Task-shifting alcohol interventions for HIV+persons in Kenya: a cost-benefit analysis

Abstract

Background:Among HIV+ patients, alcohol use is a highly prevalent risk factor for both HIV transmission and pooradherence to HIV treatment. The large-scale implementation of effective interventions for treating alcohol problemsremains a challenge in low-income countries with generalized HIV epidemics. It is essential to consider an intervention’scost-effectiveness in dollars-per-health-outcome, and the long-term economic impact—or“return on investment”inmonetary terms.Methods:We conducted a cost-benefit analysis, measuring economic return on investment, of a task-shifted cognitive-behavioral therapy (CBT) intervention delivered by paraprofessionals to reduce alcohol use in a modeled cohort of 13,440outpatients in Kenya. In our base-case, we estimated the costs and economic benefits from a societal perspective across asix-year time horizon, with a 3% annual discount rate. Costs included all costs associated with training and administeringtask-shifted CBT therapy. Benefits included the economicimpact of lowered HIV incidence as well as the improvementsin household and labor-force productivity. We conducted univariate and multivariate probabilistic sensitivity analyses totest the robustness of our results.Results:Under the base case, total costs for CBT rollout was $554,000, the value of benefits were $628,000, and thebenefit-to-cost ratio was 1.13. Sensitivity analyses showed that under most assumptions, the benefit-to-cost ratioremained above unity indicating that the intervention wascost-saving (i.e., had positive return on investment).Thedurationofthetreatmenteffectmosteffected the results in sensitivity analyses.Conclusions:CBT can be effectively and economically task-shifted to paraprofessionals in Kenya. The interventioncan generate not only reductions in morbidity and mortality, but also economic savings for the health system inthe medium and long term. The findings have implications for other countries with generalized HIV epidemics,high prevalence of alcohol consumption, and shortages of mental health professionals.Trial registration:This paper uses data derived from“Cognitive Behavioral Treatment to Reduce Alcohol Use AmongHIV-Infected Kenyans (KHBS)”with ClinicalTrials.gov registration NCT00792519 on 11/17/2008; and preliminary data from“A Stage 2 Cognitive-behavioral Trial: Reduce Alcohol First in Kenya Intervention”(NCT01503255, registered on 12/16/2011).