Impact and Cost of an HIV/AIDS Improvement Intervention in Cote d'Ivoire

Program results to date have focused on process-level improvements; this analysis aimed to extend this and assess the impact and cost-effectiveness of the HCI interventions via program-attributable changes in patient utilization and morbidity. The analysis used a retrospective cohort design based on patient records at 26 primary- and secondary-level facilities in Abidjan (public and private) that provide HIV care and treatment. Half were sites where HCI interventions had been implemented, and the other half did not participate in the intervention. Data were abstracted from patient and facility records by trained research assistants. Each facility contributed approximately 45 records from patients who had initiated antiretroviral therapy (ART) on or before March 2013, plus a subset of 10 records for an assessment of data completeness, and facility costs (medicines, laboratory supplies, human resources, plus HCI program expenses). Utilization was assessed in terms of clinical activities (assessment of CD4 level, and/or examination including patient weight, and/or a change in medication), and health outcomes (CD4 count value, weight value). These were measured as continuous variables and analyzed per 6-month period, from ART initiation until the date of data collection, or until loss to follow-up if sooner. Associations between these outcomes and the HCI program were explored in a series of univariate and multivariate models, the latter with incremental addition of covariates to control for key demographic and clinical factors. Unadjusted analyses showed that patients in HCI sites received better care in the first six months of ART initiation: 46% of patients at HCI sites received follow-up care within six months of initiating ART, versus 40% of patients at non-HCI sites (p=0.03). However, this difference did not persist for more than the six months. Approximately two-thirds of patients received care at HCI-assisted facilities within the first year of initiating ART regardless of HCI program status (p-value=0.22), and approximately half received care between one and two years of initiating ART (p= 0.45). Baseline average CD4 levels were slightly higher for HCI compared to non-HCI sites (p=0.06) and were not different by 12 months (p =0.85) or two years (p= 0.29). However, the model adjusting for confounders found no such associations in shorter or longer time periods. The analysis also found that patients in HCI sites had higher costs associated with their care, including higher costs for medicines, laboratory supplies, and human resources. The study's findings suggest that the HCI interventions may have had some short-term benefits for patients in terms of clinical activities and health outcomes, but these benefits did not persist over time. The analysis also highlights the need for further research on the cost-effectiveness of the HCI interventions and the factors that contribute to their effectiveness.