1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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