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Background Hepatitis B vaccination is recommended for persons with current or past sexually transmitted infections (STI). Our aim is to systematically assess the association of hepatitis B virus (HBV) sero-markers for current or past infection with syphilis, chlamydia, gonorrhoea, or unspecified STIs. Methods: We conducted a systematic review and meta-analysis. PubMed, Embase, and Web of Science from 1982 to 2018 were searched using medical subject headings (MeSH) terms for HBV, STIs and epidemiology. We included studies conducted in Organisation for Economic Cooperation and Development countries or Latin America that permit the calculation of prevalence ratios (PRs) for HBV and STIs and extracted PRs and counts by HBV and STI status. Results: Of 3144 identified studies, 43 met inclusion requirements, yielding 72 PRs. We stratified outcomes by HBV sero-markers [surface antigen (HBsAg), hepatitis B core antibody (anti-HBc), combined], STI pathogen (syphilis, gonorrhoea/chlamydia, unspecified), and STI history (current, past) resulting in 18 potential outcome groups, for which results were available for 14. For the four outcome groups related to HBsAg, PR point estimates ranged from 1.65 to 6.76. For the five outcome groups related to anti-HBc, PRs ranged from 1.30 to 1.82; and for the five outcome groups related to combined HBV markers, PRs ranged from 1.15 to 1.89). The median HBsAg prevalence among people with a current or past STI was 4.17; not all studies reported HBsAg. Study settings and populations varied. Conclusion: This review found evidence of association between HBV infection and current or past STIs.

Background Surgical disease increasingly contributes to global mortality and morbidity. The Lancet Commission on Global Surgery found that global cost-effectiveness data are lacking for a wide range of essential surgical procedures. This study helps to address this gap by defining the cost-effectiveness of exploratory laparotomies in a regional referral hospital in Uganda. Materials and methods A time-and-motion analysis was utilized to calculate operating theater personnel costs per case. Ward personnel, administrative, medication, and supply costs were recorded and calculated using a microcosting approach. The cost in 2018 US Dollars (USD, $) per disability-adjusted life year (DALY) averted was calculated based on age-specific life expectancies for otherwise fatal cases. Results Data for 103 surgical patients requiring exploratory laparotomy at the Soroti Regional Referral Hospital were collected over 8 mo. The most common cause for laparotomy was small bowel obstruction (32% of total cases). The average cost per patient was $75.50. The postoperative mortality was 11.7%, and 7.8% of patients had complications. The average number of DALYs averted per patient was 18.51. The cost in USD per DALY averted was $4.08. Conclusions This investigation provides evidence that exploratory laparotomy is cost-effective compared with other public health interventions. Relative cost-effectiveness includes a comparison with bed nets for malaria prevention ($6.48-22.04/DALY averted), tuberculosis, tetanus, measles, and polio vaccines ($12.96-25.93/DALY averted), and HIV treatment with multidrug antiretroviral therapy ($453.74-648.20/DALY averted). Given that the total burden of surgically treatable conditions in DALYs is more than that of malaria, tuberculosis, and HIV combined, our findings strengthen the argument for greater investment in primary surgical capacity in low- and middle-income countries.

The past decade has seen a growing emphasis on the production of high-quality costing data to improve the efficiency and cost-effectiveness of global health interventions. The need for such data is especially important for decision making and priority setting across HIV services from prevention and testing to treatment and care. To help address this critical need, the Global Health Cost Consortium was created in 2016, in part to conduct a systematic search and screening of the costing literature for HIV and TB interventions in low- and middle-income countries (LMIC). The purpose of this portion of the remit was to compile, standardise, and make publicly available published cost data (peer-reviewed and gray) for public use. We limit our analysis to a review of the quantity and characteristics of published cost data from HIV interventions in sub-Saharan Africa. First, we document the production of cost data over 25 years, including density over time, geography, publication venue, authorship and type of intervention. Second, we explore key methods and reporting for characteristics including urbanicity, platform type, ownership and scale. Although the volume of HIV costing data has increased substantially on the continent, cost reporting is lacking across several dimensions. We find a dearth of cost estimates from HIV interventions in west Africa, as well as inconsistent reporting of key dimensions of cost including platform type, ownership and urbanicity. Further, we find clear evidence of a need for renewed focus on the consistent reporting of scale by authors of costing and cost-effectiveness analyses.Keywords: costing, HIV/AIDS, LMIC, cost-effectiveness, systematic review

