Results from two studies proving the efficacy and cost-effectiveness of providing voluntary counseling and testing for HIV-1 in developing countries are reported in the new issue (July 8) of the British medical journal The Lancet.
The studies were designed to answer specific policy questions, according to Thomas J. Coates, PhD, director of the AIDS Research Institute at the University of California San Francisco and one of the lead investigators.
"Should voluntary counseling and testing be offered in sub-Saharan Africa where there is little hope of antiretroviral treatments for individuals who test positive for HIV? And, does it work and is it cost-effective in these settings? The answer to both questions is an emphatic yes," he said. The efficacy study, headed by Coates, enrolled 3,120 individuals and 586 couples in Nairobi, Kenya; Dar es Salaam, Tanzania; and Port-of-Spain, Trinidad.
The cost-effectiveness study was led by Michael Sweat, PhD, from the Johns Hopkins University School of Hygiene and Public Health, with Coates as a co-investigator. This study modeled outcomes based on behavioral and biological results from the efficacy research in Nairobi and Dar es Salaam. Cost-effectiveness was estimated for a hypothetical cohort of 10,000 persons.
"Voluntary counseling and testing saves money, as the cost of the intervention is far less than the cost of even minimal HIV treatment, not to mention the cost of orphans, lost productivity, loss of skilled labor, tuberculosis, and the enormous impact on individuals and communities," Sweat said.
According to Coates, the efficacy study is the only randomized controlled study to look at the impact of HIV voluntary counseling and testing in developing countries and is also the only randomized controlled study in the world to look at the impact of VCT on couples.
In this research project, individual and couple participants were randomly assigned to receive either voluntary counseling and testing (VCT) or basic health information (HI). Couples received results separately and then were encouraged to share their results in the presence of a counselor. All participants received unlimited condoms.
Follow-up sessions with participants were scheduled at about 7 months and about 13 months after test results were received. At the first follow-up, the HIV participants were offered VCT, and all VCT participants were offered retesting. Sexually transmitted diseases were diagnosed and treated at the first follow-up. The retention rate at the first follow-up was 82 percent for individuals and 85 percent for couples. For the second follow-up, the rate was 70 percent for individuals and 76 percent for couples.
Profound behavior changes between the two groups were observed at the first follow-up, according to Coates. Individual men assigned to VCT reported reduced unprotected intercourse with non-primary partners by 35 percent, compared to a 13 percent decrease by the men assigned HI. Women in the VCT group reported a 38 percent reduction in unprotected intercourse versus a 17 percent reduction by women assigned HI. Individuals diagnosed with HIV-1 were more likely than uninfected individuals to reduce unprotected intercourse with primary partners.
Study results also showed that couples assigned VCT reduced unprotected sex with their partner significantly more than couples assigned HI. Couples in which one or both members were diagnosed with HIV-1 were more likely to reduce unprotected intercourse with each other than couples in which both members were uninfected. In addition, at the first follow-up, when the control group receiving HI was offered VCT, 90 percent wanted to be tested.
The behavioral changes noted in the original VCT group were maintained at the second follow-up, according to study findings. Participants from the control group who elected to receive VCT replicated the behavioral changes of those initially receiving VCT.
The second study found VCT to be a very cost-effective intervention in urban East African settings. "VCT is feasible in developing country settings using local systems and personnel. It only costs about $27 per person to provide high quality VCT in East Africa," Sweat said.
The cost analysis was based on client infection status, sex, and whether VCT was received as an individual or as a couple. VCT was estimated to avert 1,104 HIV-1 infections in Kenya and 895 HIV-1 infections in Tanzania during the year after receiving VCT. The cost per averted infection in Kenya was $249 and $346 in Tanzania. The cost per disability-adjusted life-years (DALY) saved in Kenya was $12.77 and $17.78 in Tanzania.
According to Sweat, the results are comparable to other HIV interventions. "For approximately every $15 spent on VCT, one DALY is saved. This compares to a cost of $10 per DALY from enhanced sexually transmitted disease treatment and $8 from universal provision of Nevirapine to pregnant women. In addition, targeting VCT to persons likely to be infected with HIV and couples significantly enhances cost-effectiveness, " he said.
Increasing the proportion of couples to 70 percent reduces the cost per DALY to $10.71 in Kenya and $13.39 in Tanzania, according to the analysis. Targeting a population with HIV-1 prevalence of 45 percent reduces the cost per DALY to $8.36 in Kenya and $11.74 in Tanzania.
Sweat cautioned against simply providing testing. "While personnel is the major cost with the HIV test itself only costing about $4.00, counseling is an important aspect of the intervention. A member of our group, Dr. Gloria Sangiwa from Muhimbili University said to me, 'People come in for the test, but they value the counseling'."
The studies were supported by grants from AIDSCAP/Family Health International, the World Health Organization, the United Nations Program on AIDS, and the National Institute of Mental Health.
Study co-authors are Olga A. Grinstead, PhD, MPH; Steve Gregorich PhD; David Heilbron, PhD; William Wolf; Julius Schachter, MD; Peter Scheirer; and Ariane van der Straten, PhD, MPH, all of the UCSF Center For AIDS Prevention Studies; Munkolekole Claudes Kamenga, MD; Gina Dalabetta, MD, and Isabelle de Zoysa, MD, all of AIDSCAP/Family Health International; Sam Kalibala, MD; Monica Ruiz, PhD; David Miller, PhD, and Ben Nkowane, MD, all of UNAIDS; Eric Van Praag, MD, MPH, and Kevin O'Reilly, PhD, of the World Health Organization; Gloria Sangiwa, MD; Margaret Hogan, PhD; Davis Mwakagile, MD, and Japhet Killewo, MD, MPH, all of Muhimbili University College of Health Sciences; Don Balmer, PhD; Francis Kihuho; Steve Moses, MD, and Francis Plummer, MD, all of the Kenya Association of Professional Counselors and the University of Calgary; and Colin Furlonge, MD, of Queen's Park Counseling Center, Trinidad & Tobago.
Journal
The Lancet