title: A novel Markov model projecting costs and outcomes of providing antiretroviral therapy to public patients in private practices versus public clinics in South Africa.
abstract: BACKGROUND
  Providing private antiretroviral therapy (ART) care for public sector patients could increase access to ART in low- and middle-income countries. We compared the costs and outcomes of a private-care and a public-care ART program in South Africa.
  
  
  METHODS
  A novel Markov model was developed from the public-care program. Patients were first tunneled for 6 months in their baseline CD4 category before being distributed into a dynamic CD4 and viral load model. Patients were allowed to return to ART care from loss to follow up (LTFU). We then populated this modeling framework with estimates derived from the private-care program to externally validate the model.
  
  
  RESULTS
  Baseline characteristics were similar in the two programs. Clinic visit utilization was higher and death rates were lower in the first few years on ART in the public-care program. After 10 years on ART we estimated the following outcomes in the public-care and private-care programs respectively: viral load <1000 copies/ml 89% and 84%, CD4 >500 cells/μl 33% and 37%, LTFU 14% and 14%, and death 27% and 32%. Lifetime undiscounted survival estimates were 14.1 (95%CI 13.2-14.9) and (95%CI 12.7-14.5) years with costs of 18,734 (95%CI 12,588-14,022) and 13,062 (95%CI 12,077-14,047) USD in the private-care and public-care programs respectively. When clinic visit utilization in the public-care program was reduced by two thirds after the initial 6 months on ART, which is similar to their current practice, the costs were comparable between the programs.
  
  
  CONCLUSIONS
  Using a novel Markov model, we determined that the private-care program had similar outcomes but lower costs than the public-care program, largely due to lower visit frequencies. These findings have important implications for increasing and sustaining coverage of patients in need of ART care in resource-limited settings.
authors: Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa.
authors: Rory
authors: R
authors: Leisegang
authors: Gary
authors: G
authors: Maartens
authors: Michael
authors: M
authors: Hislop
authors: John
authors: J
authors: Sargent
authors: Ernest
authors: E
authors: Darkoh
authors: Susan
authors: S
authors: Cleary
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000191:economics* / Q000627:therapeutic use; D023241:Antiretroviral Therapy, Highly Active / Q000191:economics* / Q000379:methods; D015704:CD4 Antigens / Q000276:immunology; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D015658:HIV Infections / Q000188:drug therapy / Q000191:economics* / Q000276:immunology / Q000821:virology; D006801:Humans; D008297:Male; D008390:Markov Chains; D018803:Models, Economic; D011331:Private Practice / Q000191:economics*; D011634:Public Health / Q000191:economics*; D013019:South Africa; D016896:Treatment Outcome; D019562:Viral Load
chemical_list: D019380:Anti-HIV Agents; D015704:CD4 Antigens
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