Impact and cost-effectiveness of non-governmental organizations on the HIV epidemic in Ukraine among men who have sex with men

BACKGROUND: Men who have sex with men (MSM) in Ukraine have a high prevalence of HIV (2018: 5.2%). MSM-targeted non-governmental organisations (NGOs) are associated with improved HIV testing, treatment coverage and increased condom use. We use mathematical modelling to estimate the impact and cost-effectiveness of these interventions.
METHODS: A mathematical model of HIV transmission, parameterised and calibrated to bio-behavioural survey data for MSM in Ukraine (2011-2018), was used to evaluate the historical (up to 2020) and future impact (2020-2040) of status quo coverage levels of NGOs compared to scenarios where there were no NGOs over 2003-2019 or 2020-2040. Impact was measured in terms of HIV incidence, infections and HIV-related deaths averted. We then compared the costs (ART and NGO costs, in 2018 USD) and disability adjusted life years [DALY] for the status quo scenario and a counterfactual scenario (no NGOs over 2020-2025, but with NGOs thereafter to 2040) until 2040 to estimate the mean incremental cost-effectiveness ratio (ICER, cost per DALY averted). We assumed a 3% annual discount rate for costs and outcomes.
RESULTS: Over 2003-2019, the model projects there were 29,088 (26,241-31,908) HIV infections and 23,927 (20,918-27,463) HIV-related deaths with existing levels of NGO interventions, with these increasing by 18% and 11%, respectively, with no NGOs over that period. Going forward with existing NGO coverage levels, the model projects HIV prevalence will decrease from 6.4% (95% credibility interval: 5.5%-7.1%) to 3.0% (2.0%-3.9%) over 2020-2040 and HIV incidence will decrease from 0.76 (0.63-0.89) to 0.27 (0.16-0.40) per 100 person years. However, with no NGOs over this period, HIV prevalence would increase by 80% (63%-121%) by 2040 and HIV incidence by 189% (137%-334%), with there being 77% (60%-115%) more HIV infections and 38% (31%-54%) more HIV deaths over the period. Compared to a scenario where NGO activities cease over 2020-2025, the status quo scenario averts 38,993 DALYs by 2040, with the mean ICER being $302.88 per DALY averted.
CONCLUSIONS: MSM-targeted NGOs in Ukraine have prevented considerable HIV infections and deaths and are highly cost-effective compared with a willingness-to-pay threshold of 50% of Ukraine's GDP ($3,096 in 2018).