER (2018 – 2028) HIV Respondent-driven recruitment and HIV screening cost 1648.4m USD Antiretroviral therapy cost 148.8m USD Total HIV healthcare costs 1797.2m USD HIV-related DALYs averted 2.7m Incremental cost-effectiveness ratio (cost per DALY averted) 656 USD Syphilis Screening cost 283.8m USD Treatment cost 34.2m USD Total healthcare costs 318.0m USD DALYs averted 2.4m 135 USD Per capita gross domestic product (2016) 6571 USD PrEP (at 91 USD per person-year) was not cost-effective: $58,000 USD/DALY averted at 10% coverage among female sex workers and men who have sex with men across India

Conclusion Integration can be cost-effective Need to tailor integration to epidemiology and health care system Kenya—generalized epidemic integrated community-based screening for HIV, NCDs, and other conditions Nigeria—frequent mother-to-child transmission and unmet contraceptive needs Integrated PMTCT and family planning India—concentrated epidemics among FSW and MSM Integrated HIV/STI management for key populations Need stronger evidence base on effectiveness and cost of integrated services

Acknowledgements WHO Avenir Health Johns Hopkins University Chris Beyrer Karin Stenberg David Dowdy Avenir Health Parastu Kasaie John Stover Shannon Seopaul Rachel Sanders Leah Holmes Kellan Baker Stephane Labossiere