Background The US National HIV/AIDS Strategy (NHAS) emphasizes the use of technology to facilitate coordination of comprehensive care for people with HIV. We examined cost-effectiveness from the health system perspective of 6 health information technology (HIT) interventions implemented during 2008 to 2012 in a Ryan White HIV/AIDS Program (RWHAP) Special Projects of National Significance (SPNS) Program demonstration project. Methods/findings HIT interventions were implemented at 6 sites: Bronx, New York; Durham, North Carolina; Long Beach, California; New Orleans, Louisiana; New York, New York (2 sites); and Paterson, New Jersey. These interventions included: (1) use of HIV surveillance data to identify out-of-care individuals; (2) extension of access to electronic health records (EHRs) to support service providers; (3) use of electronic laboratory ordering and prescribing; and (4) development of a patient portal. We employed standard microcosting techniques to estimate costs (in 2018 US dollars) associated with intervention implementation. Data from a sample of electronic patient records from each demonstration site were analyzed to compare prescription of antiretroviral therapy (ART), CD4 cell counts, and suppression of viral load, before and after implementation of interventions. Markov models were used to estimate additional healthcare costs and quality-adjusted life-years saved as a result of each intervention. Overall, demonstration site interventions cost $3,913,313 (range = $287,682 to $998,201) among 3,110 individuals (range = 258 to 1,181) over 3 years. Changes in the proportion of patients prescribed ART ranged from a decrease from 87.0% to 72.7% at Site 4 to an increase from 74.6% to 94.2% at Site 6; changes in the proportion of patients with 0 to 200 CD4 cells/mm3 ranged from a decrease from 20.2% to 11.0% in Site 6 to an increase from 16.7% to 30.2% in Site 2; and changes in the proportion of patients with undetectable viral load ranged from a decrease from 84.6% to 46.0% in Site 1 to an increase from 67.0% to 69.9% in Site 5. Four of the 6 interventions—including use of HIV surveillance data to identify out-of-care individuals, use of electronic laboratory ordering and prescribing, and development of a patient portal—were not only cost-effective but also cost saving ($6.87 to $14.91 saved per dollar invested). In contrast, the 2 interventions that extended access to EHRs to support service providers were not effective and, therefore, not cost-effective. Most interventions remained either cost-saving or not cost-effective under all sensitivity analysis scenarios. The intervention that used HIV surveillance data to identify out-of-care individuals was no longer cost-saving when the effect of HIV on an individual’s health status was reduced and when the natural progression of HIV was increased. The results of this study are limited in that we did not have contemporaneous controls for each intervention; thus, we are only able to assess sites against themselves at baseline and not against standard of care during the same time period. Conclusions These results provide additional support for the use of HIT as a tool to enhance rapid and effective treatment of HIV to achieve sustained viral suppression. HIT has the potential to increase utilization of services, improve health outcomes, and reduce subsequent transmission of HIV., Starley Shade and co-workers assess cost-effectiveness of information technology interventions in HIV care programs in the United States., Author summary Why was this study done? The Health Resources and Services Administration’s Special Projects of National Significance Program (HRSA/SPNS) funded a 4-year initiative (2007 to 2011) in 6 demonstration sites to enhance and evaluate existing health information electronic network systems for people living with HIV (PLHIV) in underserved communities. Each of the 6 demonstration sites implemented one or more health information technology (HIT) interventions to facilitate comprehensive care and enhance engagement in HIV medical services. These interventions included: (1) use of HIV surveillance data to identify out-of-care individuals; (2) extension of access to electronic health records to support service providers; (3) use of electronic laboratory ordering and prescribing; and (4) development of a patient portal. This study estimates the total costs, cost-effectiveness, and potential cost-savings of these 6 interventions. What did researchers do and find? We used information on the cost of each intervention and the health status of PLHIV in each setting before and after implementation of each intervention to estimate: (1) changes in the cost of care and other services for PLHIV in each setting; and (2) changes in expected health status (measured as quality-adjusted life-years or QALYs) among PLHIV in each setting. We then used this information to estimate additional healthcare costs and QALYs gained for each intervention. Four of the interventions were associated with lower healthcare costs and better health outcomes (QALYs gained) for PLHIV in each setting. These interventions saved between $6.87 and $14.91 per dollar invested. Two interventions that provided access to medical record information to support service providers were not associated with improved health outcomes for PLHIV in these settings. These interventions were not effective or cost-effective. What do these findings mean? These results show that HIT interventions that facilitate changes in patient or provider behavior have the potential to improve the health status of PLHIV and reduce healthcare costs. HIT interventions that only provided additional information to support service providers were less successful. This study did not include a contemporaneous comparison group. Therefore, we do not know the degree to which improvements in the health status of PLHIV in these settings were due to changes in the quality of care for PLHIV over the life of the interventions.

We systematically reviewed the literature to assess the effectiveness of school-based programs to prevent HIV and other sexually transmitted infections (STI) among adolescents in the USA. We searched six databases including PubMed for studies published through May 2017. Eligible studies included youth ages 10-19 years and assessed any school-based programs in the USA that reported changes in HIV/STI incidence or testing. We used Cochrane tool to assess the risk of bias and GRADE to determine the evidence quality for each outcome. Three RCTs and six non-RCTs, describing seven interventions, met study inclusion criteria. No study reported changes in HIV incidence or prevalence. One comprehensive intervention, assessed in a non-RCT and delivered to pre-teens, reduced STI incidence into adulthood (RR 0.36, 95% CI 0.23-0.56). A non-RCT examining chlamydia and gonorrhea incidence before and after a condom availability program found a significant effect at the city level among young men 3 years later (RR 0.43, 95% CI 0.23-0.80). The remaining four interventions found no effect. The effect on STI prevalence was also not significant (pooled RR 0.83 from two non-RCTs, RR 0.70 from one RCT). Only one non-RCT showed an increase in HIV testing (RR 3.19, 95% CI 1.24-8.24). The quality of evidence for all outcomes was very low. Studies, including the RCTs, were of low methodological quality and had mixed findings, thus offering no persuasive evidence for the effectiveness of school-based programs. The most effective intervention spanned 6 years, was a social development-based intervention with multiple components, rather than a sex education program, and started in first grade.

Femoral shaft fractures are one of the most common injuries seen by surgeons in low- and middle-income countries (LMICs). Surgical repair in LMICs is often dismissed as not being cost-effective or unsafe, though little evidence exists to support this notion. Therefore, the goal of this study is to determine the cost of intramedullary nailing of femoral shaft fractures in Tanzania. We used micro-costing methods to estimate the fixed and variable costs of intramedullary nailing of femoral shaft fractures. Variable costs assessed included medical personnel costs, ward personnel costs, implants, medications, and single-use supplies. Fixed costs included costs for surgical instruments and administrative and ancillary staff. 46 adult femoral shaft fracture patients admitted to Muhimbili Orthopaedic Institute between June and September 2014 were enrolled and treated with intramedullary fixation. The total cost per patient was $530.87 (SD $129.99). The mean variable cost per patient was $419.87 (SD $129.99), the largest portion coming from ward personnel $144.47 (SD $123.30), followed by implant $134.10 (SD $15.00) medical personnel $106.86 (SD $28.18), and medications/supplies $30.05 (SD $12.28). The mean fixed cost per patient was $111.00, consisting of support staff, $103.50, and surgical instruments, $7.50. Our study provides empirical information on the variable and fixed costs of intramedullary nailing of femoral shaft fractures in LMICs. Importantly, the lack of surgical capacity was the primary driver of the largest cost for this procedure, preoperative ward personnel time. Our results provide the cost data for a formal cost-effectiveness analysis on this intervention.

