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Revealed willingness-to-pay versus standard cost-effectiveness thresholds: Evidence from the South African HIV Investment Case

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  • Gesine Meyer-Rath
  • Craig van Rensburg
  • Bruce Larson
  • Lise Jamieson
  • Sydney Rosen

Abstract

Background: The use of cost-effectiveness thresholds based on a country’s income per capita has been criticized for not being relevant to decision making, in particular in middle-income countries such as South Africa. The recent South African HIV Investment Case produced an alternative cost-effectiveness threshold for HIV prevention and treatment interventions based on estimates of life years saved and the country’s committed HIV budget. Methods: We analysed the optimal mix of HIV interventions over a baseline of the current HIV programme under the committed HIV budget for 2016–2018. We calculated the incremental cost-effectiveness ratio (ICER) as cost per life-year saved (LYS) of 16 HIV prevention and treatment interventions over 20 years (2016–2035). We iteratively evaluated the most cost effective option (defined by an intervention and its coverage) over a rolling baseline to which the more cost effective options had already been added, thereby allowing for diminishing marginal returns to interventions. We constrained the list of interventions to those whose combined cost was affordable under the current HIV budget. Costs are presented from the government perspective, unadjusted for inflation and undiscounted, in 2016 USD. Results: The current HIV budget of about $1.6 billion per year was sufficient to pay for the expansion of condom availability, medical male circumcision, universal treatment, and infant testing at 6 weeks to maximum coverage levels, while also implementing a social and behavior change mass media campaign with a message geared at increasing testing uptake and reducing the number of sexual partners. The combined ICER of this package of services was $547/ LYS. The ICER of the next intervention that was above the affordability threshold was $872/LYS. Conclusions: The results of the South African HIV Investment Case point to an HIV cost-effectiveness threshold based on affordability under the current budget of $547–872 per life year saved, a small fraction of the country’s GDP per capita of about $6,000.

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  • Gesine Meyer-Rath & Craig van Rensburg & Bruce Larson & Lise Jamieson & Sydney Rosen, 2017. "Revealed willingness-to-pay versus standard cost-effectiveness thresholds: Evidence from the South African HIV Investment Case," PLOS ONE, Public Library of Science, vol. 12(10), pages 1-9, October.
    • Handle: RePEc:plo:pone00:0186496
    DOI: 10.1371/journal.pone.0186496
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    1. Krishna P. Reddy & Kieran P. Fitzmaurice & Justine A. Scott & Guy Harling & Richard J. Lessells & Christopher Panella & Fatma M. Shebl & Kenneth A. Freedberg & Mark J. Siedner, 2021. "Clinical outcomes and cost-effectiveness of COVID-19 vaccination in South Africa," Nature Communications, Nature, vol. 12(1), pages 1-10, December.
    2. Caitlin M Dugdale & Tamsin K Phillips & Landon Myer & Emily P Hyle & Kirsty Brittain & Kenneth A Freedberg & Lucy Cunnama & Rochelle P Walensky & Allison Zerbe & Milton C Weinstein & Elaine J Abrams &, 2019. "Cost-effectiveness of integrating postpartum antiretroviral therapy and infant care into maternal & child health services in South Africa," PLOS ONE, Public Library of Science, vol. 14(11), pages 1-18, November.
    3. Jacob Bor & Anna Gage & Dorina Onoya & Mhairi Maskew & Yorghos Tripodis & Matthew P Fox & Adrian Puren & Sergio Carmona & Koleka Mlisana & William MacLeod, 2021. "Variation in HIV care and treatment outcomes by facility in South Africa, 2011–2015: A cohort study," PLOS Medicine, Public Library of Science, vol. 18(3), pages 1-18, March.
    4. Nicola Foster & Lucy Cunnama & Kerrigan McCarthy & Lebogang Ramma & Mariana Siapka & Edina Sinanovic & Gavin Churchyard & Katherine Fielding & Alison D Grant & Susan Cleary, 2021. "Strengthening health systems to improve the value of tuberculosis diagnostics in South Africa: A cost and cost-effectiveness analysis," PLOS ONE, Public Library of Science, vol. 16(5), pages 1-21, May.

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