Programs that are very costly per HIV infection prevented, and likely not cost-effective regardless of the changes in any parameters, include school-based education or any other programs targeted at youth, primarily because the HIV prevalence in this group is very low. Drug treatment programs are less cost-effective for HIV prevention primarily because their cost per person reached is so high compared with many other interventions. Similarly HIV antiretroviral treatment is not cost-effective as a measure to prevent secondary HIV transmission because of the high cost per person reached.
Some of the interventions that our analysis found to be the most cost-effective are not even considered by health agencies in the HIV prevention plans. Nonetheless, published studies argue that they are effective, and our analyses suggest that they may be a far better use of HIV prevention resources than some standard interventions. In particular, increasing the price of alcohol reduces alcohol consumption, which has been associated with risky sex. Price increases do not change attitudes or knowledge regarding the risks of sex, but simply alter the opportunity for high-risk behaviors. A review of the effect of alcohol tax increases on STD rates suggests that the effect of this intervention may be large.53 Mass media campaigns have the potential to be effective at changing behavior, as suggested by the Swiss STOP AIDS programs that specifically targeted condom use, and, if effective, are likely to be relatively cost-effective. Screening and treatment of curable STDs among HIV-positive persons are likely to prevent substantial HIV transmission to their partners because bacterial STDs are important cofactors in HIV transmission.
In addition, the duration of intervention effectiveness is unknown, so we cannot be sure whether all our results actually do extend to 12 months or whether the effectiveness is delayed and only appears after several years (as might be the case in school-based interventions). When interventions are evaluated, their effect is usually measured after a single time interval. It may not be appropriate to compare interventions when effectiveness is measured after different time periods. We also assumed an immediate and constant effect, which may not be the case in practice. On the other hand, if the effects of interventions last beyond the point at which we measured the outcome, our methods will underestimate the impact.
Another concern is the strength of evidence of the effectiveness of the interventions we used to conduct the analysis. Some studies were conducted using a rigorous, randomized, controlled design, whereas others were natural experiments or were not randomized. Moreover, even when the strength of the evidence is high for a particular intervention, the effectiveness in changing behavior when implemented in local communities may vary substantially from the effectiveness under research conditions.
Nevertheless, despite these limitations, our methods do provide a means to understand the general patterns of relative cost-effectiveness of different interventions, and we found that this cost-effectiveness varied between interventions by several orders of magnitude. In current practice, it is virtually impossible to use cost-effectiveness in choosing among different HIV prevention interventions, so funding and other resources for HIV prevention are likely not used to maximize the number of HIV infections prevented. At the same time, although cost-effectiveness comparisons such as these are extremely useful, they should not be the sole decision-making criteria in determining the allocation of HIV prevention resources. Other critical factors to be considered include the intervention’s strength of evidence for effectiveness, feasibility, acceptability, and replicability in the local area. Although not shown, our spreadsheet tool includes a linked application that allows these and other factors to be considered and weighted along with cost-effectiveness in prioritizing interventions. Given that current decision making for HIV prevention usually does not usually consider cost-effectiveness, this tool could substantially improve community decisions regarding the portfolio of HIV prevention interventions and thereby optimize the use of limited HIV prevention resources.
1. IOM. No Time to Lose. Getting More from HIV Prevention
. Washington, DC: National Academy Press; 2000.
2. Holtgrave DR, Pinkerton SD. Updates of cost of illness and quality of life estimates for use in economic evaluations of HIV prevention
programs. J Acquir Immune Defic Syndr Hum Retrovirol
3. Cohen D, Scribner R. An STD/HIV prevention
framework. Aids Patient Care STDS
4. Weinhardt LS, Carey MP, Johnson BT, et al. Effects of HIV counseling and testing on sexual risk behavior: a meta-analytic review of published research, 1985–1997. Am J Public Health
5. Kamb ML, Fishbein M, Douglas JM, et al. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases. JAMA
6. Bedimo AL, Pinkerton SD, Cohen DA, et al. Condom distribution: a cost-utility analysis. Int J STD AIDS
7. Weinstein M, Graham J, Siegel J, et al. Cost-effectiveness
analysis of AIDS prevention programs: concepts, complications, and illustration. In: Turner C, Miller H, Moses L, eds. AIDS: Sexual Behavior and Intravenous Drug Use
. Washington, DC: National Academy Press; 1989:471–499.
