13HIV COST-EFFECTIVENESS OF PROGRAMMATIC MODELS FOR PROVISION OF ANTIRETROVIRAL THERAPY IN RESOURCE-LIMITED SETTINGS

Tuesday, October 21, 2008
Columbus A-C (Hyatt Regency Penns Landing)
Joseph B. Babigumira, MBChB, MS1, Ajay K. Sethi, PhD, MHS2, Kathleen A. Smyth, PhD2 and Mendel E. Singer, PhD2, (1)University of Washington, Seattle, WA, (2)Case Western Reserve University School of Medicine, Cleveland, OH
Purpose: The current scale up and future sustainability of antiretroviral therapy (ART) in poor countries is limited by scarcity of resources. The objective of this study was to compare the cost-effectiveness of different programmatic models for provision of ART to adults with AIDS in this setting. Methods: We used a decision analytic Markov model to follow a hypothetical cohort of adult Ugandans with WHO clinical stage 3 and 4 AIDS living in rural areas. We compared the cost-effectiveness, from the perspective of the Ministry of Health, of three programmatic models of ART provision: facility-based care (FBC), mobile clinic care (MCC), and home-based care (HBC).  The Markov model was used to represent patient transitions over time from one health state to another.  The model had seven states: stages 3 and 4 AIDS while adherent or non-adherent with ART, not on ART, and dead. The Markov cycle time was 1 year.  Data were obtained from a combination of primary quality of life surveys and literature review. Outcome measures included cost, life expectancy and the incremental cost-effectiveness ratio (ICER) measured as cost per quality-adjusted life-year (QALY) gained. A 10-year time horizon was employed. An intervention was considered to be cost-effective if the cost per additional QALY was less than $900, which is approximately 3 times the annual per-capita GDP. One-way sensitivity analysis was performed on all parameters. A 3% annual discount rate was applied. Results: Mean total cost was $1,962 for FBC, $3,724 for MCC and $6,220 for HBC.  The life expectancy was 4.05 years for the FBC, 5.25 years for the MCC and 6.72 years for HBC. The ICER for MCC was $2,105 per QALY and the ICER for HBC was 2,415 per QALY.  HBC was cost-effective only under conditions of substantially greater access or sharply reduced first year costs. Conclusion: Facility-based care was the most cost-effective. The analysis supports the implementation of FBC for rapid scale up and long-term sustainability of ART in resource-limited settings given the need for constrained maximization in the face of extreme budget constraints. Other care models will need to demonstrate markedly superior access or adherence, and/or heavily reduced cost to become competitive.