Objectives Pneumonia is the largest infectious cause of death in children under 5 years globally, and limited resource settings bear an overwhelming proportion of this disease burden. Bubble continuous positive airway pressure (bCPAP), an accepted supportive therapy, is often thought of as cost-prohibitive in these settings. We hypothesise that bCPAP is a cost-effective intervention in a limited resource setting and this study aims to determine the cost-effectiveness of bCPAP, using Malawi as an example. Design Cost-effectiveness analysis. Setting District and central hospitals in Malawi. Participants Children aged 1 month–5 years with severe pneumonia, as defined by WHO criteria. Interventions Using a decision tree analysis, we compared standard of care (including low-flow oxygen and antibiotics) to standard of care plus bCPAP. Primary and secondary outcome measures For each treatment arm, we determined the costs, clinical outcomes and averted disability-adjusted life years (DALYs). We assigned input values from a review of the literature, including applicable clinical trials, and calculated an incremental cost-effectiveness ratio (ICER). Results In the base case analysis, the cost of bCPAP per patient was $15 per day and $41 per hospitalisation, with an incremental net cost of $64 per pneumonia episode. bCPAP averts 5.0 DALYs per child treated, with an ICER of $12.88 per DALY averted compared with standard of care. In one-way sensitivity analyses, the most influential uncertainties were case fatality rates (ICER range $9–32 per DALY averted). In a multi-way sensitivity analysis, the median ICER was $12.97 per DALY averted (90% CI, $12.77 to $12.99). Conclusion bCPAP is a cost-effective intervention for severe paediatric pneumonia in Malawi. These results may be used to inform policy decisions, including support for widespread use of bCPAP in similar settings.

Background: Globally, there is a large unmet need for family planning in the postpartum period: 90% of women in this group want family planning for birth spacing or to avoid unintended pregnancies and stop child bearing once desired family size has been reached. In total 76% of Rwandan women want family planning postpartum, yet a 26% unmet need remains. Currently, the four most commonly used postpartum family planning methods in Rwanda are injections, subdermal implants, pills, and condoms. The economic and health benefit impact of the current method selection has not yet been evaluated. Methods: To evaluate the impact of current usage rates and method types, this cost effectiveness analysis (CEA) compared the most frequently used family planning methods in Rwanda broken into two categories, longer-acting reversible contraception (LARC) (injections and subdermal implants) and shorter-acting reversible contraceptives (non-LARC) (pills and condoms). A time horizon of 24 months was used to reflect the World Health Organization suggested two-year spacing from birth until the next pregnancy, and was conducted from a health systems perspective. This CEA compared two service package options to provide a comparator for the two method types, thus enabling insights to differences between the two. Results: For women of reproductive age (15-49 years) in Rwanda, including LARC postpartum family planning methods in the options, saves $18.73 per pregnancy averted, compared to family planning options that offer non-LARC methods exclusively. Conclusion: There is an opportunity to avert unplanned pregnancies associated with increased utilization of LARC methods. The full benefits of LARC are not yet realized in Rwanda. Under the conditions presented in this study, a service package that includes LARC has the potential to be cost-saving compared with one non-LARC methods. Effective health messaging of LARC use for the postpartum population could both enhance health and reduce costs.

Background: A rapid scaling up of HIV interventions in India is anticipated, but systematic information on how costs of HIV interventions change over time and programme scale is not available to inform planning. Methods: We studied the changes in unit costs of two major interventions, voluntary counseling and testing (VCT) and sex worker programmes in the south Indian state of Andhra Pradesh between 2002-2003 and 2005-2006 fiscal years. Economic costs (from the provider perspective) and output data from 17 publicly funded VCT centers and 14 sex worker programmes were collected using standardized methods. We calculated unit costs for each programme in each period and explored possible reasons for the changes seen. Results: In 2005-2006, the VCT centers served 66445 clients and the sex worker programmes served 32 550. The unit cost of providing VCT dropped over 3 years by half to Indian Rupees (INR) 147.5 (US$3.33) mainly because the number of clients doubled. There was no decrease in the average time spent counseling each client. The unit cost of providing services to sex workers increased 2.4 times over 3 years to INR 1401 (US$31.6) as a result of increases in male condom distribution, staff salaries and training, and treatment for sexually transmitted infections, all suggesting improved services. Conclusion: The unit cost of these two interventions changed dramatically over a 3-year period, but in opposite directions. The current unit cost for VCT in Andhra Pradesh is much lower than the estimated global average for low-income settings. These local longitudinal cost data are useful to inform the currently planned scaling up of HIV interventions in India.

OBJECTIVE. We undertook a decision analysis to evaluate the economic and health effects and incremental cost-effectiveness of using targeted tuberculin skin testing, compared with universal screening or no screening, before kindergarten.METHODS. We constructed a decision tree to determine the costs and clinical outcomes of using targeted testing compared with universal screening or no screening. Baseline estimates for input parameters were taken from the medical literature and from California health jurisdiction data. Sensitivity analyses were performed to determine plausible ranges of associated outcomes and costs. We surveyed California health jurisdictions to determine the prevalence of mandatory universal tuberculin skin testing.RESULTS. In our base-case scenario, the cost to prevent an additional case of tuberculosis by using targeted testing, compared with no screening, was $524897. The cost to prevent an additional case by using universal screening, compared with targeted testing, was $671398. The incremental cost of preventing a case through screening remained above $100000 unless the prevalence of tuberculin skin testing positivity increased to >10%. More than 51% of children entering kindergarten in California live where tuberculin skin testing is mandatory.CONCLUSIONS. The cost to prevent a case of tuberculosis by using either universal screening or targeted testing of kindergarteners is high. If targeted testing replaced universal tuberculin skin testing in California, then $1.27 million savings per year would be generated for more cost-effective strategies to prevent tuberculosis. Improving the positive predictive value of the risk factor tool or applying it to groups with higher prevalence of latent tuberculosis would make its use more cost-effective. Universal tuberculin skin testing should be discontinued, and targeted testing should be considered only when the prevalence of risk factor positivity and the prevalence of tuberculin skin testing positivity among risk factor–positive individuals are high enough to meet acceptable thresholds for cost-effectiveness.

Background: Daily prophylaxis with trimethoprim-sulfamethoxazole (cotrimoxazole) by persons with HIV reduces morbidity and mortality and is recommended by Joint United Nations Program on HIV/AIDS and World Health Organization (WHO), but there are limited published cost-effectiveness data for this intervention. We assessed the cost-effectiveness of cotrimoxazole prophylaxis for persons living with HIV in rural Uganda. Methods: We modeled the cost-effectiveness of daily cotrimoxazole prophylaxis based on clinical results and operational data from a prospective cohort study of home-based care delivery to adults and children with HIV in rural Uganda who were older than the age of 5 years. Main outcome measures were net program cost and disabilityadjusted life-years (DALYs) gained. We examined the provision of cotrimoxazole prophylaxis for (A) all HIV-infected individuals regardless of immunologic or clinical criteria; (B) those with WHO stage 2 or more advanced disease; (C) those with CD4 cell counts ,500 cells/mL; and (D) those meeting criteria B or C, the current WHO recommendation. We calculated the costs and effectiveness of these 4 screening algorithms compared with no cotrimoxazole prophylaxis and calculated incremental cost-effectiveness ratios. We performed univariate and multivariate sensitivity analyses. Results: Cotrimoxazole prophylaxis for all HIV-infected individuals (algorithm A) produced 7.3 life-years and 7.55 DALYs per 100 persons over 1 year compared with no prophylaxis. Using this screening algorithm, the intervention saved $2.50 per person-year. The program costs and the DALYs gained by algorithms A, B, and D were more favorable than those for algorithm C. Among algorithms A, B, and D, strategies using screening algorithms for WHO stage or CD4 cell counts were more costly and marginally less effective than providing cotrimoxazole prophylaxis to all HIV-infected individuals. Conclusions: Daily cotrimoxazole prophylaxis for HIV-infected individuals is highly cost-effective in rural Uganda. The use of screening algorithms to identify individuals with advanced HIV disease may result in higher program costs and less favorable costeffectiveness.

