South Africa has the largest number of people living with HIV and AIDS in the world – an estimated 6.29 million people or 16.7 percent of adults aged 15-49 years. The country has also seen a related increase in incidence of tuberculosis (TB). National reviews have recommended joint TB/HIV programmes but how affordable are they?

Researchers from the University of the Western Cape, South African and the London School of Hygiene and Tropical Medicine, UK, looked at three public primary health care facilities in Cape Town: a community health centre, a primary health care clinic and a sexually transmitted infections (STI) clinic. These were among 12 pilot facilities in one of four TB/HIV pilot districts in South Africa that used ProTEST, a package of joint TB/HIV interventions supported by the World Health Organization (WHO).

The interventions in ProTEST were: voluntary counselling and rapid testing (VCT); screening for TB through intensified case-finding (ICF), isoniazid preventive therapy (IPT) and cotrimoxazole preventive therapy (CPT); and improved management of HIV-related opportunistic infections. The researchers measured the costs of all these interventions, as well as estimating their cost-effectiveness.

They found that total costs varied widely among the facilities, ranging from US$7-11 for VCT, US$81-166 for detecting a TB case, US$92-183 for completing IPT, and US$20-44 for completing six months of CPT. Staff accounted for the highest proportion (78-85 percent) of total costs, while cost of supplies including HIV tests, isoniazid and cotrimoxazole was a much lower proportion (11-17 percent). Results showed that:

• the estimated cost per HIV infection averted by VCT was US$67-112; this compared favourably with other HIV prevention interventions
• the cost of HIV counselling and testing per person was lower in the STI clinic due partly to the exclusive use of lay counsellors
• the cost per TB case prevented through VCT (by preventing HIV) was US$129-215, by ICF was US$323-664 and by IPT was US$ 86-962; these were all less than the cost of treating a new case of TB as reported in a previous study from Cape Town (estimated at US$823-1362)
• the use of chest X-rays for IPT screening decreased the cost-effectiveness of IPT in TB prevention by 36 percent
• the use of purified protein derivative (PPD) in IPT screening did not affect its cost-effectiveness.

The researchers argue that the ProTEST package is cost-saving in South Africa. In particular, VCT was less expensive than previously reported in other African countries. They conclude that VCT using lay counsellors and rapid HIV testing is a cost-effective intervention to prevent both HIV and TB in South Africa. They recommend that:

• VCT services should be expanded for prevention and to link HIV-positive clients to care and support
• ICF, IPT and CPT should be available at all primary health care facilities in South Africa for HIV-positive clients
• PPD testing should be used where it is feasible to identify people eligible for IPT in South Africa, in line with current WHO recommendations
• when assessing the affordability of these interventions in other settings, policymakers should consider the high proportion of total costs attributable to staff and the fact that salary costs are lower in many other African countries.

Source(s):
'Costs of measures to control tuberculosis/HIV in public primary care facilities in Cape Town, South Africa', Bulletin of the World Health Organization 84(7), pages 528-536, by Harry Peter Hausler, Edina Sinanovic, Lilani Kumaranayake, Pren Naidoo, Hennie Schoeman, Barbara Karpakis, and Peter Godfrey-Faussett, 2006

Funded by: South African Department of Health; Canadian Institutes for Health Research; UK Department for International Development (DFID); London School of Hygiene and Tropical Medicine (LSHTM); Stop TB Department, World Health Organization

id21 Research Highlight: 4 December 2006

Further Information:
Harry Peter Hausler
School of Public Health
University of the Western Cape
PO Box 51093
Cape Town 8002
South Africa

Tel: +27 82 779 0045
Fax: +27 21 438 7148
Contact the contributor: hhausler@uwc.ac.za

School of Public Health, University of the Western Cape, South Africa

London School of Hygiene and Tropical Medicine, UK

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'Communities provide HIV and tuberculosis care in Malawi'

'HIV increases TB risk within the first year'

'Barriers to tuberculosis diagnosis and treatment in Zambia'

'No change: spread of TB constant despite raging HIV epidemic'

'Battling the bugs – cutting death rates among HIV-positive TB patients'

'Charity begins at home - community care for HIV and TB patients in Zambia'