Abstract
BackgroundIn sub-Saharan Africa, there is increasing mortality and morbidity of adolescents due to poor linkage, retention in HIV care and adherence to antiretroviral therapy (ART). This is a result of limited adolescent-centred service delivery interventions. This cost-effectiveness and feasibility study were piggybacked on a cluster-randomized trial that assessed the impact of an adolescent-centred service delivery intervention. The service delivery intervention examined the impact of an incentive scheme consisting of conditional economic incentives and motivational interviewing on the health outcomes of adolescents living with HIV in Nigeria.MethodA cost-effectiveness analysis from the healthcare provider’s perspective was performed to assess the cost per additional patient achieving undetected viral load through the proposed intervention. The cost-effectiveness of the incentive scheme over routine care was estimated using the incremental cost-effectiveness ratio (ICER), expressed as cost/patient who achieved an undetectable viral load. We performed a univariate sensitivity analysis to examine the effect of key parameters on the ICER. An in-depth interview was conducted on the healthcare personnel in the intervention arm to explore the feasibility of implementing the service delivery intervention in HIV treatment hospitals in Nigeria.ResultThe ICER of the Incentive Scheme intervention compared to routine care was US$1419 per additional patient with undetectable viral load. Going by the cost-effectiveness threshold of US$1137 per quality-adjusted life-years suggested by Woods et al., 2016, the intervention was not cost-effective. The sensitivity test showed that the intervention will be cost-effective if the frequency of CD4 count and viral load tests are reduced from quarterly to triannually. Healthcare professionals reported that patients’ acceptance of the intervention was very high.ConclusionThe conditional economic incentives and motivational interviewing was not cost-effective, but can become cost-effective if the frequency of HIV quality of life indicator tests are performed 1–3 times per annum. Patients’ acceptance of the intervention was very high. However, healthcare professionals believed that sustaining the intervention may be difficult unless factors such as government commitment and healthcare provider diligence are duly addressed.Trial registrationThis trial is registered in the WHO International Clinical Trials Registry through the WHO International Registry Network (PACTR201806003040425).
Highlights
In sub-Saharan Africa, there is increasing mortality and morbidity of adolescents due to poor linkage, retention in Human Immunodeficiency Virus (HIV) care and adherence to antiretroviral therapy (ART)
Healthcare professionals believed that sustaining the intervention may be difficult unless factors such as government commitment and healthcare provider diligence are duly addressed
Twelve hospitals were selected from HIV treatment hospitals in Anambra state that were registered by the National Agency for the Control of Acquired Immunodeficiency Syndrome (AIDS) (NACA) to render such services and were regarded as the clusters
Summary
In sub-Saharan Africa, there is increasing mortality and morbidity of adolescents due to poor linkage, retention in HIV care and adherence to antiretroviral therapy (ART). Previous studies showed that they had poor inclusion in care, poor knowledge of their HIV status, poor linkage to HIV care and poor retention in care compared to other age groups [2,3,4] All these have led to very poor adherence to antiretroviral therapy, lower rates of viral load suppression and an increase in HIV-related morbidity and mortality in the adolescent population worldwide [2]. These outcomes are worse in sub-Saharan Africa where more than eight out of every ten of the world’s ALHIV live [2]. Retention-in-care, helps patients to maintain high medication adherence, thereby achieving viral suppression, improving health outcomes, reducing individual and population costs and reducing the risk of horizontal transmission
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