Background : Co-infection with malaria and other infectious diseases has been shown to increase viral load and accelerate HIV disease progression. A recent study in Kenya demonstrated that providing long-lasting insecticide-treated bednets (LLIN) and water filters (WF) to HIV-positive adults with CD4 >350 cells/mm 3 significantly reduced HIV progression. Design : We conducted a cost analysis to estimate the potential net financial savings gained by delaying HIV progression and increasing the time to antiretroviral therapy (ART) eligibility through delivering LLIN and WF to 10% of HIV-positive adults with CD4 >350 cells/mm 3 in Kenya. Results : Given a 3-year duration of intervention benefit, intervention unit cost of US$32 and patient-year ART cost of US$757 (2011 US$), over the lifetime of ART patients, in Kenya, we estimated the intervention could yield a return on investment (ROI) of 11 (95% uncertainty range [UR]: 5–23), based on a cost of about US$2 million and savings in ART costs of about US$26 million (95% UR: 8–50) (discounted at 3%). Our findings were subjected to a number of sensitivity analyses. Of note, deferral of time to ART eligibility could potentially result in 3,000 new HIV infections not averted by ART and thus decrease ART cost savings to US$14 million, decreasing the ROI to 6. Conclusions : Provision of LLIN and WF could be a cost-saving and practical method to defer time to ART eligibility in the context of highly resource-constrained environments experiencing donor fatigue for HIV/AIDS programs. Keywords : cost savings; insecticide-treated bednets; water filtration; HIV disease progression; antiretroviral therapy; malaria; diarrhea; Kenya; sub-Saharan Africa (Published: 10 June 2015) Citation: Glob Health Action 2015, 8 : 27695 - http://dx.doi.org/10.3402/gha.v8.27695 Supplementary Material: To access the supplementary material for this article, please see Supplementary files under ‘Article Tools’

There is wide agreement that an effective response to the global HIV epidemic requires very substantial resources. This consensus has been partially translated into increasing contributions to combat the epidemic (UNAIDS 2004). The need to spend this money efficiently can hardly be overstated: the lives of millions depend upon how effectively available funds are allocated. Available studies on the cost and cost-effectiveness of HIV prevention programs in developing countries are very limited in number, as well as in the range of prevention strategies and geographic settings examined (Marseille, Hofmann, and Kahn 2002). “Prevent AIDS: Network for Cost-Effectiveness Analysis” (PANCEA), is a three-year, five-country study funded by the U.S. National Institutes of Health. It has the purpose of providing essential information and analysis for an improved allocation of HIV prevention funds in developing countries. The study includes five countries: India, Mexico, Russia, South Africa, and Uganda. This article reviews PANCEA's data collection methods. Our purpose is two-fold. First, we aim to explicate the methods and data sources used in PANCEA. Second, we want to give other health services researchers sufficient information to judge the potential suitability of adapting PANCEA's approach to their own efforts. Further details on the project and key documents (e.g., instruments) can be found in the online-only Appendix to this article available at http://www.blackwell-synergy.com, at the PANCEA link at http://hivinsite.ucsf.edu/InSite?page=pancea, and from the authors. The remainder of the paper addresses PANCEA's conceptual approach, data collection tools, data collection process, challenges and limitations, early findings, and applications for other health program assessments.

Each year about 2 million babies are born to HIV-1- infected women. Despite widespread knowledge of proven methods to prevent mother-to-child transmission (MTCT) of the virus most infants at risk of contracting the infection from their mothers receive no prophylactic intervention. This inaction leads to the infection and ultimate death of about 800 000 children per year. It has been known since 1994 that MTCT is largely preventable and interventions appropriate for use in the developing world have been available since 1999. Singledose intrapartum and neonatal nevirapine—the simplest and perhaps most effective of the short-course antiretroviral regimens studied—has been available free of charge from the manufacturer since 2000. Nevertheless few women have access to MTCT-prevention services. In the more than 3 years since its inception the donation programme has shipped only 189 000 courses of the drug a tiny fraction (

Background: Pneumonia is the second leading cause of death in children under five globally, and resource-limited settings bear an overwhelming proportion of the disease burden. Although often thought of as cost-prohibitive in limited resource settings, bubble continuous positive airway pressure (bCPAP) is a widely accepted supportive therapy. This study addresses the cost-effectiveness of bCPAP in Malawi. Methods: We …

Gestational diabetes mellitus (GDM) is an increasing cause of morbidity in women and their offspring. Screening and intervention can reduce perinatal and most likely also long-term diabetes consequences. There have been many economic studies, but not recently systematically compared. We conducted a systematic search and abstraction of cost-effectiveness and cost-utility studies from 2002 to 2014. We standardized all findings to 2014 US dollars. We found that cost-effectiveness ratios varied widely. Most variation was found to be due to differences in geographic setting, diagnostic criteria and intervention approaches, and outcomes (e.g., inclusion or exclusion of long-term type 2 diabetes risk and associated costs). We concluded that incorporation of long-term benefits of GDM screening and treatment has huge impact on cost-effectiveness estimates. Based on the large methodological heterogeneity and varying results in the existing body of evidence, we find it unreasonable to outline any global recommendations. For future economic studies, we recommend inclusion of long-term outcomes and adaptation to local preferences, as well as examination of the impact of the diagnostic criteria recently proposed by the International Association of Diabetes in Pregnancy Study Groups (IADPSG).

