Abstract
BackgroundA randomized trial demonstrated that among people living with late-stage human immunodeficiency virus (HIV) infection initiating antiretroviral therapy, screening serum for cryptococcal antigen (CrAg) combined with adherence support reduced all-cause mortality by 28%, compared with standard clinic-based care. Here, we present the cost-effectiveness.MethodsHIV-infected adults with CD4 count <200 cells/μL were randomized to either CrAg screening plus 4 weekly home visits to provide adherence support or to standard clinic-based care in Dar es Salaam and Lusaka. The primary economic outcome was health service care cost per life-year saved as the incremental cost-effectiveness ratio (ICER), based on 2017 US dollars. We used nonparametric bootstrapping to assess uncertainties and univariate deterministic sensitivity analysis to examine the impact of individual parameters on the ICER.ResultsAmong the intervention and standard arms, 1001 and 998 participants, respectively, were enrolled. The annual mean cost per participant in the intervention arm was US$339 (95% confidence interval [CI], $331–$347), resulting in an incremental cost of the intervention of US$77 (95% CI, $66–$88). The incremental cost was similar when analysis was restricted to persons with CD4 count <100 cells/μL. The ICER for the intervention vs standard care, per life-year saved, was US$70 (95% CI, $43–$211) for all participants with CD4 count up to 200 cells/μL and US$91 (95% CI, $49–$443) among those with CD4 counts <100 cells /μL. Cost-effectveness was most sensitive to mortality estimates.ConclusionsScreening for cryptococcal antigen combined with a short period of adherence support, is cost-effective in resource-limited settings.
Highlights
A randomised trial demonstrated that among late-stage HIV-infected patients initiating antiretroviral treatment (ART), screening serum for cryptococcal antigen (CrAg) combined with community -based adherence support reduced all-cause mortality by 28%, compared with standard clinicbased care
HIV-infected adults with CD4 count
The primary economic outcome was health service care cost per life year saved as the incremental cost-effectiveness ratio (ICER), based on 2017 US$
Summary
A randomised trial demonstrated that among late-stage HIV-infected patients initiating ART, screening serum for cryptococcal antigen (CrAg) combined with community -based adherence support reduced all-cause mortality by 28%, compared with standard clinicbased care. The intervention comprised i) screening for cryptococcal infection using serum cryptococcal antigen (CrAg) combined with pre-emptive fluconazole therapy for patients testing CrAg positive; and ii) weekly home visits for the first 4 weeks for patients on ART by trained lay workers to provide adherence support. This package was compared with standard care. At 12 months of follow-up, all cause mortality was 28% (95% confidence interval (CI): 11% 43%) lower in the intervention arm compared to that in the standard care arm
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