Impact and Cost-Effectiveness of Hypothetical Strategies to Enhance Retention in Care within HIV Treatment Programs in East Africa

Value Health. 2015 Dec;18(8):946-55. doi: 10.1016/j.jval.2015.09.2940. Epub 2015 Nov 17.


Objectives: Attrition from care among HIV infected patients can lead to poor clinical outcomes. Our objective was to evaluate hypothetical interventions seeking to improve retention-in-care (RIC) for HIV-infected patients in East Africa, asking whether they could offer favorable value compared to earlier ART initiation.

Methods: We used a micro-simulation model to analyze two RIC focused strategies within an East African HIV treatment program--"risk reduction," defined as intervention(s) that decrease the risk of attrition from care; and "outreach," defined as interventions that find patients and relink them with care. We compared this to earlier ART treatment as a measure of the potential health benefits forgone (e.g., opportunity cost).

Results: Reducing attrition by 40% at an average cost of $10 per person remains a less efficient use of resources compared to ensuring full access to ART (cost- effectiveness ratio $1300 vs $3700) for ART eligible patients. An outreach intervention had limited clinical benefit in our simulation. If intervention costs are <$10 per person, however, an intervention able to achieve a 40% (or greater) reduction in attrition may be a cost-effective next implementation option following implementation of earlier ART treatment.

Conclusions: Our results suggest that programs should consider retention focused programs once they have already achieved high degrees of ART coverage among eligible patients. It is important that decision makers understand the epidemiology and associated outcomes of those patients who are classified as lost to follow up in their systems prior to implementation in order to achieve the highest value.

Keywords: Africa; HIV/AIDS; cost-effectiveness analysis; health care utilization.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Adult
  • Africa, Eastern
  • Anti-Retroviral Agents / economics*
  • Anti-Retroviral Agents / therapeutic use*
  • Computer Simulation
  • Cost-Benefit Analysis
  • Female
  • HIV Infections / drug therapy*
  • HIV Infections / economics*
  • HIV Infections / mortality
  • Humans
  • Male
  • Medication Adherence / statistics & numerical data
  • Middle Aged
  • Models, Econometric
  • Patient Compliance / statistics & numerical data*
  • Risk Reduction Behavior


  • Anti-Retroviral Agents