Summary Data on the cost-effectiveness of HIV prevention in sub-Saharan Africa and on highly active antiretroviral therapy (HAART) indicate that prevention is at least 28 times more cost effective than HAART. We aim to show that funding HAART at the expense of prevention means greater loss of life. To maximise health benefits, the next major increments of HIV funding in sub-Saharan Africa should be devoted mainly to prevention and to some non-HAART treatment and care. Funds should be allocated to HAART primarily for demonstration projects that will help prepare for scaled-up HAART provision following broad population coverage by prevention programmes. UNAIDS and the London School of Hygiene and Tropical Medicine recently estimated that at least US$9·2 billion annually is required to mount an appropriate response to the HIV pandemic, including substantial funding for HAART. To date, US$1·96 billion has been committed to the newly-established UN Global Fund to Fight AIDS, Tuberculosis, and Malaria. It is a moral imperative that expanded programmes to control HIV be implemented without delay, and that the goal of US$9·2 billion or more in annual spending be attained as rapidly as possible. The findings and recommendations of this analysis pertain to the phasing in of additional HIV-related activities during the current period of improved but inadequate funding.

Objective This study estimated the health impact, cost and cost-effectiveness of an integrated prevention campaign (IPC) focused on diarrhoea, malaria and HIV in 70 countries ranked by per capita disability-adjusted life-year (DALY) burden for the three diseases. Methods We constructed a deterministic cost-effectiveness model portraying an IPC combining counselling and testing, cotrimoxazole prophylaxis, referral to treatment and condom distribution for HIV prevention; bed nets for malaria prevention; and provision of household water filters for diarrhoea prevention. We developed a mix of empirical and modelled cost and health impact estimates applied to all 70 countries. One-way, multiway and scenario sensitivity analyses were conducted to document the strength of our findings. We used a healthcare payer9s perspective, discounted costs and DALYs at 3% per year and denominated cost in 2012 US dollars. Primary and secondary outcomes The primary outcome was cost-effectiveness expressed as net cost per DALY averted. Other outcomes included cost of the IPC; net IPC costs adjusted for averted and additional medical costs and DALYs averted. Results Implementation of the IPC in the 10 most cost-effective countries at 15% population coverage would cost US$583 million over 3 years (adjusted costs of US$398 million), averting 8.0 million DALYs. Extending IPC programmes to all 70 of the identified high-burden countries at 15% coverage would cost an adjusted US$51.3 billion and avert 78.7 million DALYs. Incremental cost-effectiveness ranged from US$49 per DALY averted for the 10 countries with the most favourable cost-effectiveness to US$119, US$181, US$335, US$1692 and US$8340 per DALY averted as each successive group of 10 countries is added ordered by decreasing cost-effectiveness. Conclusions IPC appears cost-effective in many settings, and has the potential to substantially reduce the burden of disease in resource-poor countries. This study increases confidence that IPC can be an important new approach for enhancing global health.

Summary Background Identification of economical interventions to decrease HIV-1 transmission to children is an urgent public-health priority in sub-Saharan Africa. We assessed the cost effectiveness of the HIVNET 012 nevirapine regimen. Methods We assessed cost effectiveness in a hypothetical cohort of 20 000 pregnant women in sub-Saharan Africa. Our main outcome measures were programme cost, paediatric HIV-1 cases averted, cost per case averted, and cost per disability-adjusted life-year (DALY). We compared HIVNET 012 with other short-course antiretroviral regimens. We also compared two implementation strategies: counselling and HIV-1 testing before treatment (targeted treatment), or nevirapine for all pregnant women (universal treatment, no counselling and testing). We did univariate and multivariate sensitivity analyses. Findings For universal treatment with 30% HIV-1 seroprevalence, the HIVNET 012 regimen would avert 603 cases of HIV-1 in babies, cost US$83 333, and generate 15 862 DALYs. The associated cost-effectiveness ratios were $138 per case averted or $5·25 per DALY. At 15% seroprevalence, the universal treatment option would cost $83 333 and avert 302 cases at $276 per case averted or $10·51 per DALY. For targeted treatment at 30% seroprevalence, HIVNET 012 would cost $141 922 and avert 476 cases at $298 per case averted or $11·29 per DALY. With seroprevalence higher than 3·0% for universal and 4·5% for targeted treatment, the HIVNET 012 regimen was likely to be as cost effective as other public-health interventions. The cost effectiveness of HIVNET 012 was robust under a wide range of parameters in the sensitivity analysis. Interpretation The HIVNET 012 regimen can be highly cost-effective in high seroprevalence settings. In lower seroprevalence areas, when multidose regimens are not cost effective, nevirapine therapy could have a major public-health impact at a reasonable cost.

Objectives To help stakeholders identify and prioritise countries with the best opportunities for implementation of an integrated prevention campaign (IPC) focused on diarrhoea, malaria and HIV prevention. Design Cross-sectional analysis of country-specific epidemiological data using an index tool developed for this purpose. Setting We calculated the total disability-adjusted life years (DALYs) attributed to diarrhoea, malaria and HIV for 214 World Bank economies. Criteria for inclusion were: low-income and middle-income countries, and total annual DALY burden in the top tertile (≥87 000 DALYs). 70 countries met inclusion criteria and were included in our opportunity analysis. Outcome measures We synthesised data on 10 indicators related to the potential reduction in burden and new coverage achievable by an IPC. We scored and ranked countries based on three summary opportunity metrics: DALYs per capita across the diseases, a composite score of tertile rankings of burden for each disease, and a score combining burden and intervention opportunity. Results We estimated the total annual global burden attributable to diarrhoea, malaria and HIV at 135 million DALYs. All of the countries with the highest opportunity for implementation of a diarrhoea, malaria and HIV IPC are in sub-Saharan Africa, regardless of opportunity metric used. Although the overall rank order changes, 16 countries rank among the top 23 highest opportunity countries for all three metrics. Conclusions Stakeholders can use this objective metric-based approach to prioritise countries for IPC scale-up. Priority countries are largely robust to the opportunity metric chosen.

