title: Treatment Outcomes and Costs of Providing Antiretroviral Therapy at a Primary Health Clinic versus a Hospital-Based HIV Clinic in South Africa.
abstract: BACKGROUND
  In 2010 South Africa revised its HIV treatment guidelines to allow the initiation and management of patients on antiretroviral therapy (ART) by nurses, rather than solely doctors, under a program called NIMART (Nurse Initiated and Managed Antiretroviral Therapy). We compared the outcomes and costs of NIMART between the two major public sector HIV treatment delivery models in use in South Africa today, primary health clinics and hospital-based HIV clinics.
  
  
  RESULTS
  The study was conducted at one hospital-based outpatient HIV clinic and one primary health clinic (PHC) in Gauteng Province. A retrospective cohort of adult patients initiated on ART at the PHC was propensity-score matched to patients initiated at the hospital outpatient clinic. Each patient was assigned a 12-month outcome of alive and in care or died/lost to follow up. Costs were estimated from the provider perspective for the 12 months after ART initiation. The proportion of patients alive and in care at 12 months did not differ between the PHC (76.5%) and the hospital-based site (74.2%). The average annual cost per patient alive and in care at 12 months after ART initiation was significantly lower at the PHC (US$238) than at the hospital outpatient clinic (US$428).
  
  
  CONCLUSIONS
  Initiating and managing ART patients at PHCs under NIMART is producing equally good outcomes as hospital-based HIV clinic care at much lower cost. Evolution of hospital-based clinics into referral facilities that serve complicated patients, while investing most program expansion resources into PHCs, may be a preferred strategy for achieving treatment coverage targets.
authors.affiliation: Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.|School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.|Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa.
authors.forename: Lawrence C
authors.initials: LC
authors.lastname: Long
authors.affiliation: Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.|Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa.|Center for Global Health & Development, Boston University, Boston, Massachusetts, United States of America.
authors.forename: Sydney B
authors.initials: SB
authors.lastname: Rosen
authors.affiliation: Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.|Center for Global Health & Development, Boston University, Boston, Massachusetts, United States of America.
authors.forename: Alana
authors.initials: A
authors.lastname: Brennan
authors.affiliation: Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.|Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa.
authors.forename: Faith
authors.initials: F
authors.lastname: Moyo
authors.affiliation: Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.|Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa.
authors.forename: Celeste
authors.initials: C
authors.lastname: Sauls
authors.affiliation: Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.|School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.|Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa.
authors.forename: Denise
authors.initials: D
authors.lastname: Evans
authors.affiliation: Right to Care, Johannesburg, South Africa.
authors.forename: Shookdev L
authors.initials: SL
authors.lastname: Modi
authors.affiliation: Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.|School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.|Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa.|Center for Global Health & Development, Boston University, Boston, Massachusetts, United States of America.|Right to Care, Johannesburg, South Africa.
authors.forename: Ian
authors.initials: I
authors.lastname: Sanne
authors.affiliation: Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.|School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.|Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa.|Center for Global Health & Development, Boston University, Boston, Massachusetts, United States of America.|Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America.
authors.forename: Matthew P
authors.initials: MP
authors.lastname: Fox
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000191:economics / Q000627:therapeutic use; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000191:economics / Q000628:therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010044:Outpatient Clinics, Hospital / Q000191:economics; D011320:Primary Health Care / Q000191:economics / Q000458:organization & administration; D012189:Retrospective Studies; D013019:South Africa; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents