Economic evaluation of mobile phone text message interventions to improve adherence to HIV therapy in Kenya

Anik R Patel, Jason Kessler, R Scott Braithwaite, Kimberly A Nucifora, Harsha Thirumurthy, Qinlian Zhou, Richard T Lester, Carlo A Marra, Anik R Patel, Jason Kessler, R Scott Braithwaite, Kimberly A Nucifora, Harsha Thirumurthy, Qinlian Zhou, Richard T Lester, Carlo A Marra

Abstract

Background: A surge in mobile phone availability has fueled low cost short messaging service (SMS) adherence interventions. Multiple systematic reviews have concluded that some SMS-based interventions are effective at improving antiretroviral therapy (ART) adherence, and they are hypothesized to improve retention in care. The objective of this study was to evaluate the cost-effectiveness of SMS-based adherence interventions and explore the added value of retention benefits.

Methods: We evaluated the cost-effectiveness of weekly SMS interventions compared to standard care among HIV+ individuals initiating ART for the first time in Kenya. We used an individual level micro-simulation model populated with data from two SMS-intervention trials, an East-African HIV+ cohort and published literature. We estimated average quality adjusted life years (QALY) and lifetime HIV-related costs from a healthcare perspective. We explored a wide range of scenarios and assumptions in one-way and multivariate sensitivity analyses.

Results: We found that SMS-based adherence interventions were cost-effective by WHO standards, with an incremental cost-effectiveness ratio (ICER) of $1,037/QALY. In the secondary analysis, potential retention benefits improved the cost-effectiveness of SMS intervention (ICER = $864/QALY). In multivariate sensitivity analyses, the interventions remained cost-effective in most analyses, but the ICER was highly sensitive to intervention costs, effectiveness and average cohort CD4 count at ART initiation. SMS interventions remained cost-effective in a test and treat scenario where individuals were assumed to initiate ART upon HIV detection.

Conclusions: Effective SMS interventions would likely increase the efficiency of ART programs by improving HIV treatment outcomes at relatively low costs, and they could facilitate achievement of the UNAIDS goal of 90% viral suppression among those on ART by 2020.

Conflict of interest statement

The authors have no conflicts of interest to disclose.

Figures

Figure 1
Figure 1
An influence diagram of the individual microsimulation model structure. (A) Adherence directly impacted the rate of viral suppression and HIV disease progression, which determined the prognosis for modeled individuals. SMS interventions improve individual adherence and thus impact health outcomes. (B) Individuals could disengage from care during the simulation with probabilities matching East African data. Once disengaged, simulated individuals could reengage with a health system or die out of care. SMS interventions were simulated to reduce the probability of disengagement. HIV = human immunodeficiency virus, SMS = short messaging service.
Figure 2
Figure 2
A multivariate sensitivity analysis varying intervention costs, intervention effectiveness, ASC, and average CD4 count at ART initiation. Individuals were assumed to start ART with no waiting period, consistent with the test and treat guidelines. Thresholds at which the intervention was no longer cost-effective can be seen when a variable is increased 1 level and the box turns blue. ART = antiretroviral therapy, ASC = adherence under standard care.

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