Cost-Effectiveness of Reducing HIV Infections Through Screening and Treating Alcohol Use and Depression in KwaZulu-Natal, South Africa: A Mathematical Modeling Study

Background: KwaZulu-Natal (KZN) has the second highest HIV prevalence of any province in South Africa and high prevalence of alcohol use disorder (AUD) and major depressive disorder (MDD), which increase HIV risk behaviors. We identified the effect and cost-effectiveness of screening and treatment for AUD and MDD as strategies to reduce HIV burden in KZN. Methods: Using a HIV compartmental transmission model, we simulated the effect of AUD and MDD screening and treatment on reducing HIV transmission for the general population and key populations. Screening tools included alcohol use disorders identification test and patient health questionnaire. Treatment strategies included behavioral and pharmacologic interventions. Key populations included female sex workers, men who have sex with men, people in care with unsuppressed viral load, adolescent girls and young women, adolescent boys and young men, and men ages 25–34. Outcomes were HIV infections averted through 2030, quality-adjusted life-years (QALYs) gained through 2030, cost (2019 US$) per infection averted, and cost per QALY gained. Results: Among the general population, MDD screening and behavioral treatment was most cost effective ($340/infection averted; $480/QALY gained). Combined AUD and MDD screening and behavioral and pharmacological treatment averted 179,560 infections ($2100/infection averted) and gained 129,460 QALYs ($2980/QALY gained). Targeting key populations substantially improved cost-effectiveness. The most cost-effective strategy was MDD screening and behavioral treatment among female sex workers ($350/infection averted; $490/QALY gained); followed by sequential scale-up to men who have sex with men ($690/infection averted; $960/QALY gained). Conclusions: Targeted AUD and MDD screening and treatment could substantially reduce HIV transmission in KZN with very favorable cost-effectiveness.