PLoS Med. 2009 Oct;6(10):e1000173. Epub 2009 Oct 27.
Cost-effectiveness of preventing loss to follow-up in HIV treatment programs: a Côte d'Ivoire appraisal.
Losina E,
Touré H,
Uhler LM,
Anglaret X,
Paltiel AD,
Balestre E,
Walensky RP,
Messou E,
Weinstein MC,
Dabis F,
Freedberg KA;
ART-LINC Collaboration of International Epidemiological Databases to Evaluate AIDS (IeDEA);
CEPAC International investigators.
Balestre E, Brinkhof M, Graber C, Keiser O, Seyler C, Touré H, Lewden C, Anastos K, Bangsberg D, Boulle A, Chisanga J, Delaporte E, Dickinson D, Ekong E, El Filali KM, Hosseinipour M, Kimaiyo S, Khongphatthanayothin M, Kumarasamy N, Laurent C, Luthy R, McIntyre J, Meade T, Messou E, Nash D, Mokaya WN, Pascoe M, Pepper L, Sow PS, Phiri S, Schechter M, Sidle J, Sprinz E, Tonwe-Gold B, Touré S, Van der Borght S, Weigel R, Wood R, Achmat Z, Bailey C, de Cock K, El-Sadr W, Freedberg K, Gayle H, Gilks C, Hankins C, Harries T, Katabira E, Sterne J, Wainberg M, Bender M, Chiosi J, Chu J, Chung S, Ciaranello A, Fofana MO, Freedberg KA, Hsu HE, Lu Z, Morris B, Morris B, Rhode E, Sloan C, Scott CA, Uhler L, Walensky RP, Losina E, Cotich K, Goldie SJ, Kimmel AD, Lipsitch M, Rydzak C, Seage GR 3rd, Weinstein MC, Yazdanpanah Y, Anglaret X, Salamon R, Danel C, N'Dri-Yoman T, Messou E, Moh R, Ouattara E, Touré S, Seyler C, Kumarasamy N, Ganesh AK, Wood R, Gray G, McIntyre J, Martinson NA, Mohapi L, Flanigan T, Mayer K, Paltiel AD.
Source
Division of General Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America.
Abstract
BACKGROUND:
Data from HIV treatment programs in resource-limited settings show extensive rates of loss to follow-up (LTFU) ranging from 5% to 40% within 6 mo of antiretroviral therapy (ART) initiation. Our objective was to project the clinical impact and cost-effectiveness of interventions to prevent LTFU from HIV care in West Africa.
METHODS AND FINDINGS:
We used the Cost-Effectiveness of Preventing AIDS Complications (CEPAC) International model to project the clinical benefits and cost-effectiveness of LTFU-prevention programs from a payer perspective. These programs include components such as eliminating ART co-payments, eliminating charges to patients for opportunistic infection-related drugs, improving personnel training, and providing meals and reimbursing for transportation for participants. The efficacies and costs of these interventions were extensively varied in sensitivity analyses. We used World Health Organization criteria of <3x gross domestic product per capita (3x GDP per capita = US$2,823 for Côte d'Ivoire) as a plausible threshold for "cost-effectiveness." The main results are based on a reported 18% 1-y LTFU rate. With full retention in care, projected per-person discounted life expectancy starting from age 37 y was 144.7 mo (12.1 y). Survival losses from LTFU within 1 y of ART initiation ranged from 73.9 to 80.7 mo. The intervention costing US$22/person/year (e.g., eliminating ART co-payment) would be cost-effective with an efficacy of at least 12%. An intervention costing US$77/person/year (inclusive of all the components described above) would be cost-effective with an efficacy of at least 41%.
CONCLUSIONS:
Interventions that prevent LTFU in resource-limited settings would substantially improve survival and would be cost-effective by international criteria with efficacy of at least 12%-41%, depending on the cost of intervention, based on a reported 18% cumulative incidence of LTFU at 1 y after ART initiation. The commitment to start ART and treat HIV in these settings should include interventions to prevent LTFU.
- PMID:
- 19859538
- [PubMed - indexed for MEDLINE]
- PMCID:
- PMC2762030
Free PMC ArticleFigure 2Sensitivity analysis on cost and efficacy of interventions to prevent LTFU with 18% baseline LTFU.
(A and B) Represent the cost-effectiveness of LTFU prevention strategies as a function of cost (columns) and efficacy (rows). (A) Illustrates the scenario where the cost of second-line ART is decreased to the cost of first-line ART (US$4.98/month, excluding patient co-payment). (B) Shows the scenario of stopping second-line ART after failure instead of continuing ineffective therapy. The light blue areas represent combinations of cost and efficacy of LTFU prevention strategies under each ART cost composition that ensure cost-effectiveness of LTFU strategies below 2× per capita GDP. The yellow area represents combinations of cost and efficacy of LTFU interventions that produce cost-effectiveness ratios between 2× and 3× per capita GDP. The red area represents scenarios where the cost-effectiveness ratios of LTFU interventions exceed 3× per capita GDP.
PLoS Med. PLoS Med;6(10):e1000173.
Figure 1Threshold efficacy, cost, and life expectancy associated with LTFU prevention interventions in Côte d'Ivoire.
This figure describes threshold efficacy for alternative willingness to pay thresholds, shown in blue (2× per capita GDP), green (3× per capita GDP), and orange (4× per capita GDP). Triangles represent efficacy thresholds for LTFU interventions at US$22/person/year, squares at US$41/person/year, circles at US$53/person/year, and diamonds at US$77/person/year. The vertical axis shows the per person discounted life expectancy and the horizontal axis shows the per person discounted lifetime cost. The red dot in the lower left corner represents the per person life expectancy and lifetime cost in a program with no LTFU intervention.
PLoS Med. PLoS Med;6(10):e1000173.
Figure 3Cost-effectiveness of interventions to prevent LTFU, stratified by intervention cost.
This figure shows the cost-effectiveness ratios of interventions ranging in efficacy from 10%–75%, stratified by cost (US$22, US$41, US$53, and US$77/person/year) and at cumulative incidences of LTFU ranging from 5%–40% over 1 y.
PLoS Med. PLoS Med;6(10):e1000173.
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