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Cost-Effectiveness and Impact of Depression Treatment Implementation on HIV Outcomes in Western Kenya: A Mathematical
Daniel T Citron1, Hae-Young Kim1, Roscoe Kasujja2,3
1Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA.
Introduction:
In eastern, central and southern Africa, HIV is a leading cause of mortality, and both HIV and depression contribute substantially to morbidity. Depression can impede effective HIV treatment and prevention, yet access to depression treatment remains limited. We estimated the impact and cost-effectiveness of scaling up depression screening and treatment to different population segments in western Kenya .
Methods:
We adapted a previously validated HIV transmission model for western Kenya (EMOD-HIV) to include age- and sex-specific depression incidence, remission and recurrence. The model incorporated depression's effects on HIV risk; HIV testing and linkage to care; antiretroviral therapy (ART) adherence; and ART retention. We evaluated four depression screening and treatment scale-up strategies for adults aged 15+ years: (1) universal screening/treatment for all adults; (2) co-administering depression and HIV screening; (3) screening ART recipients; and (4) screening ART recipients with unsuppressed viral load. We assumed 62% depression treatment efficacy and calculated costs from the provider perspective, including US$3.35 for depression screening and US$20.32 per person for psychotherapy; future costs were discounted at 3%, and costs were varied in sensitivity analyses. We calculated incremental cost-effectiveness ratios as the cost (2024 USD) of depression screening and treatment per overall and HIV-related disability-adjusted life-year (DALY) averted.
Results:
Without depression treatment, we projected 129,000 new HIV infections, 95,900 HIV-related deaths and 1.83 M depression episodes between 2025 and 2035. Universal screening had the highest impact, averting 29.3% (95% CI 29.2%-29.3%) of person-years lived with depression, 2.8% (95% CI 2.6%-3.1%) of HIV acquisitions and 1.4% (95% CI 1.3%-1.6%) of HIV deaths. The cost-effectiveness of universal screening and treatment was US$1291 per DALY averted (95% CI: $1288-1296). Screening ART clients was most cost-effective at $744 per DALY averted (95% CI: $730-760), followed by screening ART clients with unsuppressed viral load at $752 per DALY averted (95% CI: $710-799). Co-administering HIV and depression was dominated by other strategies.
Conclusions:
Integrating depression interventions into HIV care could substantially reduce both depression and HIV burden. Cost-effective scale-up could initially focus on individuals with unsuppressed viral load, then to all ART recipients, and finally expand to communities.
