Transmission reduction, health benefits, and upper-bound costs of interventions to improve retention on antiretroviral therapy: a combined analysis of three mathematical models

Bershteyn, Anna; Jamieson, Lise; Kim, Hae-Young; Platais, Ingrida; Milali, Masabho; Mudimu, Edinah; Brink, Debra ten; Martin-Hughes, Rowan; Kelly, Sherrie L; Phillips, Andrew; Bansi‐Matharu, Loveleen; Cambiano, Valentina; Revill, Paul; Meyer‐Rath, Gesine; Nichols, Brooke E

doi:10.1016/s2214-109x(22)00310-2

Cited by 9 publications

(8 citation statements)

References 33 publications

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“…However, retention efforts at the MPC are lower, or far lower, than those reported previously, suggesting cost efficiency. For example, a recent costing study of three HIV retention models in SSA found that improving ART retention by 25% could cost between $93 and $6518/client [ 8 ]. These retention costs pose sustainability challenges.…”

Section: Discussionmentioning

confidence: 99%

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How much does it cost to retain antiretroviral therapy (ART) clients in care? Routine financial costs of retention interventions at Lighthouse Trust’s Martin Preuss Centre (MPC) in Lilongwe, Malawi

Weldemariam,

Thawani,

Kiruthu-Kamamia

et al. 2023

Preprint

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Introduction Antiretroviral therapy (ART) improves the health of people living with HIV (PLHIV). However, a high loss to follow-up, particularly in the first year after ART initiation, is problematic. The financial expenses related to client retention in low- and middle-income countries (LMICs) in sub-Saharan Africa are not well understood. This study aimed to comprehensively assess and quantify the financial costs associated with routine ART retention care at Lighthouse Trust’s (LT) Martin Preuss Centre (MPC), a large, public ART clinic in Lilongwe, Malawi. Methods We performed activity-based microcosting using routine data to assess the expenses related to routine ART retention services at the MPC for 12 months, January-December 2021. MPC provides an “ART Buddy” from ART initiation to 12 months. The MPC’s Back-to-Care (B2C) program traces clients who miss ART visits at any time. Clients may be traced and return to care multiple times per year. We assessed client retention costs for the first 12 months of treatment with ART and conducted a sensitivity analysis. Results The total annual cost of ART retention interventions at the MPC was $237,564. The proactive Buddy phase incurred $108,504; personnel costs contributed $97,764. In the reactive B2C phase, the total cost was $129,060, with personnel expenses remaining substantial at $73,778. The Buddy unit cost was $34 per client. The reactive B2C intervention was $17 per tracing event. On average, the unit cost for ART retention in the first year of ART averaged $22 per client. Conclusion This study sheds light on the financial dimensions of ART retention interventions at the MPC of LTs. ART retention is both costly and critical for helping clients adhere to visits and remain in care. Continued investment in the human resources needed for both proactive and reactive retention efforts is critical to engaging and retaining patients on lifetime ART.

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Section: Discussionmentioning

confidence: 99%

“…Estimates across sub-Saharan Africa (SSA) report an average of 65% retained in care at 36 months [ 3 , 7 ]. Despite the critical importance of client retention, only a few studies have explored the costs of retaining clients in routine ART care in low- and middle-income countries (LMICs) in the SSA [ 8 – 13 ].…”

Section: Introductionmentioning

confidence: 99%

How much does it cost to retain antiretroviral therapy (ART) clients in care? Routine financial costs of retention interventions at Lighthouse Trust’s Martin Preuss Centre (MPC) in Lilongwe, Malawi

Weldemariam,

Thawani,

Kiruthu-Kamamia

et al. 2023

Preprint

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“…We configured the EMOD model to fit demographic and HIV trends in western Kenya, South Africa and Zimbabwe using setting-specific census, fertility, and mortality estimates as well as HIV prevalence, incidence and ART coverage ( 24 – 26 ). Kenya has a very wide range of HIV prevalence, from <0.1% in eastern regions to >25% in its western regions ( 27 ).…”

Section: Methodsmentioning

confidence: 99%

Cost-effectiveness of the dual prevention pill for contraception and HIV pre-exposure prophylaxis

