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Cost-effectiveness of a combination strategy to enhance the HIV care continuum in Swaziland: Link4Health

Author

Listed:
  • Elizabeth R Stevens
  • Lingfeng Li
  • Kimberly A Nucifora
  • Qinlian Zhou
  • Margaret L McNairy
  • Averie Gachuhi
  • Matthew R Lamb
  • Harriet Nuwagaba-Biribonwoha
  • Ruben Sahabo
  • Velephi Okello
  • Wafaa M El-Sadr
  • R Scott Braithwaite

Abstract

Introduction: Link4Health, a cluster-RCT, demonstrated the effectiveness of a combination strategy targeting barriers at various HIV continuum steps on linkage to and retention in care; showing effectiveness in achieving linkage to HIV care within 1 month plus retention in care at 12 months after HIV testing for people living with HIV (RR 1.48, 95% CI 1.19–1.96, p = 0.002). In addition to standard of care, Link4Health included: 1) Point-of-care CD4+ count testing; 2) Accelerated ART initiation; 3) Mobile phone appointment reminders; 4) Care and prevention package including commodities and informational materials; and 5) Non-cash financial incentive. Our objective was to evaluate the cost-effectiveness of a scale-up of the Link4Health strategy in Swaziland. Methods and findings: We incorporated the effects and costs of the Link4Health strategy into a computer simulation of the HIV epidemic in Swaziland, comparing a scenario where the strategy was scaled up to a scenario with no implementation. The simulation combined a deterministic compartmental model of HIV transmission with a stochastic microsimulation of HIV progression calibrated to Swaziland epidemiological data. It incorporated downstream health costs potentially saved and infections potentially prevented by improved linkage and treatment adherence. We assessed the incremental cost-effectiveness ratio of Link4Health compared to standard care from a health sector perspective reported in US$2015, a time horizon of 20 years, and a discount rate of 3% in accordance with WHO guidelines.[1] Our results suggest that scale-up of the Link4Health strategy would reduce new HIV infections over 20 years by 11,059 infections, a 7% reduction from the projected 169,019 cases and prevent 5,313 deaths, an 11% reduction from the projected 49,582 deaths. Link4Health resulted in an incremental cost per infection prevented of $13,310 and an incremental cost per QALY gained of $3,560/QALY from the health sector perspective. Conclusions: Using a threshold of

Suggested Citation

  • Elizabeth R Stevens & Lingfeng Li & Kimberly A Nucifora & Qinlian Zhou & Margaret L McNairy & Averie Gachuhi & Matthew R Lamb & Harriet Nuwagaba-Biribonwoha & Ruben Sahabo & Velephi Okello & Wafaa M E, 2018. "Cost-effectiveness of a combination strategy to enhance the HIV care continuum in Swaziland: Link4Health," PLOS ONE, Public Library of Science, vol. 13(9), pages 1-17, September.
    • Handle: RePEc:plo:pone00:0204245
    DOI: 10.1371/journal.pone.0204245
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    References listed on IDEAS

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    1. Martin W G Brinkhof & Mar Pujades-Rodriguez & Matthias Egger, 2009. "Mortality of Patients Lost to Follow-Up in Antiretroviral Treatment Programmes in Resource-Limited Settings: Systematic Review and Meta-Analysis," PLOS ONE, Public Library of Science, vol. 4(6), pages 1-9, June.
    2. Missaka Warusawitharana, 2014. "The Social Discount Rate in Developing Countries," FEDS Notes 2014-10-09, Board of Governors of the Federal Reserve System (U.S.).
    3. Margaret L McNairy & Matthew R Lamb & Averie B Gachuhi & Harriet Nuwagaba-Biribonwoha & Sean Burke & Sikhathele Mazibuko & Velephi Okello & Peter Ehrenkranz & Ruben Sahabo & Wafaa M El-Sadr, 2017. "Effectiveness of a combination strategy for linkage and retention in adult HIV care in Swaziland: The Link4Health cluster randomized trial," PLOS Medicine, Public Library of Science, vol. 14(11), pages 1-20, November.
    4. Alastair Heffernan & Ella Barber & Ranjeeta Thomas & Christophe Fraser & Michael Pickles & Anne Cori, 2016. "Impact and Cost-Effectiveness of Point-Of-Care CD4 Testing on the HIV Epidemic in South Africa," PLOS ONE, Public Library of Science, vol. 11(7), pages 1-12, July.
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