Cost-Effectiveness of Preventing Loss to Follow-up in HIV Treatment Programs: A Côte d'Ivoire Appraisal
Uhler, Lauren M.
Paltiel, A. David
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CitationLosina, Elena, Hapsatou Touré, Lauren M. Uhler, Xavier Anglaret, A. David Paltiel, Eric Balestre, Rochelle P. Walensky, et al. 2009. Cost-effectiveness of preventing loss to follow-up in HIV treatment programs: A Côte d'Ivoire appraisal. PLoS Medicine 6(10): e1000173.
AbstractBackground: Data from HIV treatment programs in resource-limited settings show extensive rates of loss to follow-up
(LTFU) ranging from 5% to 40% within 6 mo of antiretroviral therapy (ART) initiation. Our objective was to project the
clinical impact and cost-effectiveness of interventions to prevent LTFU from HIV care in West Africa.
Methods and Findings: We used the Cost-Effectiveness of Preventing AIDS Complications (CEPAC) International model to
project the clinical benefits and cost-effectiveness of LTFU-prevention programs from a payer perspective. These programs
include components such as eliminating ART co-payments, eliminating charges to patients for opportunistic infectionrelated
drugs, improving personnel training, and providing meals and reimbursing for transportation for participants. The
efficacies and costs of these interventions were extensively varied in sensitivity analyses. We used World Health
Organization criteria of ,36 gross domestic product per capita (36 GDP per capita = US$2,823 for Coˆ te d’Ivoire) as a
plausible threshold for ‘‘cost-effectiveness.’’ The main results are based on a reported 18% 1-y LTFU rate. With full retention
in care, projected per-person discounted life expectancy starting from age 37 y was 144.7 mo (12.1 y). Survival losses from
LTFU within 1 y of ART initiation ranged from 73.9 to 80.7 mo. The intervention costing US$22/person/year (e.g., eliminating
ART co-payment) would be cost-effective with an efficacy of at least 12%. An intervention costing US$77/person/year
(inclusive of all the components described above) would be cost-effective with an efficacy of at least 41%.
Conclusions: Interventions that prevent LTFU in resource-limited settings would substantially improve survival and would
be cost-effective by international criteria with efficacy of at least 12%–41%, depending on the cost of intervention, based on
a reported 18% cumulative incidence of LTFU at 1 y after ART initiation. The commitment to start ART and treat HIV in these
settings should include interventions to prevent LTFU.
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