About

Gesine Meyer-Rath is a Research Professor at the Department of Global Health at Boston University School of Public Health. She is a physician and health economist working on the economics of HIV, TB, and COVID-19 in low- and middle-income countries. Her focus lies on modeling methods for economic evaluation, including infectious disease modeling and decision analysis, and translating research into recommendations for public policy. She holds a PhD in Health Economics from the London School of Hygiene and Tropical Medicine and an MD/PhD in Physiology from Free University Berlin. Before joining BUSPH, she worked in the Pediatrics Department of Charité University Hospital Berlin, at the World Health Organization, and at the London School of Hygiene and Tropical Medicine. She is based in Johannesburg, working at the Health Economics and Epidemiology Research Office (HE2RO), a collaboration between Boston University and the University of the Witwatersrand.

Selected publications

• Corrigendum to “A cost-effectiveness analysis of South Africa's COVID-19 vaccination programme” [Vaccine 42(20) (2024) 125988

  Vaccine · 2026-01-07

  articleOpen accessSenior author
  PublisherDOI

• The cost of the plunge: the impact and cost of a cessation of PEPFAR-supported services in South Africa

  AIDS · 2025-06-20 · 9 citations

  articleOpen access1st authorCorresponding

  BACKGROUND: Globally, shifts in United States foreign-aid policy have put HIV funding under duress. South Africa is unique in the region because its HIV program is largely domestically funded, although donor funds and partnerships support key components. We estimated the potential epidemiological impact of ceasing provision of services currently supported by PEPFAR and the costs and cost-effectiveness to the South African government (SAG) of potentially taking over these services. METHODS: We used a costed version of Thembisa, a South African HIV transmission model, to simulate four scenarios: a minimum scenario assuming intervention coverage reducing proportional to PEPFAR's funding share of specific activities in 2023; a maximum scenario assuming additional health system impacts; and sub-scenarios either with 3-year recovery (2029-2031) or no recovery to previous coverage. HIV program costs were estimated from the provider perspective (SAG) in 2024/25 US dollars. RESULTS: Over 2025-2028, discontinuing activities currently funded by PEPFAR in South Africa without replacement by SAG would result in 150 000-296 000 additional new HIV infections (29-56% increase) and 56 000-65 000 additional AIDS-related deaths (33-38%). Permanent discontinuation of currently PEPFAR-supported services over the next 20 years increases this to 1.1-2.1 million additional new HIV infections and 519 000-712 000 additional AIDS-related deaths. Sustaining these services would cost an additional $620 million to $1.4 billion between 2025 and 2028. Under a reduced budget, the most cost-effective interventions to preserve are ART and PrEP for key populations. CONCLUSION: Unmanaged PEPFAR exit from South Africa threatens to undo a decade of progress unless services are taken over by other funders, including SAG.

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• Evaluation of economic strengthening in South Africa and its impact on HIV, sexually transmitted infections, and teenage births: A modelling study

