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

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

doi:10.1371/journal.pone.0186496

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

PLoS One. 2017 Oct 26;12(10):e0186496. doi: 10.1371/journal.pone.0186496. eCollection 2017.

Authors

Gesine Meyer-Rath^{1

2}, Craig van Rensburg², Bruce Larson¹, Lise Jamieson², Sydney Rosen^{1

2}

Affiliations

¹ Department of Global Health, Boston University School of Public Health, Boston, United States of America.
² Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.

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.

MeSH terms

Anti-HIV Agents / economics*
Anti-HIV Agents / therapeutic use
Budgets
Cost-Benefit Analysis*
Financing, Personal*
HIV Infections / drug therapy*
Humans
South Africa

Substances

Anti-HIV Agents

Grants and funding

This study was made possible by the generous support of the American people through the United States Agency for International Development (USAID) under award number AID 674-A-12-00029. The contents are the responsibility of the authors and do not necessarily reflect the views of USAID or the US Government. The authors acknowledge the contribution of the HIV Investment Case Steering Committee, Task Team and working groups under the leadership of the National Department of Health and the South African AIDS Council.