Below: Prevalence by job grade, 2003–2022, with workplace ART provision.
Job grade 1: unskilled worker; grades 2 and 3: semi-skilled worker; grades 4 and 5: skilled worker; grade 6: management.
Below: Total number of days absent due to HIV per CD4-cell-count-defined health state, 2003–2022
Below: Population model of changes within the workforce.
Recruits join the susceptible or infected (I) workforce depending on their HIV status at first employment. Employees move from the susceptible to the infected population according to prevalence and incidence. In the infected population, employees change between sub-populations representing different types of care (not tested, tested but not yet in care, wellness care, successful first- or second-line ART, and first-line or second-line treatment failure) according to coverage rates and, in case of treatment failure, to failure rates. Employees can drop out of care, i.e., be lost to retention, at any time and go back to the no care sub-population according to loss-to-retention rates; they can also leave the workforce for reasons related or unrelated to HIV (separations). Within each of the sub-populations, additional unidirectional changes due to ageing and promotion rates apply (not shown here); within each of the infected sub-populations, additional bi-directional changes due to transitions between CD4-cell-count-defined health states apply.
A dynamic health-state transition model, called the Workplace Impact Model (WIM), was parameterised with workplace data on workforce size, composition, turnover, HIV incidence, and CD4 cell count development. Bottom-up cost analyses from the employer perspective supplied data on inpatient and outpatient resource utilisation and the costs of absenteeism and replacement of sick workers. The model was fitted to workforce HIV prevalence and separation data while incorporating parameter uncertainty; univariate sensitivity analyses were used to assess the robustness of the model findings. As ART coverage increases from 10% to 97% of eligible employees, increases in survival and retention of HIV-positive employees and associated reductions in absenteeism and benefit payments lead to cost savings compared to a scenario of no treatment provision, with the annual cost of HIV to the company decreasing by 5% (90% credibility interval [CrI] 2%–8%) and the mean cost per HIV-positive employee decreasing by 14% (90% CrI 7%–19%) by 2022. This translates into an average saving of US$950,215 (90% CrI US$220,879–US$1.6 million) per year; 80% of these cost savings are due to reductions in benefit payments and inpatient care costs. Although findings are sensitive to assumptions regarding incidence and absenteeism, ART is cost-saving under considerable parameter uncertainty and in all tested scenarios, including when prevalence is reduced to 1%—except when no benefits were paid out to employees leaving the workforce and when absenteeism rates were half of what data suggested. Scaling up ART further through a universal test and treat strategy doubles savings; incorporating ART for family members reduces savings but is still marginally cost-saving compared to no treatment. Our analysis was limited to the direct cost of HIV to companies and did not examine the impact of HIV prevention policies on the miners or their families, and a few model inputs were based on limited data, though in sensitivity analysis our results were found to be robust to changes to these inputs along plausible ranges.
Workplace ART provision can be cost-saving for companies in high HIV prevalence settings due to reductions in healthcare costs, absenteeism, and staff turnover. Company-sponsored HIV counselling and voluntary testing with ensuing treatment of all HIV-positive employees and family members should be implemented universally at workplaces in countries with high HIV prevalence.
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