Cost and effectiveness of differentiated ART service delivery strategies in Zambia: a modelling analysis using routine data

IF 4.9 1区医学 Q2 IMMUNOLOGY

Journal of the International AIDS Society Pub Date : 2025-06-28 DOI:10.1002/jia2.70003

Nkgomeleng A. Lekodeba, Sydney Rosen, Bevis Phiri, Sithabiso D. Masuku, Caroline Govathson, Aniset Kamanga, Prudence Haimbe, Hilda Shakwelele, Muya Mwansa, Priscilla Lumano-Mulenga, Amy N. Huber, Sophie J. S. Pascoe, Lise Jamieson, Brooke E. Nichols

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Abstract

Introduction

Differentiated service delivery (DSD) models for antiretroviral treatment (ART) have been scaled up in many settings in sub-Saharan Africa to improve client-centred care and increase service delivery efficiency. However, given the multitude of models of care currently available, identifying cost-effective combinations of DSD models that maximize benefits and minimize costs remains critical for guiding their expansion.

Methods

We developed an Excel-based mathematical model using retrospective retention and viral suppression data from a national cohort of ART clients (≥15 years) in Zambia between January 2018 and March 2022 stratified by age, sex, setting (urban/rural) and model of ART delivery. Outcomes (viral suppression and retention in care), provider costs and costs to clients were estimated from the cohort and published data. The base case reflects the outcomes observed in 2022 for all DSD models for each population sub-group. For different combinations of nine DSD models and over 1-year time horizon from the provider perspective, we evaluated the incremental cost-effectiveness ratio (ICER) per additional client virally suppressed compared to the 2022 base case. Deterministic sensitivity analyses were conducted on key input parameters.

Results

Among 125 scenarios evaluated, six were on the cost-effectiveness frontier: (1) 6-month dispensing (6MMD)-only; (2) 6MMD and adherence groups (AGs); (3) AGs-only; (4) fast track refills (FTRs) and AGs; (5) FTRs-only; and 6) AGs and home ART delivery. 6MMD-only was cost-saving compared to the base case, increasing retention by 1.2% (95% CI: 0.7−1.8), viral suppression by 1.6% (95% CI: 1.0−2.7) and reducing client costs by 12.0% (95% CI: 10.8−12.4). The next cost-effective scenarios, 6MMD + AGs and AGs-only, cost $245 per additional person virally suppressed, increased viral suppression by 2.8% (95% CI: 2.2−3.3) and 4.0% (95% CI: 3.5−4.0) and increased client costs by 20.1% (95% CI: 9.5−28.1) and 52.3% (95% CI: 29.868.7), respectively. ART cost and laboratory test costs were the most influential parameters on provider costs and the ICERs.

Conclusions

Mathematical modelling using existing data can identify cost-effective DSD model mixes while ensuring all client sub-populations are considered. In Zambia, scaling up 6MMD to all eligible clients is likely cost-saving, with further health gains achievable by targeting sub-populations with selected DSD models.

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赞比亚差异化抗逆转录病毒治疗服务提供战略的成本和有效性：使用常规数据的建模分析

在撒哈拉以南非洲的许多环境中，抗逆转录病毒治疗（ART）的差异化服务提供（DSD）模式得到了推广，以改善以客户为中心的护理并提高服务提供效率。然而，鉴于目前可用的护理模式众多，确定具有成本效益的DSD模式组合，以实现效益最大化和成本最小化，对于指导其扩展仍然至关重要。方法利用2018年1月至2022年3月期间赞比亚全国ART患者（≥15岁）队列的回顾性保留和病毒抑制数据，根据年龄、性别、环境（城市/农村）和ART交付模式进行分层，建立了一个基于excel的数学模型。结果（病毒抑制和护理保留）、提供者成本和客户成本从队列和已发表的数据中进行估计。基本情况反映了2022年对每个人口子组的所有DSD模型观察到的结果。对于9种DSD模型的不同组合和超过1年的时间跨度，我们从供应商的角度评估了与2022年基本情况相比，每增加一个病毒抑制客户的增量成本效益比（ICER）。对关键输入参数进行确定性敏感性分析。结果在评估的125个方案中，有6个方案处于成本-效果前沿：(1)仅6个月的调剂（6MMD）；(2) 6MMD和依从性组（AGs）；(3) AGs-only;(4)快速通道补给（FTRs）和AGs；(5) FTRs-only;6) AGs和家庭ART交付。与基本情况相比，仅使用6mmd可节省成本，留存率提高1.2% (95% CI: 0.7 - 1.8)，病毒抑制率提高1.6% (95% CI: 1.0 - 2.7)，客户成本降低12.0% （95% CI: 10.8 - 12.4）。下一个具有成本效益的方案，6MMD + AGs和仅AGs，每增加一人病毒抑制成本为245美元，病毒抑制率分别提高2.8% （95% CI: 2.2 - 3.3）和4.0% (95% CI: 3.5 - 4.0)，客户成本分别增加20.1% （95% CI: 9.5 - 28.1）和52.3% （95% CI: 29.868.7）。ART成本和实验室检测成本是影响提供者成本和ICERs的最重要参数。使用现有数据的数学建模可以确定具有成本效益的DSD模型混合，同时确保考虑所有客户亚群。在赞比亚，向所有符合条件的客户扩大600万每日治疗可能会节省成本，通过选定的DSD模型针对亚人群，可以实现进一步的健康收益。

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来源期刊

Journal of the International AIDS Society IMMUNOLOGY-INFECTIOUS DISEASES

CiteScore

8.60

自引率

10.00%

发文量

186

审稿时长

>12 weeks

期刊介绍： The Journal of the International AIDS Society (JIAS) is a peer-reviewed and Open Access journal for the generation and dissemination of evidence from a wide range of disciplines: basic and biomedical sciences; behavioural sciences; epidemiology; clinical sciences; health economics and health policy; operations research and implementation sciences; and social sciences and humanities. Submission of HIV research carried out in low- and middle-income countries is strongly encouraged.