Cost utility of supporting family-based care to prevent HIV and deaths among orphaned and separated children in East Africa: a markov model–based simulation

Abstract

Purpose. Strengthening family-based care is a key policy response to the more than 15 million orphaned and separated children who have lost 1 or both parents in sub-Saharan Africa. This analysis estimated the cost-effectiveness of family- based care environments for preventing HIV and death in this population. Design. We developed a time-homogeneous Markov model to simulate the incremental cost per disability-adjusted life year (DALY) averted by supporting family- based environments caring for orphaned and separated children in western Kenya. Model parameters were based on data from the longitudinal OSCAR’s Health and Well-Being Project and published literature. We used a societal per- spective, annual cycle length, and 3% discount rate. Incremental cost-effectiveness ratios were simulated over 5- to 15-y horizons, comparing family-based settings to street-based ‘‘self-care.’’ Parameter uncertainty was addressed via determi- nistic and probabilistic sensitivity analyses. Results. Under base-case assumptions, family-based environments prevented 422 HIV infections and 298 deaths in a simulated cohort of 1,000 individuals over 10 y. Compared with street-based self-care, family-based care had an incremental cost of $2,528 per DALY averted (95% confidence interval [CI]: 1,798, 2,599) and $2,355 per quality-adjusted life year gained (95% CI: 1,667, 2,413). The probability of family-based care being highly cost-effective was .80% at a willingness-to-pay (WTP) threshold of $2,250/DALY averted. Households receiving government cash transfers had minimally higher cost-effectiveness ratios than households without cash trans- fers but were still cost-effective at a WTP threshold of twice Kenya’s GDP per capita. Conclusions. Compared with the status quo of street-based self-care, family-based environments offer a cost-effective approach for preventing HIV and death among orphaned children in lower-middle income countries. Decision makers should consider increasing resources to these environments in tandem with social protection programs.