Study recommends
cost-effective HIV prevention efforts

Focusing HIV-related interventions on the most cost-effective strategies may prevent substantially more HIV infections in the United States each year than current approaches, according to a Rand Corporation study issued Tuesday. "This is the first study to develop a comprehensive strategy for preventing future HIV infections in the United States based on cost-effectiveness analysis," said Deborah Cohen, a Rand senior natural scientist and lead author of the study. "By focusing funds on strategies that are more cost-effective than those currently recommended, we may be able to save many more lives."

Rand researchers examined the effectiveness of various HIV prevention methods used in the United States by creating a model based on past studies of these interventions. To date, cost-effectiveness modeling has not been widely used in public health as a way to allocate limited prevention resources. Using a proposed $400 million budget, Rand estimated the potential number of HIV infections that could by prevented by directing funds to a combination of the most cost-effective prevention methods. This included estimating the cost of reaching both high-risk and low-risk groups of people.

The study identified nine HIV interventions that when used together might prevent close to 21,000 HIV infections a year. Nationally about 40,000 new HIV infections were estimated to occur in the last year. Interventions were more cost-effective than HIV treatment if they targeted high-risk groups, such as men who have sex with men, or were found to be inexpensive for each person reached, according to the study.

These findings are in contrast to the four HIV prevention initiatives advocated by the Centers for Disease Control and Prevention. According to the Rand analysis, the CDC initiatives would prevent an estimated 7,300 cases of new HIV infections using the same $400 million budget. In order to prevent 20,000 new cases of HIV infections--using its four intervention methods--the CDC would have to increase its prevention budget from $400 million to $1.7 billion.

"There is a clear difference between the results from our model and those produced by current approaches to HIV prevention," said Thomas Farley of the Tulane University School of Public Health, coauthor of the study. "Public health leaders in the United States should expand the range of approaches used to prevent HIV infection and combine them more strategically."

The study's most notable recommendations for HIV prevention interventions include:

Community mobilization--targeting men who have sex with men--was predicted to prevent nearly 9,000 HIV infections per year.

Needle exchange programs--most cost-effective when used for injection drug users in areas with a high HIV prevalence--were estimated to prevent close to 2,300 new cases of HIV infection.

Mass-media campaigns containing messages to reduce risky sexual behavior and programs to distribute free condoms could prevent an estimated 1,100 and 1,900 new infections, respectively, among lower-prevalence populations.

HIV counseling and testing--one of the four CDC prevention methods--was found to be one of the least cost-effective prevention approaches, costing $74 per person reached and $110,000 per infection prevented. The investigative model predicted 700 HIV infections could be prevented using this method by limiting the number of people tested and counseled to 1 million annually.

Researchers note that while the study was designed to target the United States as a whole, state and local populations could use similar resource-allocation models for their HIV prevention efforts. In addition, they caution that their findings are not an absolute determination of cost-effectiveness, but indicate the relative value of these approaches.

The Rand study, titled "Cost-effective Allocation of Government Funds to Prevent HIV Infection," appears in the July-August edition of the health policy journal Health Affairs. The other author of the study is Shin-yi Wu of Rand Health, the nation's largest independent health policy research program.