Cost-effectiveness of safer conception strategies for HIV-discordant couples in Zimbabwe

Introduction: Data on the cost-effectiveness of safer conception strategies are limited, particularly where HIV is endemic. We evaluated the cost-effectiveness of antiretroviral therapy with frequent viral load monitoring (ART/VL), oral pre-exposure prophylaxis (PrEP), vaginal insemination (VI), and semen washing (SW) for HIV-discordant couples in Zimbabwe. Methods: We used decision-analytic models to compare safer conception strategies alone and in combination, with current practice. Costs (2024 USD) were estimated using micro-costing/time-and-motion studies within a safer conception program, adjusted for public-sector prices and service intensity. HIV transmission risks to partners and infants were drawn from published literature and expressed as disability-adjusted life years (DALYs). We calculated incremental cost-effectiveness ratios (ICERs) using discounted net costs and DALYs from healthcare system (base case) and societal perspectives for a single pregnancy. Results: For couples with an HIV-positive man on ART, ART/VL was dominant (more effective and less costly than current practice) and ART/VL+PrEP was cost-effective ($4,702/DALY averted). For men not on ART, PrEP (for HIV-negative partners) was dominant, ART/VL was highly cost-effective ($502/DALY averted), and ART/VL+PrEP was cost-effective ($4,942/DALY averted). For couples with an HIV-positive woman on ART, VI was dominant, and ART/VL+VI was highly cost-effective ($815/DALY averted). For women not on ART, ART(routineVL)+VI, ART/VL, and ART/VL+VI were highly cost-effective (<$1,000/DALY averted). In models excluding frequent VL monitoring and/or VI, PrEP-containing strategies remained cost-saving or highly cost-effective. SW-containing strategies were not cost-effective. Findings were robust in sensitivity analyses. Conclusions: ART/VL, PrEP, and VI offer economically efficient mechanisms to support safer conception in Zimbabwe and similar settings.