Cost-Effectiveness of HIV Retention and Re-engagement Interventions in High-Income Countries: A Systematic Literature Review

Late Re-Engagement Into HIV Care Among Adults in the Swiss HIV Cohort Study

INTRODUCTION

Little is known about the clinical status of persons with HIV who re-engage in care after an interruption. We evaluated the immunologic and clinical characteristics of individuals re-engaging in care within the Swiss HIV Cohort Study.

METHODS

Participants who re-engaged in care after an interruption >14 months with a viral load ≥100 copies/mL were classified as having interrupted antiretroviral therapy (ART). We defined late re-engagement as re-engaging with a CD4 cell count of <350 cells/µL or a new Centers for Disease Control and Prevention stage C disease. Linear and logistic regression models with restricted cubic splines were used to estimate the mean CD4 cell count at re-engagement and the probability of late re-engagement as a function of care interruption duration.

RESULTS

Of 14,864 participants with a median follow-up of 10.2 years (interquartile range 4.7-17.2 years), 2768 (18.6%) interrupted care, of whom 1489 (53.8%) re-engaged. Among those re-engaging, 62.3% had interrupted ART. For participants who interrupted ART, the mean CD4 count declined from 374 cells/µL [95% confidence interval (CI): 358 to 391 cells/µL] before the interruption to 250 cells/µL (95% CI: 221 to 281 cells/µL) among those re-engaging after 14 months, and to 185 cells/µL (95% CI: 160 to 212 cells/µL) among those re-engaging after 60 months. The estimated risk of late re-engagement in care was 68.6% (95% CI: 62.3% to 74.4%) for participants who interrupted ART for 14 months and 75.2% (95% CI: 68.9% to 80.6%) for those who interrupted ART for 60 months.

CONCLUSIONS

Although HIV care interruptions are not very common in Switzerland, most persons with HIV re-engaging after interrupting ART return with late-stage HIV.

How much does it cost to retain clients on antiretroviral treatment for one year in a large, public clinic? Routine financial costs of retention interventions at Lighthouse Trust in Lilongwe, Malawi

INTRODUCTION

Poor retention (missed appointments or treatment discontinuation) on antiretroviral therapy (ART) may lead to disease progression, increased mortality, and HIV transmission. This study quantified the financial costs of implementing 12 months of routine services to improve ART retention at a large public clinic in Lilongwe, Malawi.

METHODS

We performed activity-based micro-costing from the payer perspective using routine program data to assess the costs associated with two retention interventions: ART treatment buddies (expert clients) and Back-to-Care (B2C) tracing services. New ART initiates receive a Buddy who provides proactive retention support for 12 months. B2C traces all clients who miss ART visits by ≥ 14 days. Costs were calculated as total and per-client expenditures, reported in 2021 USD.

RESULTS

The total cost for 12 months of ART retention activities was $237,564. Buddies accounted for $108,504, with personnel costs contributing $97,764. B2C totaled $129,060, with personnel expenses remaining substantial at $73,778. The unit costs were $34 per client Buddy and $17 per B2C tracing event.

CONCLUSION

This study highlights the financial costs of delivering 12 months of ART retention services at a public, low-resource clinic. While proactive and reactive retention strategies are costly, both are essential for engaging ART clients from initiation onward.

How much does it cost to retain antiretroviral therapy (ART) clients in their first year? Routine financial costs of retention interventions at Lighthouse Trustin Lilongwe, Malawi

Introduction

Antiretroviral therapy (ART) improves the health of people living with HIV (PLHIV). However, a high loss to follow-up, particularly in the first year after ART initiation, is problematic. The financial expenses related to client retention in low- and middle-income countries (LMICs) in sub-Saharan Africa are not well understood. This study aimed to comprehensively assess and quantify the financial costs associated with routine ART retention services for clients in their first 12 months in care at Lighthouse Trust's (LT) Martin Preuss Centre (MPC), a large, public ART clinic in Lilongwe, Malawi.

Methods

We performed activity-based microcosting using routine data to assess the expenses related to routine ART retention services at the MPC for 12 months, from January to December 2021. MPC provides an "ART Buddy" from ART initiation to 12 months. The MPC's Back-to-Care (B2C) program traces clients who miss ART visits by at least 14 days. Clients may be traced and return to care multiple times per year. We assessed client retention costs for the first 12 months of treatment with ART and conducted a sensitivity analysis.

Results

The total annual cost of ART retention interventions at MPC was $237,564. The proactive Buddy phase incurred $108,504; personnel costs contributed $97,764. In the reactive B2C phase, the total cost was $129,060, with personnel expenses remaining substantial at $73,778. The Buddy unit cost was $34 per client. The reactive B2C intervention was $17 per tracing event. On average, the unit cost for ART retention in the first year of ART averaged $22 per client.

