Academic journal article Applied Health Economics and Health Policy

The Cost Effectiveness of Home-Based Provision of Antiretroviral Therapy in Rural Uganda

Academic journal article Applied Health Economics and Health Policy

The Cost Effectiveness of Home-Based Provision of Antiretroviral Therapy in Rural Uganda

Article excerpt

Background

Highly active antiretroviral therapy (HAART) offers benefits for HIV-infected patients in resource-poor countries that are similar to those reported for industrialized countries. These include reductions in viral load, increases in CD4 cells, reduced incidence of opportunistic infections, decreased mortality, and improvements in well-being and functioning.[1-6] A 3-year, home-based HAART trial in rural Uganda demonstrated the feasibility of achieving excellent health outcomes in a rural African setting.[1]

In response to worldwide demand and increased funding, implementation of HAART is proceeding rapidly in the developing world, particularly in sub-Saharan Africa.[2] The expansion of both treatment and prevention activities is a major development in the global response to HIV/AIDS, and HAART provision is a unique global expansion of resource-intensive disease management. In addition to immediate health benefits, HAART provides an opportunity for long-term enhancement of health system capacity.

Understanding the cost and cost effectiveness of HAART in Africa is important during this period of programme expansion,[3] to assist in the development and refinement of operational plans that minimize the cost of meeting programme goals. More importantly, cost-effectiveness data can help policy makers allocate resources among an increasing range of prevention, treatment and care options. Indeed, the commitment to treatment reinforces the imperative for effective prevention. Without it, access to treatment may become more expensive over time, as newly infected people are added to the millions already receiving life-time HAART. Cost-effectiveness data can shed light on the opportunity cost of various allocation options considered by health policy makers in HIV-affected African countries and by major donors, such as the President's Emergency Fund for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis (TB) and Malaria.

Several cost studies have been completed in Africa,[4-10] as well as four cost-effectiveness studies on facility-based HAART services.[11-14] Two of these compared HAART with no intervention.[12,13] However, the appropriate comparison may be with other effective and available care interventions, such as trimethoprim-sulfamethoxazole (cotrimoxazole) prophylaxis. One study found that HAART was cost saving in patients with AIDS due to savings in hospitalization and other health expenditures, and cost $US675 per life-year gained for non-AIDS patients.[12] Another found that HAART cost $US1631 per QALY gained for all treated HIV patients.[13] A third study that ranked the incremental cost effectiveness of HAART against an array of other HIV prevention and treatment options found an incremental cost ranging from international dollars (I$)547 to I$5175 per disability-adjusted life-year (DALY) averted.[11] The 10-fold range of results in this study was due to the multiple incremental programme options considered, in which the addition of each successively more costly programme element raised incremental costs faster than it raises incremental benefits. Finally, a study using a modification of a previously published simulation model predicted disease progression and treatment costs as a function of CD4 cell counts and viral loads in a Côte d'Ivoire cohort. This study, which also incorporated appropriate incremental comparisons, found that HAART cost $US620 per life-year gained compared with cotrimoxazole prophylaxis when initiated without CD4 testing, and $US1180 per life-year gained if the HAART initiation decision incorporated CD4 test results.[14]

This article assesses the cost and cost effectiveness of HAART when added to a package of home-based care provided in a rural district in eastern Uganda (i.e. HAART plus cotrimoxazole prophylaxis vs cotrimoxazole alone).

Methods

Setting

Eastern Uganda, the region that provided a large majority of study patients, is an impoverished rural area in which agriculture is the main occupation of 90. …

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