HIV; Health economics; Health insurance; Mathematical modelling; Humans; Cameroon; Female; Sex Work; Adult; HIV Infections/prevention & control; HIV Infections/transmission; Cost-Benefit Analysis; Sex Workers; Insurance, Health/economics; Models, Theoretical; Health Policy; Public Health, Environmental and Occupational Health
Abstract :
[en] [en] INTRODUCTION: HIV prevalence disproportionately affects high-risk populations, particularly female sex workers in Africa. Women and girls engaging in transactional sex (WGTS) face similar health risks from unsafe practices, economic vulnerabilities and stigma. However, they are not recognised.
METHODS: Using existing literature and data from the POWER randomised controlled trial, we developed a deterministic compartmental model to assess HIV dynamics among WGTS, their sugar daddies and low-risk populations. We evaluated the cost-effectiveness of a new structural intervention to prevent HIV among WGTS in urban Cameroon by reducing the financial need to engage in transactional sex in the case of illness and injury shocks to the household. The intervention provided free healthcare to WGTS and their economic dependents through a zero-cost health insurance package. We explored the cost-effectiveness of this intervention considering various population coverage levels (0%, 25%, 50%, 75% and 100%). We calculated the incremental cost-effectiveness ratio (ICER) per disability-adjusted life-year (DALY) and HIV infections averted, employing both univariable and global sensitivity analyses. Probabilistic sensitivity analyses considered all parameters, including the insurance effect in reducing HIV, comparing simulated ICERs to willingness-to-pay thresholds. We also compared the health insurance strategy with expanding pre-exposure prophylaxis (PrEP) coverage. All costs were evaluated in 2023 UK pounds (£) using a 3% discount rate, with Cameroon's gross domestic product (GDP) per capita recorded at £1239.
RESULTS: Implementing health insurance coverage levels of 25%, 50%, 75% and 100% yielded ICERs/DALY averted of £2795 (£2483-£2824), £2541 (£2370-£2592), £2263 (£2156-£2316) and £1952 (£1891-£1998), respectively, compared with 0% coverage. Probabilistic sensitivity analysis indicated an ICER=£2128/DALY averted at 100% coverage, with 58% of simulations showing ICERs<GDP per capita. Maintaining health insurance's effect in reducing HIV above 70% could provide significant health and economic benefits. However, antiretroviral therapy (ART) efficacy significantly impacted HIV infection prevention (partial rank correlation coefficient=-0.62, p<0.001) in global sensitivity analyses; expanding ART could reduce the cost-effectiveness of health insurance. While PrEP alone is not cost-effective, combining 20% PrEP coverage with 75%-100% health insurance for WGTS maximises DALYs averted (ICER/DALY averted=£2436-£2102) and reduces infections.
CONCLUSION: A comprehensive health insurance scheme for women in Cameroon could significantly reduce HIV infections and DALYs, promoting a more inclusive and targeted healthcare policy for women at high risk of HIV.
Disciplines :
Social economics
Author, co-author :
Allel, Kasim ; University College London, London, UK kasim.allelhenriquez@phc.ox.ac.uk a.lepine@ucl.ac.uk ; Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
Cust, Henry; University College London, London, UK ; Duke University, Durham, North Carolina, USA
Mfochive, Iliassou; John Hopkins Cameroon Program, Yaounde, Cameroon
Szawlowski, Sandie; University College London, London, UK
Nitcheu, Emile; John Hopkins Cameroon Program, Yaounde, Cameroon
Defo Tamgno, Eric ; Université de Liège - ULiège > Unité de recherche Santé publique, épidémiologie et économie de la santé (URSAPES) ; Université de Liège - ULiège > Faculté de Médecine > Form. doct. sc. santé publ. (paysage) ; Université de Liège - ULiège > Faculté de Médecine > Doct. scienc. sant. publ. ; John Hopkins Cameroon Program, Yaounde, Cameroon
Moyoum, Stephanie; John Hopkins Cameroon Program, Yaounde, Cameroon
Noo, Julienne; John Hopkins Cameroon Program, Yaounde, Cameroon
Billong, Serge; University of Yaounde, Yaoundé, Cameroon
Tamoufe, Ubald; John Hopkins Cameroon Program, Yaounde, Cameroon
Lepine, Aurelia; University College London, London, UK kasim.allelhenriquez@phc.ox.ac.uk a.lepine@ucl.ac.uk
Language :
English
Title :
Cost-effectiveness of health insurance among women engaged in transactional sex and impacts on HIV transmission in Cameroon: a mathematical model.
ESRC - Economic and Social Research Council UKRI - UK Research and Innovation
Funding text :
This project is funded by AL's (PI) UKRI Future Leaders Fellowship (round 2, 2020-2024) which is an award by the MRC/ESRC (grant number: MR/S031790/1).
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