Cost-Effectiveness Analysis of Peer-delivered Services in South Africa
Training peers to become healthcare workers can be a cost-effective approach to delivering HIV-related health care in South Africa.
The fight against HIV in South Africa is complicated by alcohol and other drug use (AOD), which has been cited as a common barrier to adherence of antiretroviral therapy (ART). The economic burden of disordered alcohol use further strains the country’s public health resources through increased healthcare utilization, social welfare payments, crime, and lost productivity. Improving ART adherence will require interventions that are effective and cost-effective at addressing the co-occurring conditions of HIV and AOD.
A recently completed pilot study called Khanya produced promising results detailing the feasibility and acceptability of a “task-sharing” peer-delivered behavioral intervention. In the study, peers with lived AOD experience were trained and supervised by clinical providers to support other individuals with HIV and AOD on their health goals. Findings demonstrated that Khanya improved ART adherence among people with HIV/AIDS and have AOD.
To understand the economic value of Khanya, lead author and CHERISH Research Affiliate Thanh Lu conducted a cost-effectiveness analysis to compare Khanya with enhanced treatment as usual (ETAU), an outpatient treatment model that offered behavioral therapy sessions led by a licensed therapist or counselor. Researchers estimated the costs in 2023 US dollars and 2023 South African Rand (ZAR) from the perspective of the healthcare sector and calculated the incremental cost-effectiveness ratio (ICER) as the cost per percentage point improvement in daily ART adherence and cost per one unit improvement in the Global ASSIST score (a measure of substance use behavior).
Thanh Lu, PhD
Thanh Lu is a research economist at RTI International, a CHERISH Research Affiliate, and a 2021-2022 CHERISH pilot grant recipient.
Key Findings
Training peers to become healthcare workers can be a cost-effective approach to improving ART adherence, but the intervention is less likely to be a cost-effective approach to reduce AOD in South Africa.
- The average cost to gain an additional percentage point improvement in ART adherence through Khanya was US$0.40 (0.7 ZAR).
- Healthcare sector stakeholders who are willing to pay US$0.40 per percentage point improvement were 10% confident in finding the Khanya intervention cost-effective compared to ETAU. To become 95% confident, the willingness-to-pay would have to increase to US$8 (44 ZAR).
- There were no notable differences in a reduction of AOD use between the two interventions. Regardless of the willingness-to-pay for an additional percentage point improvement in the Global ASSIST score, Khanya was less likely to be considered as a cost-effective intervention for mitigating AOD.
The economic evidence generated through this cost-effectiveness analysis strengthens the case for adopting task-sharing models of care for HIV/AOD services in South Africa when taking into account ART adherence, but not the reduction of AOD. In the U.S., researchers have applied preliminary findings from Khanya to address substance use disorder treatment gaps in Washington D.C., Baltimore, Detroit, and rural Maryland. The economic value of Khanya, therefore, can also have global implications for improving care delivery in settings that have a high burden of HIV and are experiencing healthcare shortages and budget restraints.
The study, “Cost-effectiveness of a peer-delivered behavioral intervention for adherence to antiretroviral therapy and alcohol and drug use in South African HIV care,” was published in AIDS Care on January 22, 2026. CHERISH co-authors include lead author and CHERISH Research Affiliate Thanh Lu, and senior author and CHERISH Co-director Sean M. Murphy.