Cost-effectiveness of voluntary HIV-1 counselling and testing in reducing sexual transmission of HIV-1 in Kenya and Tanzania

Background Access to HIV-1 voluntary counselling and testing (VCT) is sever ely limited in less-developed countries. We undertook a multisite trial of HIV-1 VCT to assess its impact, cost, and cost-effectiveness in less-develo ped country settings. Methods The cost-effectiveness of HIV-1 VCT was estimated for a hypothetica l cohort of 10 000 people seeking VCT in urban east Africa. Outcomes were m odelled based on results from a randomised controlled trial of HIV-1 VCT in Tanzania and Kenya. Our main outcome measures included programme cost, num ber of HIV-1 infections averted, cost per HIV-1 infection averted, and cost per disability-adjusted life-year (DALY) saved. We also modelled the impac t of targeting VCT by HIV-1 prevalence of the client population, and the pr oportion of clients who receive VCT as a couple compared with as individual s. Sensitivity analysis was done on all model parameters. Findings HIV-1 VCT was estimated to avert 1104 HIV-1 infections in Kenya an d 895 in Tanzania during the subsequent year, The cost per HIV-1 infection averted was US$249 and $346, respectively, and the cost per DALY saved was $12.77 and $17.78. The intervention was most cost-effective for HIV-1-infec ted people and those who received VCT as a couple. The cost-effectiveness o f VCT was robust, with a range for the average cost per DALY saved of $5.16 -27.36 in Kenya, and $6.58-45.03 in Tanzania. Analysis of targeting showed that increasing the proportion of couples to 70% reduces the cost per DALY saved to $10.71 in Kenya and $13.39 in Tanzania, and that targeting a popul ation with HIV-1 prevalence of 45% decreased the cost per DALY saved to $8. 36 in Kenya and $11.74 in Tanzania. Interpretation HIV-1 VCT is highly cost-effective in urban east African set tings, but slightly less so than interventions such as improvement of sexua lly transmitted disease services and universal provision of nevirapine to p regnant women in high-prevalence settings. With the targeting of VCT to pop ulations with high HIV-1 prevalence and couples the cost-effectiveness of V CT is improved significantly.