The cost effectiveness of home-based provision of antiretroviral therapy in rural Uganda - PubMed (original) (raw)

Randomized Controlled Trial

The cost effectiveness of home-based provision of antiretroviral therapy in rural Uganda

Elliot Marseille et al. Appl Health Econ Health Policy. 2009.

Abstract

Background: Highly active antiretroviral therapy (HAART) provides dramatic health benefits for HIV-infected individuals in Africa, and widespread implementation of HAART is proceeding rapidly. Little is known about the cost and cost effectiveness of HAART programmes.

Objective: To determine the incremental cost effectiveness of a home-based HAART programme in rural Uganda.

Methods: A computer-based, deterministic cost-effectiveness model was used to assess a broad range of economic inputs and health outcomes. From the societal perspective, the cost effectiveness of HAART and cotrimoxazole prophylaxis was compared with cotrimoxazole alone, and with the period before either intervention. Data for 24 months were derived from a trial of home-based HAART in 1045 patients in the Tororo District in eastern Uganda. Costs and outcomes were projected out to 15 years. All costs are in year 2004 values. The main outcome measures were HAART programme costs, health benefits accruing to HAART recipients, averted HIV infections in adults and children and the resulting effects on medical care costs. The first-line HAART regimen consisted of standard doses of stavudine, lamivudine, and either nevirapine or, for patients with active tuberculosis, efavirenz. Second-line therapy consisted of tenofovir, didanosine and lopinavir/ritonavir. For children, first-line HAART consisted of zidovudine, lamivudine and nevirapine syrup; second-line therapy was stavudine, didanosine and lopinavir/ritonavir.

Results: The HAART programme, standardized for 1000 patients, cost an incremental US1.39millioninitsfirst2years.Comparedwithcotrimoxazoleprophylaxisalone,theprogrammereducedmortalityby87US1.39 million in its first 2 years. Compared with cotrimoxazole prophylaxis alone, the programme reduced mortality by 87%, and averted 6861 incremental disability-adjusted life-years (DALYs). Benefits were accrued from reduced mortality in HIV-infected adults (67.5% of all benefits), prevention of death in HIV-negative children (20.7%), averted HIV infections in adults (9.1%) and children (1.0%), and improved health status (1.7%). The net programme cost, including the medical cost implications of these health benefits, was US1.39millioninitsfirst2years.Comparedwithcotrimoxazoleprophylaxisalone,theprogrammereducedmortalityby87US4.10 million. The net cost per DALY averted was US597comparedwithcotrimoxazolealone.ManyHIVinterventionshaveacost−effectivenessratiointherangeofUS597 compared with cotrimoxazole alone. Many HIV interventions have a cost-effectiveness ratio in the range of US597comparedwithcotrimoxazolealone.ManyHIVinterventionshaveacost−effectivenessratiointherangeofUS1-150 per DALY averted.

Conclusions: This study suggests that a home-based HAART programme in rural Africa may be more cost effective than most previous estimates for facility-based HAART programmes, but remains less cost effective than many HIV prevention and care interventions, including cotrimoxazole prophylaxis.

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Conflict of interest statement

Conflict of Interest Statement

All authors declare that they have not conflicts of interest to declare. We will provide signed statements to that effect as needed.

Figures

Figure 1

Figure 1

Breakdown of HAART two-year program costs by major expenditure categories. Overhead and administration account for 11.1% of total costs, and have been allocated to each of the six categories shown. All incremental program costs are included such as the HAART-related portion of personnel, transportation and supplies associated with home visits.

Figure 2

Figure 2

Source of disability-adjusted life-years averted by HBAC clients, their HIV-negative children and future case prevented.

Figure 3

Figure 3

Univariate sensitivity analyses: Variation in incremental cost-effectiveness as the most influential variables assume values across the ranges specified in Table 1. The base case cost-effectiveness is $597 per DALY averted, which is obtained when input variables are at their 50- percentile (base case) value shown in Table 1.

Comment in

References

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