  PLoS Medicine · 2025-12-18 · 2 citations

  articleOpen accessSenior author

  BACKGROUND: High incidence rates of HIV, sexually transmitted infections (STIs), and teenage pregnancy are major challenges facing South Africa. The role of socio-economic factors in driving these incidence rates is complex, with high socio-economic status protecting against some risk behaviours (condomless sex, early sexual debut, and casual/transactional sex in females) but increasing other risk behaviours (e.g., male engagement in casual and commercial sex). We aimed to model the effect of socio-economic status, and associated economic strengthening interventions, in South Africa. METHODS AND FINDINGS: We extended a previously-developed agent-based model of HIV, STIs, and fertility in South Africa to assess effects of education, employment, and per capita household income on sexual behaviours. We estimated these effects from literature and from calibration of the model to African randomized controlled trials of economic strengthening interventions. Population attributable fractions (PAFs) were calculated. We considered three intervention types, all targeting households with log per capita income below the national average: school support to reduce school dropout; vocational training for unemployed adults; and unconditional cash transfers. We estimate that low socio-economic status accounted for 13% of new HIV infections, 7% of incident STIs (gonorrhoea, chlamydia, and trichomoniasis) and 31% of teenage births in South Africa, over 2000-2020. However, because of uncertainties regarding effect sizes, confidence intervals around these PAFs are wide (1,50% for HIV; -1,19% for STIs; and 10,76% for teenage births). Over 2025-2040, none of the interventions are estimated to reduce HIV, STIs, or teenage births significantly, due to limited impact on secondary economic outcomes. The greatest impact would be that of school support on teenage births (a 5% reduction, 95% CI: -1,12%). Key limitations include the assumption of uniform STI treatment access across socio-economic strata, and the exclusion of possible socio-economic effects at a community level. CONCLUSIONS: Although poverty is likely to be a significant driver of HIV, STIs, and teenage pregnancy in South Africa, precise quantification is challenging. Recently trialled economic strengthening interventions have insufficient impact on socio-economic status to reduce HIV and STIs significantly at a population level.

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• COST-EFFECTIVENESS OF DIFFERENT HPV VACCINATION STRATEGIES FOR CERVICAL CANCER PREVENTION IN SOUTH AFRICA

  International Journal of Gynecological Cancer · 2025-11-01

  article
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• Taking injectable PrEP to scale: Optimising the value of lenacapavir for South Africa’s HIV response

  medRxiv · 2025-12-15 · 1 citations

  articleOpen accessSenior author

  Abstract Background South Africa accounts for 20% of the global HIV infections and has one of the highest HIV incidence rates in the world. Six-monthly injectable lenacapavir (LEN) for HIV pre-exposure prophylaxis (PrEP) has superior efficacy to oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC), and similar efficacy to 2-monthly injectable cabotegravir (CAB). With LEN’s recent regulatory approval and the newly negotiated generic price of $40 per person per year, South Africa faces critical implementation decisions amid constrained domestic resources and reduced international funding. We evaluated the epidemiological impact on HIV infections and life years lost, cost-effectiveness, and optimal populations for LEN roll-out in South Africa. Methods and Findings Using Thembisa v4.8, a deterministic compartmental HIV transmission model of the South African HIV epidemic, we simulated the impact of LEN scale-up, expanded oral TDF/FTC, and CAB scale-up, compared to a baseline of current TDF/FTC provision over 20 years (2026-2045). We scaled PrEP among adolescent girls and young women (AGYW), female sex workers (FSW), pregnant and breastfeeding women (PBFW), men who have sex with men (MSM), and heterosexual men. For TDF/FTC scale-up, we doubled baseline initiation rates. For LEN and CAB, conservative and optimistic scenarios assumed initiation rates similar to or double those under TDF/FTC scale-up, respectively. Duration of use varied by subpopulation under TDF/FTC (3-6 months), conservative (LEN: 6-12 months, CAB: 4-8 months), and optimistic (LEN: 12-24 months, CAB: 8-16 months). We modelled strategies to maximise the impact of ~500,000 LEN doses currently allocated for 2026-2027, or large-scale roll-out. Costs are presented from the South African government’s perspective in undiscounted 2025 USD. Providing LEN to 1.7-2.9 million South Africans per year averted 19-31% of infections and saved 3-5% of life years anticipated to be lost to HIV, reaching incidence <0.1% in 2039-2043, 10-14 years earlier than baseline. Estimating the number of individuals needed to initiate each PrEP type to avert one HIV infection, LEN required 35-65 initiations/infection averted, compared to CAB (45-125 initiations/infection averted) and TDF/FTC (280 initiations/infection averted). TDF/FTC and conservative LEN scale-up increased HIV programme costs by 3%; however, LEN was more cost-effective, costing $2,301-$3,567/life year saved (LYS) versus $8,143/LYS (TDF/FTC scale-up) and $11,114-$16,118/LYS (CAB). Prioritising PBFW, MSM, and FSW for the initial allocation maximized infections averted. Large-scale roll-out strategies prioritizing FSW and MSM were most cost-effective ($276-$958/LYS). Limitations to this study include uncertainty in achieving modelled uptake and assumptions of risk-differentiated uptake of long-acting products, and limited data on real-world implementation costs. Interpretation Delivering LEN to persons with elevated HIV risk in South Africa is more cost-effective than existing PrEP options and can speed up HIV incidence reduction. Prioritising uptake among groups at highest risk is essential to maximise impact and cost-effectiveness.

