Modelling minimum resource requirements to reach Ending the HIV Epidemic (EHE) goal in KwaZulu-Natal, South Africa

Introduction: KwaZulu-Natal (KZN), South Africa’s provincial HIV epicentre with a prevalence of over 20%, strives to accelerate progress toward the global End the HIV Epidemic (EHE) 2030 goal. This modelling study aimed to maximize HIV prevention in KZN, given resource constraints. Methods: We performed allocative efficiency analyses (i.e. identifying the allocation of resources that maximizes benefits) with an HIV compartmental transmission model calibrated to HIV prevalence and incidence in KZN since 1990, under two perspectives, 1) “status quo,” building on 2022 funding and coverage levels and allocating additional resources, and 2) “perfect reallocation,” shifting resources toward more efficient interventions before allocating additional resources. Outcomes included infections averted, quality-adjusted life years added, time to reach the EHE goal, and annual programmatic costs. Results: With “status quo,” KZN will fall short of the 2030 EHE goal by approximately 500,000 infections, requiring additional annual expenditures of US$355 million across 11 interventions, from greatest to least efficiency: long-acting PrEP; HIV self-testing; DREAMS; index testing; VMMC; defaulter tracing; community-based testing; differentiated care; condom distribution, ART adherence support for detectable viral load; and oral PrEP. Alternatively, a “perfect reallocation” strategy that shifts funds from lower-efficiency to higher-efficiency interventions could avert 240,000 additional infections, narrowing the EHE gap by nearly half and reducing additional annual expenditures to US$344 million to close the gap. Conclusions: KZN will require additional resources to achieve its 2030 EHE goals, but strategic prioritization and reallocation toward more efficient interventions can maximize HIV prevention within resource constraints.