Despite Côte d'Ivoire epidemic being labeled as “generalized,” key populations (KPs) are important to overall transmission. Using a dynamic model of HIV transmission, we previously estimated the impact of several treatment-as-prevention strategies that reached—or missed—the UNAIDS 90-90-90 targets in different populations groups, including KP and clients of female sex workers (CFSWs). To inform program planning and resources allocation, we assessed the cost-effectiveness of these scenarios.
Costing was performed from the provider's perspective. Unit costs were obtained from the Ivorian Programme national de lutte contre le Sida (USD 2015) and discounted at 3%. Net incremental cost-effectiveness ratios (ICER) per adult HIV infection prevented and per disability-adjusted life-years (DALY) averted were estimated over 2015–2030.
The 3 most cost-effective and affordable scenarios were the ones that projected current programmatic trends [ICER = $210; 90% uncertainty interval (90% UI): $150–$300], attaining the 90-90-90 objectives among KP and CFSW (ICER = $220; 90% UI: $80–$510), and among KP only (ICER = $290; 90% UI: $90–$660). The least cost-effective scenario was the one that reached the UNAIDS 90-90-90 target accompanied by a 25% point drop in condom use in KP (ICER = $710; 90% UI: $450–$1270). In comparison, the UNAIDS scenario had a net ICER of $570 (90% UI: $390–$900) per DALY averted.
According to commonly used thresholds, accelerating the HIV response can be considered very cost-effective for all scenarios. However, when balancing epidemiological impact, cost-effectiveness, and affordability, scenarios that sustain both high condom use and rates of viral suppression among KP and CFSW seem most promising in Côte d'Ivoire.
aDepartment of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Québec, Canada;
bDépartement de Maladies Infectieuses et Tropicales, Université Alassane Ouattara, Bouaké, Côte d'Ivoire;
cCentre de Recherche du CHU de Québec, Université Laval, Québec City, Québec, Canada;
dDepartment of Infectious Disease Epidemiology, Imperial College London, St Mary's Hospital, London, United Kingdom;
eDepartment of Epidemiology, Key Populations Program, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD;
fProgramme national de lutte contre le Sida, Ministère de la santé et de l'hygiène publique, Abidjan, Côte d'Ivoire;
gEnda Santé, Dakar, Sénégal;
hDépartement de médecine sociale et préventive, Université Laval, Québec City, Québec, Canada; and
iInstitut national de santé publique du Québec, Québec City, Québec, Canada.
Correspondence to: Mathieu Maheu-Giroux, ScD, Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, 1020 Avenue des Pins Ouest, Montréal, QC H3A 1A2, Canada (e-mail: firstname.lastname@example.org).
Presented in part at the 19th International Conference on AIDS and STIs in Africa (ICASA 2017); December 4, 2017; Abidjan, Côte d'Ivoire.
M.M.-G.'s research program is funded by a career award from the Fonds de recherche du Québec – Santé. M.M.-G., S.D., and M.A. also acknowledge funding from the Réseau de recherche en santé des populations du Québec. The remaining authors have no funding or conflicts of interest to disclose.
J.F.V., M.A., M.-C.B., M.M.-G., and S.D. conceived and designed the study. AK, M.M.-G., N.J.-P, S.D., and V.W. collected and summarized costing data. M.M.-G., N.J.-P., and S.D. performed the analyses. D.D., J.F.V., M.A., M.-C.B., M.M.-G., N.J.-P, S.B., and S.D. interpreted the results. M.M.-G. drafted the manuscript, and all authors critically reviewed it for important intellectual content. All authors approved the final version.
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Received September 12, 2018
Accepted December 12, 2018