Population health impact, cost-effectiveness, and affordability of community-based HIV treatment and monitoring in South Africa: a health economics modelling study

Abstract Introduction Community-based delivery and monitoring of antiretroviral therapy (ART) for HIV has the potential to increase viral suppression for individual- and population-level health benefits. However, the cost-effectiveness and budget impact are needed for public health policy. Methods and Findings We used a mathematical model of HIV transmission in KwaZulu-Natal, South Africa, to estimate population prevalence, incidence, mortality, and disability-adjusted life-years (DALYs) from 2020 to 2060 for two scenarios: 1) standard clinic-based HIV care and 2) five-yearly home testing campaigns with community ART for people not reached by clinic-based care. We parameterised model scenarios using observed community-based ART efficacy. We evaluated incremental cost-effectiveness and net health benefits using a threshold of $750/DALY averted. Sensitivity analyses varied costs of ART, hospitalisation, and testing. Uncertainty ranges (URs) were estimated across 25 best-fitting parameter sets. By 2060, community ART following home testing averted 27.9% (UR: 24.3–31.5) of incident HIV infections, 27.8% (26.8–28.8) of HIV-related deaths, and 18.7% (17.9–19.7) of DALYs compared to standard of care. Adolescent girls and young women aged 15–24 years experienced the greatest reduction in incident HIV (30.7%, 27.1–34.7). In the first five years (2020–2024), community ART required an additional $44.9 million (35.8–50.1) annually, representing 14.3% (11.4–16.0) of the current HIV budget. The cost per DALY averted was $102 (85–117) for community ART compared with standard of care. Providing six-monthly refills instead of quarterly refills further increased cost-effectiveness to $78.5 per DALY averted (62.9–92.8). Cost-effectiveness was robust to sensitivity analyses. Conclusions In a high-prevalence setting, scale-up of decentralised ART dispensing and monitoring for people not already virally suppressed can provide large population health benefits and is cost-effective in preventing death and disability due to HIV.