title: Retention in care, resource utilization, and costs for adults receiving antiretroviral therapy in Zambia: a retrospective cohort study.
abstract: BACKGROUND
  Of the estimated 800,000 adults living with HIV in Zambia in 2011, roughly half were receiving antiretroviral therapy (ART). As treatment scale up continues, information on the care provided to patients after initiating ART can help guide decision-making. We estimated retention in care, the quantity of resources utilized, and costs for a retrospective cohort of adults initiating ART under routine clinical conditions in Zambia.
  
  
  METHODS
  Data on resource utilization (antiretroviral [ARV] and non-ARV drugs, laboratory tests, outpatient clinic visits, and fixed resources) and retention in care were extracted from medical records for 846 patients who initiated ART at ≥15 years of age at six treatment sites between July 2007 and October 2008. Unit costs were estimated from the provider's perspective using site- and country-level data and are reported in 2011 USD.
  
  
  RESULTS
  Patients initiated ART at a median CD4 cell count of 145 cells/μL. Fifty-nine percent of patients initiated on a tenofovir-containing regimen, ranging from 15% to 86% depending on site. One year after ART initiation, 75% of patients were retained in care. The average cost per patient retained in care one year after ART initiation was $243 (95% CI, $194-$293), ranging from $184 (95% CI, $172-$195) to $304 (95% CI, $290-$319) depending on site. Patients retained in care one year after ART initiation received, on average, 11.4 months' worth of ARV drugs, 1.5 CD4 tests, 1.3 blood chemistry tests, 1.4 full blood count tests, and 6.5 clinic visits with a doctor or clinical officer. At all sites, ARV drugs were the largest cost component, ranging from 38% to 84% of total costs, depending on site.
  
  
  CONCLUSIONS
  Patients initiate ART late in the course of disease progression and a large proportion drop out of care after initiation. The quantity of resources utilized and costs vary widely by site, and patients utilize a different mix of resources under routine clinical conditions than if they were receiving fully guideline-concordant care. Improving retention in care and guideline concordance, including increasing the use of tenofovir in first-line ART regimens, may lead to increases in overall treatment costs.
authors.forename: Callie A
authors.initials: CA
authors.lastname: Scott
authors.forename: Hari S
authors.initials: HS
authors.lastname: Iyer
authors.forename: Kelly
authors.initials: K
authors.lastname: McCoy
authors.forename: Crispin
authors.initials: C
authors.lastname: Moyo
authors.forename: Lawrence
authors.initials: L
authors.lastname: Long
authors.affiliation: Center for Global Health and Development, Boston University, Crosstown Center, 3rd Floor, 801 Massachusetts Avenue, Boston, MA 02118, USA. blarson@bu.edu.
authors.forename: Bruce A
authors.initials: BA
authors.lastname: Larson
authors.forename: Sydney
authors.initials: S
authors.lastname: Rosen
mesh_terms: D000225:Adenine / Q000031:analogs & derivatives / Q000627:therapeutic use; D000328:Adult; D000554:Ambulatory Care Facilities; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D003695:Delivery of Health Care / Q000191:economics*; D005260:Female; D019983:Guideline Adherence; D015658:HIV Infections / Q000188:drug therapy / Q000191:economics*; D017048:Health Care Costs; D006295:Health Resources; D006801:Humans; D008297:Male; D009819:Office Visits; D063065:Organophosphonates / Q000627:therapeutic use; D010352:Patient Dropouts; D012189:Retrospective Studies; D000068698:Tenofovir; D015024:Zambia
chemical_list: D019380:Anti-HIV Agents; D063065:Organophosphonates; D000068698:Tenofovir; D000225:Adenine