The Impact of Immediate Initiation of Antiretroviral Therapy on Patients' Healthcare Expenditures: A Stepped-Wedge Randomized Trial in Eswatini

Abstract

Immediate initiation of antiretroviral therapy (ART) for all people living with HIV has important health benefits but implications for the economic aspects of patients' lives are still largely unknown. This stepped-wedge cluster-randomized controlled trial aimed to determine the causal impact of immediate ART initiation on patients’ healthcare expenditures in Eswatini. Fourteen healthcare facilities were randomly assigned to transition at one of seven time points from the standard of care (ART eligibility below a CD4 count threshold) to the immediate ART for all intervention (EAAA). 2261 patients living with HIV were interviewed over the study period to capture their past-year out-of-pocket healthcare expenditures. In mixed-effects regression models, we found a 49% decrease (RR 0.51, 95% CI 0.36, 0.72, p < 0.001) in past-year total healthcare expenditures in the EAAA group compared to the standard of care, and a 98% (RR 0.02, 95% CI 0.00, 0.02, p < 0.001) decrease in spending on private and traditional healthcare. Despite a higher frequency of HIV care visits for newly initiated ART patients, immediate ART initiation appears to have lowered patients’ healthcare expenditures because they sought less care from alternative healthcare providers. This study adds an important economic argument to the World Health Organization’s recommendation to abolish CD4-count-based eligibility thresholds for ART.

Effect of universal HIV testing and treatment on socioeconomic wellbeing in rural Kenya and Uganda: a cluster-randomised controlled trial

“…These findings are in slight contrast to a stepped-wedge trial in Eswatini which found that immediate initiation of ART reduced health-care expenditures but had no shortterm improvement on employment. 32,33 Overall, our results suggest that the considerable investments needed to expand access to ART might have significant shortterm and long-term economic returns.…”

“…Our study builds upon the existing literature that has shown large and significant increases in employment and income following ART initiation. [8][9][10]17,18,32,33 However, with the exception of one study that evaluated economic outcomes of people living with HIV and their household members, relatively few of these studies have used a cluster-randomised trial design to evaluate the effects of early ART initiation on socioeconomic outcomes. Our results support the hypothesis that earlier ART initiation can protect employment and other economic indicators for adults and lead to benefits in children's education.…”

Out-of-pocket Expenses and Time Spent on Clinic Visits Among HIV Pre-exposure Prophylaxis Users and Other Clinic Attendees in Eswatini

“…The final sample size was determined by pragmatic aspects such as the availability of a research assistant on a scheduled study day and the travel time to a clinic. Tablet-assisted personal interviews were conducted based on a self-developed questionnaire with new, adapted, and previously used questions [ 30 , 31 ] (Supplement A). The interview included questions about different categories of OOPE, the arrival time at the clinic, travel time to the clinic, forgone earning opportunities, and lost income.…”

Traditional healers’ knowledge and infection control practices related to HIV in Bukavu City, Democratic Republic of the Congo

“…Early HIV diagnosis and prompt treatment are critical for improving HIV treatment outcomes [ 4 ], lowering the cost of medical care [ 5 ], and significantly impacting disease prevention [ 6 – 9 ].…”