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Kimaro, Godfather Dickson, Guiness, Lorna, Shiri, Tinevimbo 
ORCID: https://orcid.org/0000-0002-9092-3268, Kivuyo, Sokoine, Chanda, Duncan, Bottomley, Christian, Chen, Tao ORCID: https://orcid.org/0000-0002-5489-6450, Kahwa, Amos, Hawkins, Neil, Mwaba, Peter, Mfinanga, Sayoki, Harrison, Thomas S, Jaffar, Shabbar ORCID: https://orcid.org/0000-0002-9615-1588 and Niessen, Louis ORCID: https://orcid.org/0000-0002-8639-5191
(2020)
'Cryptococcal meningitis screening and community-based early adherence support in people with advanced HIV infection starting antiretroviral therapy in Tanzania and Zambia: a cost-effectiveness analysis.'. Clinical Infectious Diseases, Vol 70, Issue 8, pp. 1652-1657.
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Abstract
Background
A randomised trial demonstrated that among late-stage HIV-infected patients initiating ART, screening serum for cryptococcal antigen (CrAg) combined with community -based adherence support reduced all-cause mortality by 28%, compared with standard clinic-based care. Here, we present the cost-effectiveness estimates.
Methods
HIV-infected adults with CD4 count<200 cells/l were randomised individually to either CrAg screening plus 4-weekly home visits conducted by lay-workers to provide adherence support or to standard clinic-based care in Dar es Salaam and in Lusaka. Data on individual resource use and health outcomes were collected from all participants.
Unit costs were obtained in Dar es Salaam. The primary economic outcome was health service care cost per life year saved as the incremental cost-effectiveness ratio (ICER), based on 2017 US$. Regression models were used to estimate adjusted mean incremental costs and death rates. Life years saved were estimated based on reported comparable survival data. We used non-parametric bootstrapping to assess uncertainties, and univariate deterministic sensitivity analysis to examine the impact of individual parameters on the ICER.
Results
1,001 and 998 participants from the intervention and standard arms were enrolled respectively. The annual mean costs per participant in the intervention arm was US$ 339 (95% confidence interval (CI): 331 – 347 ), resulting in an incremental cost of the intervention of US$ 77 (95% CI: 66 - 88). The incremental cost was similar when analysis was restricted to persons with CD4 count <100 cells /l.
The ICER for the intervention versus standard care, per life year saved, was US$ 70 (95%CI: 43 -211) for all participants with CD4 count up to 200 cells/l and US$91 (49–443) among those with CD4 counts <100 cells /l. The cost-effectiveness results were most sensitive to mortality estimates.
Conclusions
Screening for cryptococcal antigen in patients with CD4 count up to 200 cells/l, combined with a short period of home-based adherence support, is cost-effective in resource-limited settings.
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