Gestational diabetes mellitus (GDM) is associated with elevated risks of perinatal complications and type 2 diabetes mellitus, and screening and intervention can reduce these risks. We quantified the cost, health impact and cost-effectiveness of GDM screening and intervention in India and Israel, settings with contrasting epidemiologic and cost environments.We developed a decision-analysis tool (the GeDiForCE™) to assess cost-effectiveness. Using both local data and published estimates, we applied the model for a general medical facility in Chennai, India and for the largest HMO in Israel. We computed costs (discounted international dollars), averted disability-adjusted life years (DALYs) and net cost per DALY averted, compared with no GDM screening.The programme costs per 1000 pregnant women are $259,139 in India and $259,929 in Israel. Net costs, adjusted for averted disease, are $194,358 and $76,102, respectively. The cost per DALY averted is $1626 in India and $1830 in Israel. Sensitivity analysis findings range from $628 to $3681 per DALY averted in India and net savings of $72,420-8432 per DALY averted in Israel.GDM interventions are highly cost-effective in both Indian and Israeli settings, by World Health Organization standards. Noting large differences between these countries in GDM prevalence and costs, GDM intervention may be cost-effective in diverse settings.

In a Perspective accompanying Hill and colleagues, Elliot Marseille and James Kahn compare the history of pricing and availability of ART for HIV with that of the new HCV drugs and discuss strategies for providing treatment in LMIC even in the face of high costs.

Background We estimated the unit costs and cost-effectiveness of a government ART program in 45 sites in Zambia supported by the Centre for Infectious Disease Research Zambia (CIDRZ). Methods We estimated per person-year costs at the facility level, and support costs incurred above the facility level and used multiple regression to estimate variation in these costs. To estimate ART effectiveness, we compared mortality in this Zambian population to that of a cohort of rural Ugandan HIV patients receiving co-trimoxazole (CTX) prophylaxis. We used micro-costing techniques to estimate incremental unit costs, and calculated cost-effectiveness ratios with a computer model which projected results to 10 years. Results The program cost $69.7 million for 125,436 person-years of ART, or $556 per ART-year. Compared to CTX prophylaxis alone, the program averted 33.3 deaths or 244.5 disability adjusted life-years (DALYs) per 100 person-years of ART. In the base-case analysis, the net cost per DALY averted was $833 compared to CTX alone. More than two-thirds of the variation in average incremental total and on-site cost per patient-year of treatment is explained by eight determinants, including the complexity of the patient-case load, the degree of adherence among the patients, and institutional characteristics including, experience, scale, scope, setting and sector. Conclusions and Significance The 45 sites exhibited substantial variation in unit costs and cost-effectiveness and are in the mid-range of cost-effectiveness when compared to other ART programs studied in southern Africa. Early treatment initiation, large scale, and hospital setting, are associated with statistically significantly lower costs, while others (rural location, private sector) are associated with shifting cost from on- to off-site. This study shows that ART programs can be significantly less costly or more cost-effective when they exploit economies of scale and scope, and initiate patients at higher CD4 counts.

Gestational diabetes mellitus (GDM) is increasingly recognized as an opportunity for early prevention of diabetes and other diseases over the lifespan, and may be responsible for up to 30% of cases of type 2 diabetes. A newly developed mathematical model (the GDModel) provides provisional estimates of the cost and health impact of various GDM screening and management choices, and calculates averted disability-adjusted life-years (DALYs). The model was piloted in 5 different healthcare facilities in India and Israel. Universal screening of pregnant women followed by postpartum lifestyle management yielded net savings of US$78 per woman with GDM in India and US$1945 per woman in Israel. The estimated DALYs averted were 2.33 in India and 3.10 in Israel. With lower GDM prevalence, intervention efficacy, and type 2 diabetes incidence, the intervention had a net cost in India, with a cost per DALY averted of US$11.32. This was far below the WHO definition of "very cost-effective," set at annual GDP per capita. The intervention in Israel remained cost-saving. GDM screening and postpartum lifestyle management are either cost-saving or have a net cost but an attractive cost-effectiveness ratio. Some input values are currently being refined. Nevertheless, the current findings of cost-savings or favorable cost-effectiveness are robust to a wide range of plausible input values, including highly unfavorable values. The GDModel will be further developed into a user-friendly tool that can guide policy-makers on decisions regarding GDM screening strategies and guidelines.

The association between gestational diabetes mellitus (GDM), perinatal complications and long-term morbidity is gaining increased attention. However, the global burden of GDM and the existing responses are not fully understood. We aimed to assess country prevalence and to summarize practices related to GDM screening and management.Data on prevalence and country practices were obtained from a survey administered to diabetologists, obstetricians and others working on GDM in 173 countries.GDM prevalence estimates range from1% to 28%, with data derived from expert estimates, and single-site, multi-site and national prevalence assessments. Seventy-four percent of countries that completed the survey have national GDM guidelines or recommendations. Countries use a variety of screening approaches. In the countries where universal screening is recommended, the percentage of pregnant women screened ranges from 10% to90%.We found large variations in estimated GDM prevalence, but direct comparison between countries is difficult due to different diagnostic strategies and subpopulations. Many countries do not perform systematic screening for GDM, and practices often diverge from guidelines. Countries need to carefully assess the cost and health impact of scaling up GDM screening and management in order to identify the best policy option for their population.

© 2016 American Medical Association. All rights reserved. Importance Novel treatments for hepatitis C virus (HCV) infection are highly efficacious but costly. Thus, many insurers cover therapy only in advanced fibrosis stages. The added health benefits and costs of early treatment are unknown. Objective To assess the cost-effectiveness of (1) treating all patients with HCV vs only those with advanced fibrosis and (2) treating each stage of fibrosis. Design, Setting, and Participants This study used a decision-analytic model for the treatment of HCV genotype 1. The model used a lifetime horizon and societal perspective and was representative of all US patients with HCV genotype 1 who had not received previous treatment. Comparisons in the model included antiviral treatment of all fibrosis stages (METAVIR [Meta-analysis of Histological Data in Virial Hepatitis] stages F0 [no fibrosis] to F4 [cirrhosis]) vs treatment of stages F3 (numerous septa without cirrhosis) and F4 only and by specific fibrosis stage. Data were collected from March 1 to September 1, 2014, and analyzed from September 1, 2014, to June 30, 2015. Interventions Six HCV therapy options (particularly combined sofosbuvir and ledipasvir therapy) or no treatment. Main Outcomes and Measures Cost and health outcomeswere measured using total medical costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs), calculated as the difference in costs between strategies divided by the difference inQALYs. Results We simulated 1000 individuals, but present the Results normalized to a single HCV-infected person. In the base-case analysis, among patients receiving 8 or 12 weeks of sofosbuvir-ledipasvir treatment, treating all fibrosis stages compared with treating stages F3 and F4 adds 0.73 QALYs and $28 899, for an ICER of $39 475 per QALY gained. Treating at stage F2 (portal fibrosis with rare septa) costs $19 833 per QALY gained vs waiting until stage F3; treating at stage F1 (portal fibrosis without septa), $81 165 per QALY gained compared with waiting until stage F2; and treating at stage F0, $187 065 per QALY gained compared with waiting until stage F1. Results for other regimens show a similar pattern. At base-case drug prices, treating 50% of all eligible US patients with HCV genotype 1 would cost $53 billion. In sensitivity analyses, the ICER for treating all stages vs treating stages F3 and F4 was most sensitive to cohort age, drug costs, utility values in stages F1 and F2, and percentage of patients eligible for 8-week therapy. Except for patients aged 70 years, the ICER remains less than $100 000 per QALY gained. A 46%reduction in cost of sofosbuvir-ledipasvir therapy decreases the ICER for treating at all fibrosis stages by 48%. Conclusions and Relevance In this simulated model, treating HCV infection at early stages of fibrosis appeared to improve health outcomes and to be cost-effective but incurred substantial aggregate costs. The findings may have implications for health care coverage policies and clinical decision making.

