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Cost-effectiveness of programmatic models for provision of antiretroviral therapy in resource-limited settings
Presented by Joseph Babigumira, United States.
J. Babigumira1, A. Sethi2, K. Smyth2, M. Singer2
1University of Washington, Pharmacy, Seattle, United States, 2Case Western Reserve University, Epidemiology, Cleveland, United States
Background: The current scale up and future sustainability of antiretroviral therapy (ART) in poor countries is limited by resource scarcity. 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). 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 cost-effective if the cost per additional QALY was less than $900, 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. 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 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.
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