The cost-effectiveness of a resilience-based psychosocial intervention for HIV prevention among MSM in India

Abstract

Objective: MSM in India are at a high risk for HIV infection given psychosocial challenges, sexual orientation stress, and stigma. We examined the cost-effectiveness of a novel resilience-based psychosocial intervention for MSM in India.

Design: We parameterized a validated microsimulation model (CEPAC) with India-specific data and results from a randomized trial and examined two strategies for MSM: status quo HIV care ( SQ ), and a trial-based psychosocial intervention ( INT ) focused on building resilience to stress, improving mental health, and reducing condomless anal sex (CAS).

Methods: We projected lifetime clinical and economic outcomes for MSM without HIV initially. Intervention effectiveness, defined as reduction in self-reported CAS, was estimated at 38%; cost was $49.37/participant. We used a willingness-to-pay threshold of US$2100 (2019 Indian per capita GDP) per year of life saved (YLS) to define cost-effectiveness. We also assessed the 5-year budget impact of offering this intervention to 20% of Indian MSM.

Results: Model projections showed the intervention would avert 2940 HIV infections among MSM over 10 years. Over a lifetime horizon, the intervention was cost-effective (ICER = $900/YLS). Results were most sensitive to intervention effectiveness and cost; the intervention remained cost-effective under plausible ranges of these parameters. Offering this intervention in the public sector would require an additional US$28 M over 5 years compared with SQ .

Conclusion: A resilience-based psychosocial intervention integrated with HIV risk reduction counseling among MSM in India would reduce HIV infections and be cost-effective. Programs using this approach should be expanded as a part of comprehensive HIV prevention in India.

Figure 1.. One-way sensitivity analyses on the cost-effectiveness of a psychosocial HIV intervention for MSM in India.

This “tornado” diagram portrays the results of a series of one-way sensitivity analyses. Each horizontal bar represents the range of incremental cost-effectiveness ratios (ICERs) for the intervention compared to SQ when a given model parameter is varied across a wide range. Ranges examined are presented next to the parameter name as (parameter input corresponding to the lowest ICER - parameter input corresponding to the highest ICER; base case parameter value). Parameters are arranged along the vertical axis in order of their impact on the ICER, with the most influential parameters at the top of the figure. The vertical black line represents the base case ICER of $900/YLS for the intervention; the dashed line represents the 2019 Indian per capita gross-domestic product (GDP) of $2,100. ICERs to the left of the dashed line are considered “cost-effective.” MSM: men who have sex with men; YLS: year of life saved, ICER: incremental cost-effectiveness ratio; SQ: status quo HIV care

Figure 2.. Multi-way sensitivity analysis on the cost-effectiveness of a psychosocial HIV intervention for MSM in India, varying intervention effectiveness and cost.

This shows the cost-effectiveness of the intervention compared to SQ when the intervention effectiveness and intervention cost are varied simultaneously. Intervention effectiveness is varied from the base case value of 38% along the horizontal axis. Intervention cost is varied along the vertical axis across a range of per-person costs, from the base case of $49. Blue indicates ranges where the intervention would be cost saving (i.e., costs less and confers greater life-years than SQ); dark green indicates that the ICER is <0.5 times the 2019 Indian per capita GDP, i.e., <US$1,050; light green indicates that the ICER is between 0.5 and 1.0 times the 2019 per capita GDP; red indicates that the ICER is >1.0 times the annual per capita GDP. The X on the figure marks the base case value. We considered ICERs below the annual Indian per capita GDP to be cost-effective (see Methods). MSM: men who have sex with men; ICER: incremental cost-effectiveness ratio; SQ: status quo HIV care

Figure 3.. Five-year budget impact of a psychosocial HIV intervention for MSM in India compared to status quo.

This shows the total undiscounted HIV program expenditures over five years for 3.0 million MSM without HIV in India, with 20% uptake of the intervention. Strategies include SQ, INT, INT (0.75x effectiveness), INT (0.5x cost), and INT (1.5x cost). Expenditures are stratified into four categories: 1) Expenditures directly attributed to the intervention, which includes intervention personnel, overhead, and space costs; 2) antiretroviral therapy (ART) expenditures, which include the cost of ART drugs for those who acquire HIV; 3) other HIV care expenditures, which include all other associated HIV medical costs, such as CD4 count testing, viral load testing, clinic visits, and costs associated with treatment of opportunistic diseases; and 4) HIV testing expenditures, including costs associated with current levels of HIV screening in India. In the four bars reflecting the intervention, total expenditures reflect savings from reduced transmission among MSM. MSM: men who have sex with men; HVL: HIV viral load test; M: millions; USD: US dollars; ART: antiretroviral therapy; SQ: status quo HIV care; INT: psychosocial intervention with background HIV testing