Investing in the education of the children of parents on antiretroviral therapy may be an efficient way to retain people in care

Cost-effectiveness of socioeconomic support as part of HIV care for the poor in an urban community-based antiretroviral program in Uganda.

Stella-Talisuna A, Bilcke J, Colebunders R, Beutels P. J Acquir Immune Defic Syndr. 2014 Oct 1;67(2):e76-83. doi: 10.1097/QAI.0000000000000280.

Background: Socioeconomic support reduced nonretention in a community-based antiretroviral therapy (ART) program in Uganda. However, resource implications of expanding socioeconomic support are large, and cost-effectiveness analysis can inform budget priorities. We compared the incremental benefits and costs of providing education, food, or both forms of support (dual support) with existing ART services from a health care provider's perspective.

Methods: Costs and outcome data were collected from a cohort of 2371 adult patients with HIV receiving education, food, or dual support from Reach Out Mbuya between 2004 and 2010. The primary outcome was averted loss to follow-up. The number of follow-up days was calculated for each patient along with accrued service and fixed program costs for the alternative forms of socioeconomic support in USD by standard costing methods. The socioeconomic support types were compared incrementally over the study period.

Results: After 7 years, 762 (33%) of the patients were loss to follow-up with 42% of them receiving food. In the presence of providing ART, education support was less costly and more effective than the alternatives. The average unit cost for education, food, and dual support were $237, $538, and $776, respectively. The average total annual costs were $88 643 for education, $538 005 for food, and $103 045 for dual support.

Conclusions: Compared with food or dual support, investing in education of the children of ART patients is less costly and more effective in improving patient retention. Reach Out Mbuya should embrace this paradigm shift and channel its resources more efficiently and effectively by focusing on education support.

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Editor’s notes: The importance of socioeconomic factors for the initiation and retention of people in antiretroviral therapy (ART) is increasingly recognised. Programmes are adopting various approaches to improve retention. This study considers the technical efficiency of socioeconomic support provided in an NGO, Reach Out Mbuya’s, ART programme in Uganda over a significant period of time (2004-2010). It estimates the costs of food support for food-insecure ART individuals and their households, education support for the children of people on ART, and dual support. By comparing these costs to the number of cases of loss-to-follow-up averted by each support package, it analyses which support would be most cost-efficient. This is a useful starting point when considering what socioeconomic support to provide ART individuals, and specifically what would be most affordable. The study does not adjust for the different patient mix in the different programme categories, making it difficult to compare their outcomes. Indeed, it is highly likely that the people receiving food and dual support were also the most vulnerable and the most likely to be lost to follow-up. Nonetheless, the high costs estimated for direct food support raise concerns for programme scale up and sustainability. This suggests that education support may be better value for money from the perspective of retention in ART care. The potential spill-over benefits for household economic well-being, child survival and school attendance were not captured and may improve the economic case for food support, as a broader development programme with multiple objectives.

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