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• The effectiveness, cost-effectiveness, budget impact, and return on investment of scaling up tuberculosis screening and preventive treatment in Brazil, Georgia, Kenya, and South Africa: a modelling study

  The Lancet Global Health · 2025-10-15 · 5 citations

  articleOpen access

  BACKGROUND: Closing the tuberculosis diagnostic gap and scaling up tuberculosis preventive treatment (TPT) are two global priorities to end tuberculosis. We aimed to estimate the cost-effectiveness, budget impact, and societal return on investment of a comprehensive intervention to improve tuberculosis screening and prevention in Brazil, Georgia, Kenya, and South Africa-four distinct epidemiological settings. METHODS: In this modelling study, in partnership with national tuberculosis programmes we defined a set of interventions (the intervention package) related to tuberculosis screening and TPT in three priority populations: people with HIV, household contacts, and a country-defined high-risk population (people deprived of liberty [Brazil], people accessing care for injection drug use [Georgia], people in informal settlements in nine districts with a high prevalence of tuberculosis [Kenya], and people in the 22 subdistricts with the highest prevalence of tuberculosis [South Africa]). We developed transmission models calibrated to country-specific epidemiology and collated cost data for tuberculosis-related activities and patient costs in 2023 US dollars (US$). We compared the intervention package scaled up to reach all priority populations by 2030 to a status quo scenario based on projected tuberculosis epidemiology over a 27-year time horizon (Jan 1, 2024, to Dec 31, 2050); to delineate the impact of intervention components, we also evaluated the intervention package without TPT. Outcomes were health system and societal costs, number of tuberculosis episodes, tuberculosis deaths, and disability-adjusted life years (DALYs). We calculated the budget impact, health system cost per DALY averted, and societal return on the health system investment for each country. Outcomes were discounted at 3% per annum. FINDINGS: With the status quo scenario, by 2050, tuberculosis incidence is projected to be 41 per 100 000 population (95% uncertainty range 32-53) in Brazil, 45 per 100 000 population (36-60) in Georgia, 214 per 100 000 population (146-266) in Kenya, and 261 per 100 000 population (133-406) in South Africa. The percentage of all tuberculosis episodes prevented by implementing the intervention package in all priority populations is projected to be 15·0% (12·8-17·5) in Brazil, 14·3% (13·1-15·8) in Georgia, 21·3% (15·2-27·6) in Kenya, and 26·4% (21·1-31·8) in South Africa by 2050. If implemented without TPT (ie, tuberculosis disease screening alone), corresponding reductions were lower at 10·4% (8·6-12·2) in Brazil, 10·2% (9·5-11·2) in Georgia, 12·6% (9·5-15·9) in Kenya, and 16·8% (13·0-20·4) in South Africa. In 2030, the percentage of the national tuberculosis programme budget required for the intervention package was 62% in Brazil, 10% in Georgia, 67% in Kenya, and 44% South Africa. The incremental cost per DALY averted of the intervention package compared with the status quo in all priority populations is $386 in Brazil, $491 in Georgia, $53 in Kenya, and $160 in South Africa. The corresponding societal return per health system dollar invested is projected to be $51 in Brazil, $8 in Georgia, $27 in Kenya, and $54 in South Africa. INTERPRETATION: Scaling up tuberculosis screening and TPT requires substantial investment but is projected to be cost-effective compared with the status quo, to greatly reduce tuberculosis incidence, and to provide large returns on investment. FUNDING: World Health Organization.

