title: Cost-effectiveness of nurse-led versus doctor-led antiretroviral treatment in South Africa: pragmatic cluster randomised trial.
abstract: OBJECTIVE
  To estimate the cost-effectiveness of nurse-led versus doctor-led antiretroviral treatment (ART) for HIV-infected people.
  
  
  METHODS
  Cost-effectiveness analysis alongside a pragmatic cluster randomised controlled trial in 31 primary care clinics (16 intervention, 15 controls) in Free State Province, South Africa. Participants were HIV-infected patients, aged ≥16 years. Cohort 1 (CD4 count ≤350 cells/μl, not yet receiving ART at enrolment): consisted of 5 390 intervention patients and 3 862 controls; Cohort 2 (already received ART for ≥6 months at enrolment) of 3 029 intervention patients and 3 202 controls. Nurses were authorised and trained to initiate and represcribe ART. Management and ART provision were decentralised to primary care clinics. In control clinics, doctors initiated and re-prescribed ART, nurses monitored ART. Main outcome measure(s) were health service costs, death (cohort 1) and undetectable viral load (<400 copies/ml) (cohort 2) during the 12 months after enrolment.
  
  
  RESULTS
  For Cohort 1, the intervention had an estimated incremental cost of US$102.52, an incremental effect of 0.42% fewer deaths and an incremental cost-effectiveness ratio (ICER) of US$24 500 per death averted. For Cohort 2, the intervention had an estimated incremental cost of US$59.48, an incremental effect of 0.47% more undetectable viral loads and an ICER of US$12 584 per undetectable viral load.
  
  
  CONCLUSIONS
  Nurse-led ART was associated with higher mean health service costs than doctor-led care, with small effects on primary outcomes, and a high associated level of uncertainty. Given this, and the shortage of doctors, further implementation of nurse-led ART should be considered, although this may increase health service costs.
authors.affiliation: Norwich Medical School, University of East Anglia, Norwich, UK. g.barton@uea.ac.uk
authors.forename: Garry R
authors.initials: GR
authors.lastname: Barton
authors.forename: Lara
authors.initials: L
authors.lastname: Fairall
authors.forename: Max O
authors.initials: MO
authors.lastname: Bachmann
authors.forename: Kerry
authors.initials: K
authors.lastname: Uebel
authors.forename: Venessa
authors.initials: V
authors.lastname: Timmerman
authors.forename: Carl
authors.initials: C
authors.lastname: Lombard
authors.forename: Merrick
authors.initials: M
authors.lastname: Zwarenstein
mesh_terms: D000163:Acquired Immunodeficiency Syndrome / Q000188:drug therapy / Q000191:economics*; D000328:Adult; D019380:Anti-HIV Agents / Q000191:economics* / Q000627:therapeutic use; D003362:Cost-Benefit Analysis; D003695:Delivery of Health Care / Q000191:economics*; D005260:Female; D017048:Health Care Costs; D006801:Humans; D008297:Male; D008875:Middle Aged; D009726:Nurses / Q000191:economics*; D010820:Physicians / Q000191:economics*; D013019:South Africa; D016896:Treatment Outcome; D019562:Viral Load
chemical_list: D019380:Anti-HIV Agents