8. Pinkerton SD, Holtgrave DR, Leviton LC, et al. Model-based evaluation of HIV prevention
interventions. Eval Rev
9. Mastro TD, de Vincenzi I. Probabilities of sexual HIV-1 transmission. AIDS
. 1996;10(Suppl A):S75–S85.
10. Mastro TD, Kitayaporn D. HIV type 1 transmission probabilities: estimates from epidemiological studies. AIDS R Hum Retrovirus
. 1998;14(Suppl 3):S223–S227.
11. Vittinghoff E, Douglas J, Judson F, et al. Per-contact risk of human immunodeficiency virus transmission between male sexual partners. Am J Epidemiol
12. Kaplan EH, Heimer R. A model-based estimate of HIV infectivity via needle sharing. J Acquir Immune Defic Syndr
13. Kaplan EH, Heimer R. A model-based estimate of HIV infectivity via needle sharing. J Acquir Immune Defic Syndr
14. Pinkerton SD, Holtgrave DR, DiFranceisco W, et al. Cost-threshold analyses of the national AIDS demonstration research HIV prevention
15. Allard R. A mathematical model to describe the risk of infection from sharing injection equipment. J Acquir Immune Defic Syndr
16. Laumann E, Gagnon J, Michael R, et al. The Social Organization of Sexuality: Sexual Practices in the United States
. Chicago: University of Chicago Press; 1994.
17. Kelly JA, Murphy DA, Sikkema KJ, et al. Randomised, controlled, community-level HIV-prevention intervention for sexual-risk behaviour among homosexual men in US cities. Community HIV Prevention
Research Collaborative. Lancet
18. Holmberg SD. The estimated prevalence and incidence of HIV in 96 large US metropolitan areas. Am J Public Health
19. Anonymous. HIV prevention
through early detection and treatment of other sexually transmitted diseases—United States Recommendations of the Advisory Committee for HIV and STD Prevention. MMWR Morbid Mortal Wk Rep
20. Chesson CW, Pinkerton SD. Sexually transmitted diseases and the increased risk for HIV transmission: implications for cost-effectiveness
analyses of sexually transmitted disease prevention interventions. J Acquir Immune Defic Syndr Hum Retrovirol
21. Pinkerton SD, Holtgrave DR, DiFranceisco WJ, et al. Cost-effectiveness
of a community-level HIV risk reduction intervention. Am J Public Health
22. Pinkerton SD, Holtgrave DR, Jemmott JB 3rd. Economic evaluation of HIV risk reduction intervention in African-American male adolescents. J Acquir Immune Defic Syndr
23. Pinkerton SD, Holtgrave DR, Valdiserri RO. Cost-effectiveness
of HIV-prevention skills training for men who have sex with men. AIDS
24. Pinkerton SD, Johnson–Masotti AP, Holtgrave DR, et al. Using cost-effectiveness
league tables to compare interventions to prevent sexual transmission of HIV. AIDS
25. Holtgrave DR, Pinkerton SD, Jones TS, et al. Cost and cost-effectiveness
of increasing access to sterile syringes and needles as an HIV prevention
intervention in the United States. J Acquir Immune Defic Syndr Hum Retrovirol
. 1998;18(Suppl 1):S133–S138.