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• Reaching priority populations with different HIV self-testing distribution models in South Africa: an analysis of programme data

  BMC Infectious Diseases · 2025-02-25 · 3 citations

  articleOpen access

  BACKGROUND: As in much of sub-Saharan Africa, substantial HIV testing gaps remain in South Africa, particularly among adult men ages 20-35, young people ages 15-24 and key populations. Innovative strategies, such as HIV self-testing (HIVST), are needed to reach such under-served populations. We evaluated a range of HIV self-test kit distribution models' potential to reach adult men, young people and key populations in South Africa, to inform targeted approaches. METHODS: This cross-sectional study used data from community and facility-based HIV self-test kit distribution models implemented from October 2017 to April 2020. Self-test kits were distributed as part of the Unitaid-funded Self-Testing AfRica (STAR) programme. Data were collected from individuals who obtained self-test kits through five distribution models. Frequencies and proportions were used to describe the characteristics of the study populations and self-test kit distribution approaches. RESULTS: Over 2.5 years, 1 071 065 self-test kits were distributed across the five models. Community-based distribution accounted for 63% of total kits distributed, while the private sector (primarily workplace) accounted for 26%. Distribution at public sector health facilities accounted for 7% and distribution through the key population and secondary distribution models accounted for 2% each. Of those obtaining kits, and for whom we collected previous testing data (n = 771 612, 72%), 11% had never tested for HIV, 29% had not tested for at least a year, 41% had tested within the last 4-12 months and 19% had tested within the preceding three months. More men (64%) than women obtained self-test kits across all distribution models. The majority (80%) of men obtaining self-test kits were aged 20-40 years, and primarily received these at public transport terminals (36%), workplaces (18%) and hotspots (14%). A small proportion of men was reached through female sex workers. CONCLUSIONS: This analysis of programme data enabled us to identify HIV self-test kit distribution models that are best suited to reach specific priority and under-tested populations, particularly adult men and young people. Models/sub-models that reach self-test users where they live, work and spend time, are likely to result in higher HIVST uptake. Study findings can inform future HIVST scale-up in South Africa.

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• Cost-effectiveness of different HPV vaccination strategies for cervical cancer prevention in South Africa

  Vaccine · 2025-09-23 · 3 citations

  articleOpen access

  BACKGROUND: Most cervical cancers can be prevented by population-wide vaccination of pre-adolescent girls with highly efficacious HPV vaccines. In South Africa, first-dose coverage of bivalent HPV vaccination among girls aged 10 is ∼80 %. We investigated the additional impact and cost-effectiveness of different bivalent and nonavalent vaccination strategies among the general population and women with HIV (WHIV). METHODS: We used an individual-based, population-level model for HPV and HIV transmission in South Africa to estimate the epidemiological impact of HPV vaccination. The costs of interventions in the cervical cancer care cascade are estimated in 2024 USD based on resource use and prices obtained from research studies. To estimate cost-effectiveness of different bivalent strategies, we calculated the median cost per disability adjusted life-year averted (DALY) between 2024 and 2120 and compared it to an opportunity cost (OC) threshold of USD 3015. We calculated a threshold price at which nonavalent vaccination will be cost-effective in South Africa. RESULTS: Current interventions are projected to reduce age-standardised cervical cancer incidence from 54 to 12 per 100,000 women by 2120. Increasing girl-only bivalent coverage to 90 % would prevent an additional 5 % of cases and be cost-saving. Gender-neutral vaccination at 80 % coverage would yield similar impact, with a USD/DALY averted of USD 2782 compared to girls-only vaccination. Vaccinating WHIV up to age 45 could prevent 10 % of cervical cancer cases in this group and remains cost-effective. The nonavalent vaccine would be cost-effective if priced below USD 40 per dose. CONCLUSION: Enhanced HPV vaccination strategies-including higher coverage, gender-neutral programs, and targeted vaccination of WHIV-are cost-effective in South Africa. However, no vaccination strategy alone will reach elimination, which will require integrated approaches combining vaccination with cervical cancer screening and treatment.

