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The cost effectiveness of home-based provision of antiretroviral therapy in rural Uganda

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Abstract

Background

Highly active antiretroviral therapy (HAART) provides dramatic health benefits for HIV-infected individuals in Africa, and widespread implementation of HAART is proceeding rapidly. Little is known about the cost and cost effectiveness of HAART programmes.

Objective

To determine the incremental cost effectiveness of a home-based HAART programme in rural Uganda.

Methods

A computer-based, deterministic cost-effectiveness model was used to assess a broad range of economic inputs and health outcomes. From the societal perspective, the cost effectiveness of HAART and cotrimoxazole prophylaxis was compared with cotrimoxazole alone, and with the period before either intervention. Data for 24 months were derived from a trial of home-based HAART in 1045 patients in the Tororo District in eastern Uganda. Costs and outcomes were projected out to 15 years. All costs are in year 2004 values. The main outcome measures were HAART programme costs, health benefits accruing to HAART recipients, averted HIV infections in adults and children and the resulting effects on medical care costs.

The first-line HAART regimen consisted of standard doses of stavudine, lamivudine, and either nevirapine or, for patients with active tuberculosis, efavirenz. Second-line therapy consisted of tenofovir, didanosine and lopinavir/ritonavir. For children, first-line HAART consisted of zidovudine, lamivudine and nevirapine syrup; second-line therapy was stavudine, didanosine and lopinavir/ritonavir.

Results

The HAART programme, standardized for 1000 patients, cost an incremental $US1.39 million in its first 2 years. Compared with cotrimoxazole prophylaxis alone, the programme reduced mortality by 87%, and averted 6861 incremental disability-adjusted life-years (DALYs). Benefits were accrued from reduced mortality in HIV-infected adults (67.5% of all benefits), prevention of death in HIV-negative children (20.7%), averted HIV infections in adults (9.1%) and children (1.0%), and improved health status (1.7%). The net programme cost, including the medical cost implications of these health benefits, was $US4.10 million. The net cost per DALY averted was $US597 compared with cotrimoxazole alone. Many HIV interventions have a cost-effectiveness ratio in the range of $US1-150 per DALY averted.

Conclusions

This study suggests that a home-based HAART programme in rural Africa may be more cost effective than most previous estimates for facility-based HAART programmes, but remains less cost effective than many HIV prevention and care interventions, including cotrimoxazole prophylaxis.

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Acknowledgements

The authors contributed to this study in the following ways. Elliot Marseille (first author): concept, design, parameter estimation, literature review, analysis and writing; Dr Marseille had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis; James G. Kahn: concept, design, parameter estimation, analysis and writing; Rebecca Bunnell: concept, design, parameter estimation, analysis and writing; Christian Pitter: concept, design, parameter estimation, analysis and writing; William Epalatai: parameter estimation, analysis and revision; Emmanuel Jawe: parameter estimation, analysis and revision; Willy Were: parameter estimation, analysis and revision; and Jonathan Mermin: concept, design, parameter estimation, analysis and writing.

No ethical approval was required for this research.

Funding was provided by the US Centers for Disease Control and Prevention (CDC) and the Agency for International Development through the President’s Emergency Plan for AIDS Relief. Only CDC staff and consultants on contract to CDC were involved in the study design and implementation, data analysis, and writing of the manuscript. The corresponding author had full access to all data in the study and takes final responsibility for the decision to submit the paper for publication. The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the CDC.

The authors have no conflicts of interest that are directly relevant to the content of this study.

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Authors and Affiliations

  1. Health Strategies International, 555 59th Street, Oakland, CA, 94609, USA

    Elliot Marseille

  2. Super Models for Global Health, and the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA

    James G. Kahn

  3. Elizabeth Glaser Pediatric Aids Foundation, Washington, DC, USA

    Christian Pitter

  4. Global AIDS Program, National Center for HIV, STD and TB Prevention, CDC-Kenya, Nairobi, Kenya

    Rebecca Bunnell & Jonathan Mermin

  5. Global AIDS Program, CDC-Uganda, Entebbe, Uganda

    William Epalatai, Emmanuel Jawe & Willy Were

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  1. Elliot Marseille
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Correspondence to Elliot Marseille.

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Marseille, E., Kahn, J.G., Pitter, C. et al. The cost effectiveness of home-based provision of antiretroviral therapy in rural Uganda. Appl Health Econ Health Policy 7, 229–243 (2009). https://doi.org/10.1007/BF03256157

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