Economic costs and cost-effectiveness of conditional cash transfers for the uptake of services for the prevention of vertical HIV transmissions in a resource-limited setting

Abstract

Background: Prevention of mother-to-child transmission (PMTCT) is critical for halting the HIV epidemic. However, innovative approaches to improve PMTCT uptake may be resource-intensive. We examined the economic costs and cost-effectiveness of conditional cash transfers (CCTs) for the uptake of PMTCT services in the Democratic Republic of Congo.

Methods: We leveraged data from a randomized controlled trial of CCTs (n = 216) versus standard PMTCT care alone (standard of care (SOC), n = 217). Economic cost data came from multiple sources, with costs analyzed from the societal perspective and reported in 2016 international dollars (I$). Effectiveness outcomes included PMTCT uptake (i.e., accepting all PMTCT visits and services) and retention (i.e., in HIV care at six weeks post-partum). Generalized estimating equations estimated effectiveness (relative risk) and incremental costs, with incremental effectiveness reported as the number of women needing CCTs for an additional PMTCT uptake or retention. We evaluated the cost-effectiveness of the CCTs at various levels of willingness-to-pay and assessed uncertainty using deterministic sensitivity analysis and cost-effectiveness acceptability curves.

Results: Mean costs per participant were I$516 (CCTs) and I$431 (SOC), representing an incremental cost of I$85 (95% CI: 59, 111). PMTCT uptake was more likely for CCTs vs SOC (68% vs 53%, p < 0.05), with seven women needing CCTs for each additional PMTCT service uptake; twelve women needed CCTs for an additional PMTCT retention. The incremental cost-effectiveness of CCTs vs SOC was I$595 (95% CI: I$550, I$638) for PMTCT uptake and I$1028 (95% CI: I$931, I$1125) for PMTCT retention. CCTs would be an efficient use of resources if society's willingness-to-pay for an additional woman who takes up PMTCT services is at least I$640. In the worst-case scenario, the findings remained relatively robust.

Conclusions: Given the relatively low cost of the CCTs, policies supporting CCTs may decrease onward HIV transmission and expedite progress toward ending the epidemic.

Keywords: Conditional cash transfers; Cost-effectiveness; Economic costs; HIV; PMTCT; Retention; The Democratic Republic of the Congo; Uptake.

Figure 1:

One-way sensitivity analysis of unit costs This figure shows how the incremental cost-effectiveness ratio responds to changes in unit costs for PMTCT uptake (Panel 1) and PMTCT retention (Panel 2). The x-axis shows the change in the incremental cost-effectiveness ratio due to variations in unit costs, with the labels on either end of each bar representing the lower and upper bound values. The y-axis shows the individual unit costs varied. In each panel, the thick vertical line corresponds to the incremental cost-effectiveness ratios calculated using the base case unit costs. For both outcomes, the incremental cost-effectiveness ratio was sensitive to the value of the cash incentives followed by the cost of health facility deliveries. Abbreviations: ICER, incremental cost-effectiveness ratio; PMTCT, prevention of mother-to-child transmission of HIV.

Figure 2:

Cost-effectiveness acceptability curve for conditional cash transfers compared to standard PMTCT care. This figure shows the probability that conditional cash transfers plus standard PMTCT are cost-effective compared to standard PMTCT care alone. The x-axis represents society’s maximum willingness-to-pay for the intervention, while the y-axis shows the probability the intervention is cost-effective at a given willingness-to-pay value. Points B and F correspond to the incremental cost-effectiveness ratio point estimates and have a 0.5 probability of being cost-effective. Given the data and a maximum willingness-to-pay of I$1100 per additional participant taking up PMTCT services or being retained in PMTCT care, the intervention has a 100% chance of being cost-effective. Abbreviations: ICER, incremental cost-effectiveness ratio; PMTCT, prevention of maternal-to-child transmission.