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• Implementing oral (event-driven and daily) and long-acting pre-exposure prophylaxis in mobile men in sub-Saharan Africa: a phase 3b, open-label, hybrid type 2 implementation and effectiveness trial (MOBILE MEN)

  Trials · 2025-11-10 · 1 citations

  articleOpen access

  BACKGROUND: Men who are mobile for work are a key population at high risk of acquiring HIV. Flexible pre-exposure prophylaxis (PrEP) options, including event-driven (ED) oral PrEP and long-acting injectable cabotegravir (CAB-LA), may offer increased access and acceptability for these men. However, limited data exist on the effectiveness and implementation of CAB-LA and ED PrEP among mobile men in Africa. Our study aims to assess the effectiveness and implementation of CAB-LA and oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) (both daily and ED) through comparison of uptake, retention in care, coital coverage, and participant choice. METHODS: We will conduct a mixed0method, phase 3b, open-label, hybrid type 2 implementation and effectiveness randomised controlled trial (RCT). The trial will be carried out in 400 HIV-negative men aged 18 years or older in South Africa and Uganda. Men will be randomised 1:1 to either Group A: oral TDF/FTC PrEP (ED or daily) or Group B: CAB-LA over 9 months. After 9 months, participants from both groups will be offered a choice of PrEP (oral TDF/FTC or CAB-LA) for a further 9 months, with the ability to change their choice as required. Various strategies to support PrEP adoption, initiation, and persistence will be implemented, monitored, and reported on using a RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) implementation science framework. DISCUSSION: This study will provide critical data to inform scalable delivery models for both oral and injectable PrEP among mobile men at high risk for HIV acquisition. Findings will also highlight the potential of PrEP choice delivery and its benefits, offering evidence for governments to consider in the rollout of injectable PrEP in public health systems. Trial registration NCT06133686. Registered on 14 November 2023. PACTR202409632006463. Registered on 2 September 2024.

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• Breast Cancer Screening Using Clinical Breast Examination: A Cost-Effectiveness Analysis for South Africa

  Value in Health Regional Issues · 2025-05-27 · 1 citations

  articleOpen access

  OBJECTIVES: The World Health Organization emphasizes screening and early diagnosis to reduce advanced cancer incidence and mortality. In low-to-middle-income countries, breast cancer (BC) survival rates are low because of late detection. South Africa's policy recommends twice-yearly clinical breast examinations (CBEs) for asymptomatic women aged 40 to 69. We assessed the impact of scaling up CBE screening on mortality and cost-effectiveness. METHODS: Using trial data on downstaging, we compared the current baseline (5% coverage) with scenario 1 (25% coverage by year 5 [ie, 5% increase annually]) and scenario 2 (75% coverage by year 5, [ie, 17.5% increase annually]). A cohort model tracked women from screening to diagnosis, estimating downstaging's impact on BC cases over their lifetime. Costs from the healthcare payer's perspective are presented in 2022 US dollars. RESULTS: Five-year screen detection rates were 2.39 and 2.08 per 1000 women screened for scenarios 1 and 2, respectively. Scenario 1 reduced BC mortality by 0.7% and scenario 2 by 2.3%. Compared with no screening, the current baseline screening program averts 1645 disability-adjusted life years (DALYs) at $20 341/DALY averted. Scenario 1 averted 3823 DALYs with economic efficiency improving to $17 776/DALY averted, whereas scenario 2 averted 12 165 DALYs at $19 552/DALY averted. CONCLUSIONS: CBE scale-up effectively saves life years but is not cost-effective under the country's opportunity cost-derived threshold of $3015/DALY averted. However, decisions on the best screening policy are not solely based on cost-effectiveness. They involve careful consideration of budgetary constraints and competing healthcare priorities. Scale-up should consider system capacity, minimum care standards and cost-effective early detection strategies.

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