The objective of this study is to assess the costs cost-effectiveness and HIV epidemic impact of 3 antiretroviral therapy (ART) policy options. We constructed an epidemiologic model to predict the course of the HIV epidemic in the absence of expanded ART availability. Based on background studies of the willingness to pay for ART among patients with AIDS of the costs to the government of the alternative treatment interventions and of ARTs likely effects on HIV transmission we simulated the consequences of 3 possible alternative government ART policies. A program to reduce the negative consequences of the currently unstructured private-sector provision of ART is the most cost-effective of the 3 options at a 10% discount rate and least cost-effective at a 3% rate. The costs and cost-effectiveness of all options are highly sensitive to the effect of ART on condom use. The design of ART policy should capitalize on the potential of ART to decrease HIV transmission through institutional arrangements that reward effective prevention programs thereby raising the likelihood that treatment has beneficial rather than negative external effects. (authors)

Background Immigrants to the U.S. are required to undergo overseas screening for tuberculosis (TB), but the value of evaluation and treatment following entry to the U.S. is not well understood. We determined the cost-effectiveness of domestic follow-up of immigrants identified as tuberculosis suspects through overseas screening. Methods Using a stochastic simulation for tuberculosis reactivation, transmission, and follow-up for a hypothetical cohort of 1000 individuals, we calculated the incremental cost-effectiveness of follow-up and evaluation interventions. We utilized published literature, California Reports of Verified Cases of Tuberculosis (RVCTs), demographic estimates from the California Department of Finance, Medicare reimbursement, and Medi-Cal reimbursement rates. Our target population was legal immigrants to the United States, our time horizon is twenty years, and our perspective was that of all domestic health-care payers. We examined the intervention to offer latent tuberculosis therapy to infected individuals, to increase the yield of domestic evaluation, and to increase the starting and completion rates of LTBI therapy with INH (isoniazid). Our outcome measures were the number of cases averted, the number of deaths averted, the incremental dollar cost (year 2004), and the number of quality-adjusted life-years saved. Results Domestic follow-up of B-notification patients, including LTBI treatment for latently infected individuals, is highly cost-effective, and at times, cost-saving. B-notification follow-up in California would reduce the number of new tuberculosis cases by about 6–26 per year (out of a total of approximately 3000). Sensitivity analysis revealed that domestic follow-up remains cost-effective when the hepatitis rates due to INH therapy are over fifteen times our best estimates, when at least 0.4 percent of patients have active disease and when hospitalization of cases detected through domestic follow-up is no less likely than hospitalization of passively detected cases. Conclusion While the current immigration screening program is unlikely to result in a large change in case rates, domestic follow-up of B-notification patients, including LTBI treatment, is highly cost-effective. If as many as three percent of screened individuals have active TB, and early detection reduces the rate of hospitalization, net savings may be expected.

The objective of this study was to determine the financial incentives that companies have to treat HIV-infected employees, in a health care services company in Kampala, Uganda.Cost-benefit analysis from the company's perspective of three interventions to treat HIV-infected employees.The costs and benefits of each intervention were compared with no intervention and with each other: cotrimoxazole prophylaxis (CTX) starting at WHO stage 2; highly active antiretroviral therapy (HAART) plus CTX starting at WHO stage 2; and a 'hybrid' strategy that begins with CTX at WHO stage 2 and later includes HAART. The 5-year health and economic outcomes were calculated using a Markov model. Inputs for disease progression rates and effects of HIV on company costs were derived from published and unpublished data and a survey administered to company officers.The analysis showed that the 'hybrid' intervention is the most cost-effective. For 100 skilled employees it would save the company 38,939 US dollars and 73 disability adjusted life-years (DALYs). For unskilled workers 'CTX' is the most cost effective and would save 16,417 US dollars and 60 DALYs. 'Hybrid' has an incremental cost-effectiveness ratio of 45 US dollars per DALY for unskilled workers whereas HAART is far less economical at an incremental cost per DALY of 4118 US dollars. For 'CTX', net savings are preserved across the full range of input values.A 'hybrid' intervention combining CTX prophylaxis followed by HAART would generate savings to a Ugandan company. Governments and other donors may find opportunities to share costs with the private sector as part of their phase-in strategy for antiretroviral therapy.

Background Control of sexually transmitted infections (STIs) is an important part of the effort to reduce the risk of HIV/AIDS. STI clinics in the government hospitals in India provide services predominantly to the poor. Data on the cost and efficiency of providing STI services in India are not available to help guide efficient use of public resources for these services. Methods Standardised methods were used to obtain detailed cost and output data for the 2003–2004 fiscal year from written records and interviews in 14 government STI clinics in the Indian state of Andhra Pradesh. The economic cost per patient receiving STI treatment was calculated, and the variations of total and unit costs across the STI clinics analysed. Multivariate regression technique was used to estimate incremental unit costs. The optimal number of STIs that could be handled by the clinics was estimated. Results 18807 STIs were diagnosed and treated at the 14 STI clinics in fiscal year 2003–2004 (range 323–2784, median 1199). The economic cost of treating each STI varied 5-fold from Indian Rupees (INR) 225.5 (US$ 4.91) to INR 1201.5 (US$ 26.15) between 13 clinics, with one other clinic having a very high cost of INR 2478.5 (US$ 53.94). The average cost per STI treated for all 14 clinics combined was INR 729.5 (US$ 15.88). Personnel salaries made up 76.2% of the total cost. The number of STIs treated per doctor full-time equivalent and cost-efficiency for each STI treated had a significant direct non-linear relation (p < 0.001, R2 = 0.81; power function). With a multiple regression model, apart from the fixed costs, the incremental cost for each STI detected and cost of treatment was INR 55.57 (US$ 1.21) and for each follow-up visit was INR 3.75 (US$ 0.08). Based on estimates of optimal STI cases that could be handled without compromising quality by each doctor full-time equivalent available, it was projected that at 8 of the 14 clinics substantially more STI cases could be handled, which could increase the total STI cases treated at the 14 clinics combined by 38% at an additional cost of only 3.5% for service provision. Conclusion There is un-utilised capacity in the public sector STI clinics in this Indian state. Efforts to facilitate utilisation of this capacity would be useful, as this would enable more poor patients with STIs to be served at minimal additional cost, and would also reduce the cost per STI treated leading to more efficient use of public resources.

