title: Treatment outcomes and cost-effectiveness of shifting management of stable ART patients to nurses in South Africa: an observational cohort.
abstract: BACKGROUND
  To address human resource and infrastructure shortages, resource-constrained countries are being encouraged to shift HIV care to lesser trained care providers and lower level health care facilities. This study evaluated the cost-effectiveness of down-referring stable antiretroviral therapy (ART) patients from a doctor-managed, hospital-based ART clinic to a nurse-managed primary health care facility in Johannesburg, South Africa.
  
  
  RESULTS
  Criteria for down-referral were stable ART (≥11 mo), undetectable viral load within the previous 10 mo, CD4>200 cells/mm(3), <5% weight loss over the last three visits, and no opportunistic infections. All patients down-referred from the treatment-initiation site to the down-referral site between 1 February 2008 and 1 January 2009 were compared to a matched sample of patients eligible for down-referral but not down-referred. Outcomes were assigned based on vital and health status 12 mo after down-referral eligibility and the average cost per outcome estimated from patient medical record data. The down-referral site (n = 712) experienced less death and loss to follow up than the treatment-initiation site (n = 2,136) (1.7% versus 6.2%, relative risk = 0.27, 95% CI 0.15-0.49). The average cost per patient-year for those in care and responding at 12 mo was US$492 for down-referred patients and US$551 for patients remaining at the treatment-initiation site (p<0.0001), a savings of 11%. Down-referral was the cost-effective strategy for eligible patients.
  
  
  CONCLUSIONS
  Twelve-month outcomes of stable ART patients who are down-referred to a primary health clinic are as good as, or better than, the outcomes of similar patients who are maintained at a hospital-based ART clinic. The cost of treatment with down-referral is lower across all outcomes and would save 11% for patients who remain in care and respond to treatment. These results suggest that this strategy would increase treatment capacity and conserve resources without compromising patient outcomes.
authors.affiliation: Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa. llong@heroza.org
authors.forename: Lawrence
authors.initials: L
authors.lastname: Long
authors.forename: Alana
authors.initials: A
authors.lastname: Brennan
authors.forename: Matthew P
authors.initials: MP
authors.lastname: Fox
authors.forename: Buyiswa
authors.initials: B
authors.lastname: Ndibongo
authors.forename: Imogen
authors.initials: I
authors.lastname: Jaffray
authors.forename: Ian
authors.initials: I
authors.lastname: Sanne
authors.forename: Sydney
authors.initials: S
authors.lastname: Rosen
mesh_terms: D000293:Adolescent; D000328:Adult; D044966:Anti-Retroviral Agents / Q000191:economics / Q000627:therapeutic use*; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D017048:Health Care Costs; D006801:Humans; D008297:Male; D008875:Middle Aged; D009729:Nursing / Q000379:methods*; D017063:Outcome Assessment, Health Care; D013019:South Africa; D016896:Treatment Outcome
chemical_list: D044966:Anti-Retroviral Agents