26. Holtgrave DR, Valdiserri RO, Gerber AR, et al. Human immunodeficiency virus counseling, testing, referral, and partner notification services. A cost–benefit analysis. Arch Intern Med
27. Kahn JG, Kegeles SM, Hays R, et al. Cost-effectiveness
of the Mpowerment Project, a community-level intervention for young gay men. J Acquir Immune Defic Syndr Hum Retrovirol
28. Wang LY, Davis M, Robin L, et al. Economic evaluation of safer choices: a school-based human immunodeficiency virus, other sexually transmitted diseases, and pregnancy prevention program. Arch Pediatr Adolesc Med
29. Varghese B, Peterman TA, Holtgrave DR. Cost-effectiveness
of counseling and testing and partner notification: a decision analysis. AIDS
30. O’Donnell CR, O’Donnell L, San Doval A, et al. Reductions in STD infections subsequent to an STD clinic visit: using video-based patient education to supplement provider interactions. Sex Transm Dis
31. Kelly JA, Murphy DA, Washington CD, et al. The effects of HIV/AIDS intervention groups for high-risk women in urban clinics. Am J Public Health
32. Holtgrave DR, Kelly JA. Preventing HIV/AIDS among high-risk urban women: the cost effectiveness of a behavioral group intervention. Am J Public Health
33. Shain RN, Piper JM, Newton ER, et al. A randomized, controlled trial of a behavioral intervention to prevent sexually transmitted disease among minority women. N Engl J Med
34. Wykoff RF, Jones JL, Longshore ST, et al. Notification of the sex and needle-sharing partners of individuals with human immunodeficiency virus in rural South Carolina: 30-month experience. Sex Transm Dis
35. Toomey KE, Peterman TA, Dicker LW, et al. Human immunodeficiency virus partner notification. Cost and effectiveness data from an attempted randomized controlled trial. Sex Transm Dis
36. Coyle K, Basen–Engquist K, Kirby D, et al. Short-term impact of safer choices: a multicomponent, school-based HIV, other STD, and pregnancy prevention program. J Sch Health
37. St Lawrence JS, Brasfield TL, Jefferson KW, et al. Cognitive-behavioral intervention to reduce African American adolescents’ risk for HIV infection. J Consult Clin Psychol
38. Kelly JA, St Lawrence JS, Stevenson LY, et al. Community AIDS/HIV risk reduction: the effects of endorsements by popular people in three cities. Am J Public Health
39. Sikkema KJ, Kelly JA, Winett RA, et al. Outcomes of a randomized community-level HIV prevention
intervention for women living in 18 low-income housing developments. Am J Public Health
40. Wendell DA, Cohen DA, LeSage D, et al. Street outreach for HIV prevention
: effectiveness of a state-wide program. Int J STD AIDS
41. Lauby JL, Smith PJ, Stark M, et al. A community-level HIV prevention
intervention for inner-city women: results of the Women and Infants Demonstration Projects. Am J Public Health
42. Kegeles SM, Hays RB, Coates TJ. The Mpowerment Project: a community-level HIV prevention
intervention for young gay men. Am J Public Health
43. Prendergast ML, Podus D, Chang E. Program factors and treatment outcomes in drug dependence treatment: an examination using meta-analysis. Subst Use Misuse
44. Grosskurth H, Mosha F, Todd J, et al. Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania: randomised controlled trial. Lancet
45. Farley T, Cohen D, Wu S, et al. STD screening in HIV clinics: value and implications. JAIDS
. 2003. In press.
46. Lepri AC, Miller V, Phillips AN, et al. The virological response to highly active antiretroviral therapy over the first 24 weeks of therapy according to the pre-therapy viral load and the weeks 4–8 viral load. AIDS
47. Weiss HA, Quigley MA, Hayes RJ. Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis. AIDS
48. Cohen DA, Farley TA, Bedimo–Etame JR, et al. Implementation of condom social marketing in Louisiana, 1993 to 1996. Am J Public Health
49. Heimer R, Khoshnood K, Bigg D, et al. Syringe use and reuse: effects of syringe exchange programs in four cities. J Acquir Immune Defic Syndr Hum Retrovirol
. 1998;18(Suppl 1):S37–S44.
50. Kaplan EH. Economic analysis of needle exchange. AIDS
51. Groseclose SL, Weinstein B, Jones TS, et al. Impact of increased legal access to needles and syringes on practices of injecting-drug users and police officers—Connecticut, 1992–1993. J Acquir Immune Defic Syndr Hum Retrovirol
52. Anonymous. Impact of new legislation on needle and syringe purchase and possession—Connecticut, 1992. MMWR Morbid Mortal Wk Rep
53. Anonymous. Alcohol policy
and sexually transmitted disease rates—United States, 1981–1995. MMWR Morbid Mortal Wk Rep
54. O’Donnell L, Stueve A, San Doval A, et al. The effectiveness of the Reach for Health Community Youth Service Learning Program in reducing early and unprotected sex among urban middle school students. Am J Public Health
55. Dubois–Arber F, Jeannin A, Konings E, et al. Increased condom use without other major changes in sexual behavior among the general population in Switzerland. Am J Public Health