The largest investments in AIDS prevention targeted to the general population are being made in interventions where the evidence for large-scale impact is uncertain.

Objective: To assess the potential cost-effectiveness of short-course antiviral regimens to prevent mother-to-child transmission (MCT) of HIV in sub-Saharan Africa. Design: Cost-effectiveness analysis. Methods: No intervention was compared with three regimens of twice daily zidovudine and lamivudine: regimen A, starting at 36 weeks of gestation and continuing to 1 week postpartum; regimen B, from intrapartum through 1 week postpartum; and regimen C, intrapartum only. Model inputs were estimated from published and unpublished data. Absolute percentage reductions in HIV transmission extrapolated from zidovudine monotherapy trials were estimated at 12.4, 8.6 and 4.3% for regimens A, B, and C, respectively. Outcome measures were net costs to the public sector health-care system, cost per infection averted, and cost per disability-adjusted life-year (DALY) gained. Multiple sensitivity analyses were conducted. Results: Based on the hypothetical efficacy estimates, regimen C was the most cost-effective. For a cohort of 100 women with 15% HIV prevalence, net costs to the public sector health-care systems were estimated at US$ 3617 for regimen A, US$ 1667 for regimen B, and US$ 351 for regimen C. Regimen C had a cost of US$ 1129 per HIV infection averted and a cost of US$ 60 per DALY. Regimens B and A cost US$ 2680 and 5134 per infection averted and US$ 143 and 274 per DALY, respectively. Cost-effectiveness declined rapidly at efficacy below 10% or HIV prevalence below 7%. Results were very sensitive to antiviral drug costs. For example, at 20% of current prices, the cost per DALY for regimen A fell to US$ 64, and to about US$ 42 for regimens B and C. Conclusion: Antiviral therapy may be cost-effective compared with other health interventions if HIV prevalence is high, if clinical trials confirm estimated efficacies, and if drug prices are reduced.

The cost-effectiveness of public health cataract programs in low-income countries has been well documented. Equity, another important dimension of program quality which has received less attention is analyzed here by comparisons of surgical coverage rates for major sub-groups within the intended beneficiary population of the Nepal blindness program (NBP). Substantial differences in surgical coverage were found between males and females and between different age groups of the same gender. Among the cataract blind, the surgical coverage of males was 70% higher than that of females. For both genders, the cataract blind over 55 received proportionately fewer services than younger people blind from cataract. Blind males aged 45–54 had a 500% higher rate of surgical coverage than blind males over 65. Blind females aged 35–44 had nearly a 600% higher rate of surgical coverage than blind females over 65. There was wide variation in overall surgical coverage between geographic zones, but little variation by terrain type, an indicator of the logistical difficulties in delivery of services. Members of the two highest caste groupings had somewhat lower surgical coverage than members of lower castes. Program managers should consider developing methods to increase services to women and to those over 65. Reaching these populations will become increasingly important as those most readily served receive surgery and members of the under-served groups form a growing portion of the remaining cataract backlog.

Objective To examine the cost and cost effectiveness of quarterly CD4 cell count and viral load monitoring among patients taking antiretroviral therapy (ART). Design Cost effectiveness study. Setting A randomised trial in a home based ART programme in Tororo, Uganda. Participants People with HIV who were members of the AIDS Support Organisation and had CD4 cell counts Main outcome measures Outcomes calculated for the study period and projected 15 years into the future included costs, disability adjusted life years (DALYs), and incremental cost effectiveness ratios (ICER; $ per DALY averted). Cost inputs were based on the trial and other sources. Clinical inputs derived from the trial; in the base case, we assumed that point estimates reflected true differences even if non-significant. We conducted univariate and multivariate sensitivity analyses. Interventions Three monitoring strategies: clinical monitoring with quarterly CD4 cell counts and viral load measurement (clinical/CD4/viral load); clinical monitoring and quarterly CD4 counts (clinical/CD4); and clinical monitoring alone. Results With the intention to treat (ITT) results per 100 individuals starting ART, we found that clinical/CD4 monitoring compared with clinical monitoring alone increases costs by $20 458 (£12 780, €14 707) and averts 117.3 DALYs (ICER=$174 per DALY). Clinical/CD4/viral load monitoring compared with clinical/CD4 monitoring adds $142 458, and averts 27.5 DALYs ($5181 per DALY). The superior ICER for clinical/CD4 monitoring is robust to uncertainties in input values, and that strategy is dominant (less expensive and more effective) compared with clinical/CD4/viral load monitoring in one quarter of simulations. If clinical inputs are based on the as treated analysis starting at 90 days (after laboratory monitoring was initiated), then clinical/CD4/viral load monitoring is dominated by other strategies. Conclusions Based on this trial, compared with clinical monitoring alone, monitoring of routine CD4 cell count is considerably more cost effective than additionally including routine viral load testing in the monitoring strategy and is more cost effective than ART.

Background: Low body mass index (BMI) individuals starting antiretroviral therapy (ART) for HIV infection in sub-Saharan Africa have high rates of death and loss to follow-up in the first 6 months of treatment. Nutritional supplementation may improve health outcomes in this population, but the anticipated benefit of any intervention should be commensurate with the cost given resource limitations and the need to expand access to ART in the region. Methods: We used Markov models incorporating historical data and program-wide estimates of treatment costs and health benefits from the Zambian national ART program to estimate the improvements in 6-month survival and program retention among malnourished adults necessary for a combined nutrition support and ART treatment program to maintain cost-effectiveness parity with ART treatment alone. Patients were stratified according to World Health Organization criteria for severe (BMI