Conclusion

This study sheds light on the financial dimensions of ART retention during the first year on ART among clients in a routine public setting. ART retention is both costly and critical for helping clients adhere to visits and remain in care. Continued investment in the human resources needed for both proactive and reactive retention efforts is critical to engaging and retaining patients on lifetime ART.

Retention in Care Among People Living with HIV in Nigeria: A Systematic Review and Meta-analysis

BACKGROUND

In 2021, Nigeria had an estimated 1.9 million people living with the human immunodeficiency virus (PLHIV) and 1.7 million (90%) on antiretroviral therapy (ART). Study Design: A systematic review and meta-analysis.

METHODS

This meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 guidelines. We searched PubMed, Embase, PsychINFO, CINAHL, Global Index Medicus, and Cochrane Library. Studies were included if they reported on ART retention in care among PLHIV in Nigeria. The random-effects meta-analyses were used to combine the studies that had complete retention data. The I2 statistic was used to assess the heterogeneity of the studies. A sensitivity analysis was then done by conducting a leave-one-out analysis. Afterward, data were analyzed using STATA version 18.

RESULTS

The search yielded 966 unique articles, of which 52 studies met the inclusion criteria for the meta-analysis, and four experimental studies were split into their component arms. The total number of study participants was 563,410, and the pooled retention rate was 72% (95% CI: 67%, 76%; I2=99.9%; n=57). Sub-analysis showed that the Southeast region of Nigeria had the highest retention of 86% (95% CI: 78%, 92%), and the South-South had the lowest retention (58%; 95% CI: 38%, 79%).

CONCLUSION

In Nigeria, the pooled ART retention rate is less than optimal to achieve the UNAIDS goal of 95%, thus developing new models for ART retention is needed.

Exploring the Feasibility of an Electronic Tool for Predicting Retention in HIV Care: Provider Perspectives

Retention in care for people living with HIV (PLWH) is important for individual and population health. Preemptive identification of PLWH at high risk of lapsing in care may improve retention efforts. We surveyed providers at nine institutions throughout Chicago about their perspectives on using an electronic health record (EHR) tool to predict the risk of lapsing in care. Sixty-three percent (20/32) of providers reported currently assessing patients' risk for lapsing in care, and 91% (29/32) reported willingness to implement an EHR tool. When compared to those with other job roles, prescribers agreed (vs. neutral) that the tool would be less biased than personal judgment (OR 13.33, 95% CI 1.05, 169.56). Prescribers were also more likely to identify community health workers as persons who should deliver these interventions (OR 10.50, 95% CI 1.02, 108.58). Transportation, housing, substance use, and employment information were factors that providers wanted to be included in an EHR-based tool. Social workers were significantly more likely to indicate the inclusion of employment information as important (OR 10.50, 95% CI 1.11, 98.87) when compared to other participants. Acceptability of an EHR tool was high; future research should investigate barriers and evaluate the effectiveness of such a tool.

How much does it cost to retain antiretroviral therapy (ART) clients in care? Routine financial costs of retention interventions at Lighthouse Trust's Martin Preuss Centre (MPC) in Lilongwe, Malawi

Introduction

Antiretroviral therapy (ART) improves the health of people living with HIV (PLHIV). However, a high loss to follow-up, particularly in the first year after ART initiation, is problematic. The financial expenses related to client retention in low- and middle-income countries (LMICs) in sub-Saharan Africa are not well understood. This study aimed to comprehensively assess and quantify the financial costs associated with routine ART retention care at Lighthouse Trust's (LT) Martin Preuss Centre (MPC), a large, public ART clinic in Lilongwe, Malawi.

Methods

We performed activity-based microcosting using routine data to assess the expenses related to routine ART retention services at the MPC for 12 months, January-December 2021. MPC provides an "ART Buddy" from ART initiation to 12 months. The MPC's Back-to-Care (B2C) program traces clients who miss ART visits at any time. Clients may be traced and return to care multiple times per year. We assessed client retention costs for the first 12 months of treatment with ART and conducted a sensitivity analysis.

Results

The total annual cost of ART retention interventions at the MPC was $237,564. The proactive Buddy phase incurred $108,504; personnel costs contributed $97,764. In the reactive B2C phase, the total cost was $129,060, with personnel expenses remaining substantial at $73,778. The Buddy unit cost was $34 per client. The reactive B2C intervention was $17 per tracing event. On average, the unit cost for ART retention in the first year of ART averaged $22 per client.

Conclusion

This study sheds light on the financial dimensions of ART retention interventions at the MPC of LTs. ART retention is both costly and critical for helping clients adhere to visits and remain in care. Continued investment in the human resources needed for both proactive and reactive retention efforts is critical to engaging and retaining patients on lifetime ART.