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

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.