Cost-effectiveness of Zvandiri, a community-based support intervention to reduce virological failure in adolescents living with HIV in Zimbabwe: Results of a decision analytical model

Improving antiretroviral therapy (ART) adherence among adolescents living with HIV (ALHIV) improves outcomes, but with resource implications. We conducted a cost-effectiveness analysis extrapolating the costs and benefits of a community-based peer-support intervention (Zvandiri) among ALHIV in Zimbabwe. We used a de-novo multistate Markov decision-analytic model that simulated Zvandiri lifetime costs and benefits on viral suppression, death rates, life-years (LY) and quality-adjusted-life-years (QALYs) gained from the healthcare system perspective. We estimate the incremental cost-effectiveness ratio (ICER) per LY and QALY gained and compare the ICER to proposed cost-effectiveness thresholds of $500 and $700 per LY or QALY gained. We explore parameter uncertainty using probabilistic sensitivity analyses. Cohort-microsimulation suggests that after 40 years under SoC, 21% of 280 ALHIV will have undetectable viral-load (VL), 12% will have low VL (<1000 copies/mL), 10% will have high VL (≥1000 copies/mL) and 57% would have died. With Zvandiri, ART adherence improves, decreasing annual probability of virological failure or death. After 40 years, 65% will have undetectable viral load, 23% low VL, 3% high VL and 9% would have died. Zvandiri results in 1,345 LYs gained at incremental cost of $500,587, yielding a discounted ICER of $372 per LY gained. Zvandiri also results in 1,246 QALYs at incremental cost of $123,645, yielding a discounted ICER of $99 per QALY. The ICER is highly sensitive to programme costs, health-related utilities, and the discount rate. Zvandiri is a cost-effective intervention for reducing virological failure and death in ALHIV. Our analysis likely underestimates the full benefits of the intervention by not accounting for reductions in HIV transmissions resulting from higher virological suppression observed in full transmission models.