2. Expenditures and effects of couples’ voluntary HIV counseling and testing in reducing heterosexual transmission of HIV-1 Bellington Vwalika 1, Kristin Wall 3 Mubiana Inambao 2, William Kilembe 1, Rachel Parker 3, Tyronza Sharkey 1, Divya Sonti 3, Amanda Tichacek 3, Eric Hunter 3, Robert Yohnka 3, Joseph Abdallah 3, Ibou Thior 4, Julie Pulerwitz 4, Susan Allen 1,3 1 Zambia Emory HIV Research Project, Lusaka, Zambia; 2 Zambia Emory HIV Research Project, Ndola, Zambia 3 Rwanda Zambia; HIV Research Group, Emory University, Atlanta, GA, United States, 4 Arise Program, PATH, Washington D.C., United States

3. Introduction In sub-Saharan Africa, heterosexual transmission of HIV predominates and the majority of new infections occur in stable, concordant HIV- or discordant couples. CVCT is an evidence-based intervention that significantly increases condom use and decreases HIV/ STI incidence in such couples. Despite WHO recommendations supporting couples’ voluntary HIV counseling and testing (CVCT) for HIV prevention, only a small percentage of African adults has been tested with their partners.

4. Benefits of CVCT Observational studies show HIV incidence in jointly counselled discordant couples to be 1/2 to 2/3 that of discordant couples unaware of their joint serostatus. We have previously estimated that 45% and 53% of new HIV infections in married Zambian men and women, respectively could be averted through CVCT (Dunkle et al, Lancet, 2008)

5. Methods From 2010-2015, CVCT with follow-up was established in 73 Zambian government clinics. CVCT cost-per-HIV-infection averted (CHIA) was calculated using actual expenditures and observed HIV prevention impact. CHIA estimates for a hypothetical 5-year national expansion of CVCT, antiretroviral treatment-as-prevention (TasP) for discordant couples identified after CVCT, and blanket TasP for all HIV+ married or cohabiting adults are compared.

6. Expenditures of CVCT Implementation

7. Results: Couples tested and HIV incidence 172,981 couples were tested at $52/couple. Among discordant couples in which the HIV- positive partner self-reported ART use, HIV incidence was 9.6/100 person-years (PY) before CVCT, dropping to 1.6/100PY after CVCT (84% reduction). Corresponding reductions for non-ART using discordant and concordant negative couples were 78% and 63%, respectively.

8. Observed effects and CHIA

9. Results: Cost savings An estimated 71% of new infections were averted by CVCT at $440 CHIA. In a hypothetical 5-year national implementation, CVCT CHIA is $229-$330. For TasP in discordant couples following CVCT, CHIA is $5,865-$23,698; and blanket TasP without CVCT is $11,193-$27,552. CVCT is a one-time intervention with long-term impact. In Contrast, TasP only works as long as the drugs are taken, and CHIA for TasP is therefore an annual cost. By year five, the maintenance cost of this hypothetical nationwide CVCT implementation drops to 2% of the annual PEPFAR budget to Zambia. The annual cost of TasP would stabilize at 19-35% of the budget while blanket TasP would stabilize at 49-91% of the budget.

10. CVCT compared to TasP after CVCT - Observed

11. CVCT compared to TasP after CVCT - Conservative

12. Blanket TasP compared to TasP limited to discordant couples after CVCT - Observed

13. Blanket TasP compared to TasP limited to discordant couples after CVCT- Conservative CVCT, optimistic TasP

14. Conclusions Our results demonstrate: 1)CVCT is sufficiently effective to prevent the majority of infections in discordant and concordant negative couples; 2)CVCT is sustainable and affordable; 3)CVCT is effective for therapeutic ART users, for whom ART use alone only partially mitigated transmission risk 4)TasP programs, where affordable, should not be implemented without prior CVCT.

15. References Dunkle KL, Greenberg L, Lanterman A, Stephenson R, Allen S. Source of new infections in generalised HIV epidemics – Authors' reply. Lancet 2008;372:1300-1. AIDSinfo. 2014. (Accessed April 2, 2015, at http://www.unaids.org/en/dataanalysis/datatools/aidsinfo/.)http://www.unaids.org/en/dataanalysis/datatools/aidsinfo/. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. The New England journal of medicine 2011;365:493-505. Meyer-Rath G, Over M, Klein DJ, Bershteyn A. The Cost and Cost-Effectiveness of Alternative Strategies to Expand Treatment to HIV-Positive South Africans: Scale Economies and Outreach Costs. Health and Development Discussion Paper 2015. PEPFAR. 2014 Report on Costs of Treatment in the President’s Emergency Plan for AIDS Relief (PEPFAR) Washington, DC2014. World Population Prospects: The 2012 Revision. United Nations, 2015. (Accessed April 2, 2015, at http://esa.un.org/wpp/unpp/panel_indicators.htm.) http://esa.un.org/wpp/unpp/panel_indicators.htm. Indicators. The World Bank Group, 2015. (Accessed April 3, 2015, at http://data.worldbank.org/indicator/.)http://data.worldbank.org/indicator/. ICF International. (Accessed November 1, 2014, at http://www.measuredhs.com/.)http://www.measuredhs.com/. Chemaitelly H, Cremin I, Shelton J, Hallett TB, Abu-Raddad LJ. Distinct HIV discordancy patterns by epidemic size in stable sexual partnerships in sub-Saharan Africa. Sexually transmitted infections 2012;88:51-7. Zambia Country Report: Monitoring the Declaration of Commitment on HIV and AIDS and the Universal Access. 2014. (Accessed June 23, 2015, at http://www.unaids.org/sites/default/files/country/documents/ZMB_narrative_report_2014.pdf.) http://www.unaids.org/sites/default/files/country/documents/ZMB_narrative_report_2014.pdf.

16. Support for this project was provided by the Canadian Government through PATH and the Department of Foreign Affairs Trade and Development. The views expressed by the authors do not necessarily reflect the views of PATH, the Canadian Government or the Department of Foreign Affairs Trade and Development. This document was produced under Arise—Enhancing HIV Prevention Programs for At-Risk Populations, through financial support provided by the Canadian Government through Foreign Affairs, Trade and Development Canada, and via financial and technical support provided by PATH. Arise implements innovative HIV prevention initiatives for vulnerable communities, with a focus on determining cost-effectiveness through rigorous evaluations.