Milali

Resar

Kaftan

et al. 2023

Front. Reprod. Health

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IntroductionWomen in sub-Saharan Africa (SSA) experience the world's highest rates of both HIV infection and unintended pregnancy. The Dual Prevention Pill (DPP) is a novel multipurpose prevention technology (MPT) that co-formulates HIV pre-exposure prophylaxis (PrEP) and combined hormonal oral contraception into a single daily pill. As a dual indication product, the DPP may be preferred by women facing these overlapping health risks. However, most SSA countries face severe healthcare resource constraints. Research is needed to assess whether, in what populations, and in what use cases the DPP would be cost-effective.MethodsWe augmented an agent-based SSA HIV model with maternal health parameters including unintended pregnancy, abortion, and maternal mortality. Based on a previous market analysis, we assumed a primary DPP user population of current oral contraceptive users ages 25–49, and alternative user populations in different risk groups (age 15–24, sex workers, HIV-serodiscordant couples) and baseline product use profiles (unmet need for contraception, oral PrEP use, condom use). In three geographies (western Kenya, Zimbabwe, South Africa), we estimated HIV infections averted, pregnancies averted, disability-adjusted life-years (DALYs) averted, and the incremental cost-effectiveness ratio (ICER) over a 30-year time horizon, assuming equivalent adherence to the DPP as to oral contraceptives, higher adherence, or lower adherence.ResultsThe DPP is likely to be a cost-effective alternative to oral PrEP among users in need of contraception. Among women not already using PrEP, the DPP is likely to be cost-saving in sex workers and serodiscordant couples. The DPP is unlikely to be cost-effective in oral contraceptive users in the general population. Switching from oral contraception to the DPP could be net harmful in some settings and populations if it were to substantially reduces adherence to oral contraception. Results were robust to a range of time horizons or discount rates.ConclusionThe DPP has the potential to be cost-effective and cost-saving in populations at substantial HIV risk. Outcomes are sensitive to adherence, implying that effective counseling and decision-making tools for users considering the DPP will be essential. More research is needed to understand real-life adherence patterns and ensure health benefits achieved from contraception alone are not lost.

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“…Most efforts to address LTFU are reactive, waiting for clients to miss visits before intervening, resulting in tracing delays that reduce the likelihood of finding, returning, and retaining clients in care [5, 6]. Addressing retention gaps is costly, often relying on healthcare workers (HCWs) to call or trace clients identified as LTFU in-person [7]. Recent reductions in global funding, chronic shortages of HCWs, and increasing client volumes exacerbate retention challenges.…”

Section: Introductionmentioning

confidence: 99%

The effect of proactive, interactive, two-way texting on 12-month retention in antiretroviral therapy: findings from a quasi-experimental study in Lilongwe, Malawi

Feldacker,

Klabbers,

Huwa

et al. 2024

Preprint

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Background: Retaining clients on antiretroviral therapy (ART) is challenging especially during the first year on ART. Mobile health (mHealth) interventions show promise to close retention gaps. We aimed to assess reach (who received the intervention?) and effectiveness (did it work?) of a hybrid two-way texting (2wT) intervention to improve ART retention at a large public clinic in Lilongwe, Malawi. Methods: Between August 2021 - June 2023, a quasi-experimental study compared outcomes between two cohorts of new ART clients: 1) those opting into 2wT with combined automated, weekly motivation short messaging service (SMS) messages and response-requested appointment reminders; and 2) a matched historical cohort receiving standard of care (SoC). Reach was defined as “the proportion clients ≤6 months of ART initiation eligible for 2wT”. 2wT effectiveness was assessed in time-to-event analysis comparing Kaplan-Meier plots of 6- and 12-month retention between 2wT and SoC using a log-rank test. The effect of 2wT on ART drop out was estimated using multivariable Cox proportional hazard models, adjusting for sex, age and WHO stage at ART initiation. Results: Of the 1,146 clients screened, 645 were ineligible (56%) largely due to lack of phone access (393/645; 61%) and illiteracy (149/645; 23%): a reach of 44%. Among 468 2wT participants, the 12-month probability of ART retention was 91% (95%CI: 88% - 93%) compared to 75% (95%CI: 71% - 79%) among 468 SoC participants (p<0.0001). Compared to SoC participants, 2wT participants had a 62% lower hazard of dropping out of ART care at all time points (hazard ratio 0.38, 95% CI: 0.26-0.54; p<0.001). Conclusions: Not all clients were reached with 2wT. For those who opted-in, 2wT reduced drop out throughout the first year on ART and significantly increased 12-month retention. The proactive 2wT approach should be expanded as a complement to other interventions in routine, low-resource settings to improve ART retention.

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Transmission reduction, health benefits, and upper-bound costs of interventions to improve retention on antiretroviral therapy: a combined analysis of three mathematical models

Cited by 9 publications

References 33 publications

How much does it cost to retain antiretroviral therapy (ART) clients in care? Routine financial costs of retention interventions at Lighthouse Trust’s Martin Preuss Centre (MPC) in Lilongwe, Malawi

How much does it cost to retain antiretroviral therapy (ART) clients in care? Routine financial costs of retention interventions at Lighthouse Trust’s Martin Preuss Centre (MPC) in Lilongwe, Malawi

Cost-effectiveness of the dual prevention pill for contraception and HIV pre-exposure prophylaxis

The effect of proactive, interactive, two-way texting on 12-month retention in antiretroviral therapy: findings from a quasi-experimental study in Lilongwe, Malawi

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