Abstract
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. 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%. 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.
Highlights
Antiretroviral therapy (ART) has been proven to be highly effective at reducing human immunodeficiency virus (HIV)/Acquired immunodeficiency syndrome (AIDS)-related morbidity and mortality in resource-limited settings [1,2,3,4,5]
Poor retention in HIV care can undermine the impact of scale-up, but can lead to overstating the performance of HIV programs, because individuals lost to follow-up are generally sicker than those who are retained in care and may experience poorer long-term outcomes than those who remain in care [19,20]
We examined the assumption that patients who were lost to follow-up re-enter care at the time of a severe opportunistic infection (OI) by considering that those lost to follow-up never re-enter care, that they re-enter care upon the occurrence of any OI, or that they re-enter with CD4 count,50/ ml
Summary
Antiretroviral therapy (ART) has been proven to be highly effective at reducing HIV/AIDS-related morbidity and mortality in resource-limited settings [1,2,3,4,5]. As a result of this scaling-up process, the number of HIV-infected persons treated with ART in subSaharan Africa increased from only 100,000 in 2003 to 2.1 million by the end of 2007—a 20-fold expansion over 4 y [7,8,9,10,11,12]. 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. About 33 million people are infected with the human immunodeficiency virus (HIV), which causes AIDS. According to World Health Organization (WHO) estimates, at least 9.7 million people in low- and middleincome countries need ART and as of 2007, 3 million of those people had reliable access to the drugs
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