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Ruanne Barnabas, MD, chief of the Division of Infectious Diseases at Massachusetts General Hospital and a professor of Medicine at Harvard Medical School, is the senior author of a new study published in PLOS, Population Health Impact, Cost-Effectiveness, and Affordability of Community-Based HIV Treatment and Monitoring in South Africa: A Health Economics Modelling Study

What Question Were You Investigating?

The DO ART Study, published in 2020, showed that community-based HIV care improved clinical outcomes compared to clinic care and was particularly effective at engaging men in care. 

Our follow-up health economics modelling study projects that by 2060, scaled up community-based HIV care could avert 28% of HIV-associated deaths and new infections.

Because more men would access treatment that controls their infection, adolescent girls and young women aged 15-24 would also see a 31% reduction in new HIV infections. 

The intervention is also highly cost-effective over 40 years. 
Client-centered differentiated services that meet the needs of all genders are crucial in the global fight against HIV.  

What Methods or Approach Did You Use?

We used an HIV transmission model, parameterized using clinical and cost data from the DO ART Study results published in 2020.  

We examined two model scenarios: 

  1. Baseline HIV testing reflecting observed levels of HIV testing in KwaZulu-Natal, and HIV care for initiation, monitoring and refills provided at local ART clinics (“Standard of Care”) 
  2. Community-based home HIV testing and counselling (HTC) campaigns, conducted once every five years, followed by quarterly community-based ART delivery and monitoring for people who are not reached by the standard of care (“Home Testing + Community ART”; representing the DO ART intervention provided at scale).

We estimated the following: 

  • 40-year trends in HIV incidence, prevalence, mortality and disability-adjusted life year (DALY)
  • 40-year costs, cost-effectiveness, and net health benefits
  • Five-year budget impact (i.e. comparing with the current HIV budget)
  • We conducted a sensitivity analysis around the costs and various assumptions

What Did You Find?

Our modelling study projects that by 2060, community-based HIV treatment and monitoring averts 28% of HIV-related deaths and 28% of new infections. 

  • The demographic group receiving the greatest benefits are adolescent girls and young women aged 15-24, who see a 31% reduction in new HIV infections.
  • In the first five years of program implementation, community ART required $45 million, representing an additional 14% investment in the annual HIV budget; however, by 2049 the annual cost of community ART is less than that of clinic care due to reduced new cases of HIV
  • Over 40 years, community-based care is highly cost-effective. Quarterly community dispensing requires just $102 per DALY averted compared to the standard of care. With six-monthly refills, it’s only $78.5 per DALY averted, well below thresholds for cost-effectiveness.

What are the Implications?

In a high-prevalence setting, scale-up of decentralized ART dispensing and monitoring can provide large population health benefits and is cost-effective in preventing death and disability due to HIV. 

Paper cited:

Sahu, M., Bayer, C. J., Roberts, D. A., van Rooyen, H., van Heerden, A., Shahmanesh, M., Asiimwe, S., Sausi, K., Sithole, N., Ying, R., Rao, D. W., Krows, M. L., Shapiro, A. E., Baeten, J. M., Celum, C., Revill, P., & Barnabas, R. V. (2023). Population health impact, cost-effectiveness, and affordability of community-based HIV treatment and monitoring in South Africa: A health economics modelling study. PLOS global public health, 3(9), e0000610. https://doi.org/10.1371/journal.pgph.0000610

About the Massachusetts General Hospital

Massachusetts General Hospital, founded in 1811, is the original and largest teaching hospital of Harvard Medical School. The Mass General Research Institute conducts the largest hospital-based research program in the nation, with annual research operations of more than $1 billion and comprises more than 9,500 researchers working across more than 30 institutes, centers and departments. In July 2022, Mass General was named #8 in the U.S. News & World Report list of "America’s Best Hospitals." MGH is a founding member of the Mass General Brigham healthcare system.