title: Estimated Costs for Delivery of HIV Antiretroviral Therapy to Individuals with CD4+ T-Cell Counts >350 cells/uL in Rural Uganda.
abstract: BACKGROUND
  Evidence favoring earlier HIV ART initiation at high CD4+ T-cell counts (CD4>350/uL) has grown, and guidelines now recommend earlier HIV treatment. However, the cost of providing ART to individuals with CD4>350 in Sub-Saharan Africa has not been well estimated. This remains a major barrier to optimal global cost projections for accelerating the scale-up of ART. Our objective was to compute costs of ART delivery to high CD4+count individuals in a typical rural Ugandan health center-based HIV clinic, and use these data to construct scenarios of efficient ART scale-up.
  
  
  METHODS
  Within a clinical study evaluating streamlined ART delivery to 197 individuals with CD4+ cell counts >350 cells/uL (EARLI Study: NCT01479634) in Mbarara, Uganda, we performed a micro-costing analysis of administrative records, ART prices, and time-and-motion analysis of staff work patterns. We computed observed per-person-per-year (ppy) costs, and constructed models estimating costs under several increasingly efficient ART scale-up scenarios using local salaries, lowest drug prices, optimized patient loads, and inclusion of viral load (VL) testing.
  
  
  RESULTS
  Among 197 individuals enrolled in the EARLI Study, median pre-ART CD4+ cell count was 569/uL (IQR 451-716). Observed ART delivery cost was $628 ppy at steady state. Models using local salaries and only core laboratory tests estimated costs of $529/$445 ppy (+/-VL testing, respectively). Models with lower salaries, lowest ART prices, and optimized healthcare worker schedules reduced costs by $100-200 ppy. Costs in a maximally efficient scale-up model were $320/$236 ppy (+/- VL testing). This included $39 for personnel, $106 for ART, $130/$46 for laboratory tests, and $46 for administrative/other costs. A key limitation of this study is its derivation and extrapolation of costs from one large rural treatment program of high CD4+ count individuals.
  
  
  CONCLUSIONS
  In a Ugandan HIV clinic, ART delivery costs--including VL testing--for individuals with CD4>350 were similar to estimates from high-efficiency programs. In higher efficiency scale-up models, costs were substantially lower. These favorable costs may be achieved because high CD4+ count patients are often asymptomatic, facilitating more efficient streamlined ART delivery. Our work provides a framework for calculating costs of efficient ART scale-up models using accessible data from specific programs and regions.
authors.affiliation: HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco (UCSF), San Francisco, CA, United States of America.|Makerere University-UCSF (MU-UCSF) Research Collaboration, Kampala, Uganda.
authors.forename: Vivek
authors.initials: V
authors.lastname: Jain
authors.affiliation: Philip R. Lee Institute for Health Policy Studies, UCSF, San Francisco, CA, United States of America.
authors.forename: Wei
authors.initials: W
authors.lastname: Chang
authors.affiliation: Makerere University-UCSF (MU-UCSF) Research Collaboration, Kampala, Uganda.
authors.forename: Dathan M
authors.initials: DM
authors.lastname: Byonanebye
authors.affiliation: Makerere University-UCSF (MU-UCSF) Research Collaboration, Kampala, Uganda.
authors.forename: Asiphas
authors.initials: A
authors.lastname: Owaraganise
authors.affiliation: Makerere University-UCSF (MU-UCSF) Research Collaboration, Kampala, Uganda.
authors.forename: Ellon
authors.initials: E
authors.lastname: Twinomuhwezi
authors.affiliation: Makerere University Joint AIDS Program (MJAP), Kampala, Uganda.
authors.forename: Gideon
authors.initials: G
authors.lastname: Amanyire
authors.affiliation: HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco (UCSF), San Francisco, CA, United States of America.|Makerere University-UCSF (MU-UCSF) Research Collaboration, Kampala, Uganda.
authors.forename: Douglas
authors.initials: D
authors.lastname: Black
authors.affiliation: Health Strategies International, Oakland, CA, United States of America.
authors.forename: Elliot
authors.initials: E
authors.lastname: Marseille
authors.affiliation: Makerere University-UCSF (MU-UCSF) Research Collaboration, Kampala, Uganda.|Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.
authors.forename: Moses R
authors.initials: MR
authors.lastname: Kamya
authors.affiliation: HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco (UCSF), San Francisco, CA, United States of America.|Makerere University-UCSF (MU-UCSF) Research Collaboration, Kampala, Uganda.
authors.forename: Diane V
authors.initials: DV
authors.lastname: Havlir
authors.affiliation: Philip R. Lee Institute for Health Policy Studies, UCSF, San Francisco, CA, United States of America.
authors.forename: James G
authors.initials: JG
authors.lastname: Kahn
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000191:economics* / Q000627:therapeutic use; D018791:CD4 Lymphocyte Count; D015496:CD4-Positive T-Lymphocytes; D003695:Delivery of Health Care / Q000191:economics*; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000191:economics* / Q000276:immunology; D017048:Health Care Costs; D006801:Humans; D008297:Male; D018803:Models, Economic; D012424:Rural Population; D014454:Uganda; D019562:Viral Load
chemical_list: D019380:Anti-HIV Agents