Cost-effectiveness of staff and workload profiles in retaining patients on antiretroviral therapy in KwaZulu-Natal, South Africa.

BACKGROUND: There is paucity of information on the cost-effectiveness of delivery strategies to retain patients on antiretroviral therapy (ART) and this study tries to fill this gap. METHODS: The analysis is based on a representative sample of 2835 patients attending 32 ART sites in KwaZulu-Natal (KZN), South Africa. Extended Cox regression and Kaplan Meier were used to estimate the transition probabilities to remain on ART among patients who attended sites with different staff and workload profiles. Annual costs per patient-year of observation for these delivery profiles were estimated. Probabilistic sensitivity analysis took into account parameters' uncertainty. RESULTS: The delivery sites with a full-time doctor and a full-time senior professional nurse and an intake of less than 200 new patients per doctor per year were the most cost-effective in retaining patients on ART. If 1000 new patients were followed up by this type of site, 724 patients would still be on ART after 10 years at a discounted cost of US$8.41 million at 2006 value with an incremental cost-effectiveness ratio of US$12,271 per extra retained patient over the second not dominated site profile. CONCLUSIONS: The results could be used to estimate the human resources needed for a sustainable scaling up of ART in KZN.

Retrospective study on the critical factors for retaining patients on antiretroviral therapy in KwaZulu-Natal, South Africa.

OBJECTIVE: To analyze the critical factors favoring the retention of patients under antiretroviral therapy (ART) in KwaZulu-Natal (KZN), South Africa. DESIGN AND METHODS: This retrospective study was based on the review of a representative sample of patients who began ART between March 2004 and May 2006 in 32 public sector sites and were followed up to July 1, 2007. Extended Cox proportional hazard models were used to identify the factors which significantly influenced treatment retention during the first 2 years of treatment. Kaplan-Meyer provided the probabilities of remaining on ART if these factors were present. RESULTS: The 2835 sampled patients corresponded to about 10% of the universe of patients under ART in the 32 sites; 929 (33%) were males, and the median age of the sampled patients was 34 (interquartile range: 28-41). The analysis identified factors that significantly decreased the probability of remaining on ART. Patients' risk factors were initial CD4 <100 cells per microliter, lack of a telephone contact number, and being male. Sites' risk factors were the presence of a part time (PT) versus a full time (FT) senior professional nurse, a PT versus FT doctor, and intakes of 200 or more new patients per doctor per year. The probability of remaining on ART declined significantly for each increasing level of workload, but having a FT versus a PT doctor made a significant difference only for level of workload of 200 or more new patients per year. CONCLUSIONS: The analysis has identified the conditions influencing retention of ART patients in KZN. This has provided a method to estimate absorption capacity of the ART delivery sites, which is of added value for a sustainable expansion of the ART coverage.