Estimated Costs for Delivery of HIV Antiretroviral Therapy to Individuals with CD4+ T-Cell Counts >350 cells/uL in Rural Uganda

Abstract

Background: Evidence favoring earlier HIV ART initiation at high CD4+ T-cell counts (CD4>350/uL) has grown, and guidelines now recommend earlier HIV treatment. However, the cost of providing ART to individuals with CD4>350 in Sub-Saharan Africa has not been well estimated. This remains a major barrier to optimal global cost projections for accelerating the scale-up of ART. Our objective was to compute costs of ART delivery to high CD4+count individuals in a typical rural Ugandan health center-based HIV clinic, and use these data to construct scenarios of efficient ART scale-up.

Methods: Within a clinical study evaluating streamlined ART delivery to 197 individuals with CD4+ cell counts >350 cells/uL (EARLI Study: NCT01479634) in Mbarara, Uganda, we performed a micro-costing analysis of administrative records, ART prices, and time-and-motion analysis of staff work patterns. We computed observed per-person-per-year (ppy) costs, and constructed models estimating costs under several increasingly efficient ART scale-up scenarios using local salaries, lowest drug prices, optimized patient loads, and inclusion of viral load (VL) testing.

Findings: Among 197 individuals enrolled in the EARLI Study, median pre-ART CD4+ cell count was 569/uL (IQR 451-716). Observed ART delivery cost was $628 ppy at steady state. Models using local salaries and only core laboratory tests estimated costs of $529/$445 ppy (+/-VL testing, respectively). Models with lower salaries, lowest ART prices, and optimized healthcare worker schedules reduced costs by $100-200 ppy. Costs in a maximally efficient scale-up model were $320/$236 ppy (+/- VL testing). This included $39 for personnel, $106 for ART, $130/$46 for laboratory tests, and $46 for administrative/other costs. A key limitation of this study is its derivation and extrapolation of costs from one large rural treatment program of high CD4+ count individuals.

Conclusions: In a Ugandan HIV clinic, ART delivery costs--including VL testing--for individuals with CD4>350 were similar to estimates from high-efficiency programs. In higher efficiency scale-up models, costs were substantially lower. These favorable costs may be achieved because high CD4+ count patients are often asymptomatic, facilitating more efficient streamlined ART delivery. Our work provides a framework for calculating costs of efficient ART scale-up models using accessible data from specific programs and regions.

Conflict of interest statement

Competing Interests: VJ has an investigator-initiated grant from Gilead Sciences. An antiretroviral medication (Truvada) was donated to the study by Gilead Sciences. This funder (as with other study funders) had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. All other authors have declared that no competing interests exist. This does not alter the authors'adherence to PLOS ONE policies on sharing data and materials.

Figures

Fig 1. Estimated ART Delivery Costs under Modeled Scenarios of Efficient ART Scale-Up.

Costs for ART delivery under six modeled scenarios are displayed inclusive of viral load testing. Model costs excluding viral load testing are also shown. Model A: steady-state patient load, MJAP program salary scale and standard core laboratory monitoring schedule. Model B: model A + lowest available ARV drug costs. Model C: model B + Uganda Ministry of Health 2013 salary scales. Model D: model C + increased healthcare worker efficiency due to full use of workday. Model E: model D + expansion of healthcare worker effort to full 8-hour workday. Model F: model E + higher MJAP program salary scales.