The clinical and economic impact of interventions to prevent loss to followup LTFU in resourcelimite

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The clinical and economic impact of
interventions to prevent loss to follow-up
(LTFU) in resource-limited settings

• Elena Losina, Hapsatou Touré, Lauren Uhler,
• Xavier Anglaret, A. David Paltiel, Eric Balestre,
  
• Rochelle Walensky, Eugène Messou, Milton
  Weinstein,
• François Dabis, Kenneth Freedberg for the CEPAC
  International and ART-LINC investigators
• Supported by NIAID and the ANRS

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Background

• Nearly 4 million people have started ART
• 10-51 of patients in ART programs in Africa have
  been lost to follow up at one year
• Most interventions focus on patients lost after
  starting ART
• Many of these patients develop OIs or die before
  returning to care

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Background

• Preventing LTFU could be more effective than
  efforts to find patients
• No LTFU prevention studies have been reported
  from resource-limited settings
• Questions of efficacy and cost

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Cost-effectiveness analysis and modeling

• Evaluating clinical trial results for policy
• What if analyses
• Provide targets for efficacy and cost, before
  studies are done
• To understand how interventions might have a role
  in HIV care

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Objective

• To conduct a what if analysis to project the
  survival gains and cost-effectiveness of
  interventions to prevent LTFU in Côte dIvoire

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Cost-effectiveness of Preventing AIDS
Complications (CEPAC) International Model

• Detailed simulation model of HIV disease
• Key elements of natural history and treatment
• Outcome is the cost-effectiveness ratio
• a measure of value for money (/YLS)
• Value highlighted by Stefano Bertozzi

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What is a Cost-effective Intervention?

• WHO Commission on Macroeconomics and Health
• If ratio lt3x per capita GDP, cost-effective
• If ratio lt1x per capita GDP, very
  cost-effective
• Côte dIvoire per capita GDP (2007) was 940
• 3X GDP was 2820

IMF 2007
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Clinical Data

• Aconda program, Côte dIvoire
• CePReF, Abidjan, dedicated HIV treatment center
• 3,500 HIV-infected patients
• 18 primary health centers, not HIV-specific
• 6,700 HIV-infected patients
• Mean CD4 at presentation 140/µl
• Cumulative LTFU 1 year after ART initiation
• 11 at CePReF
• 18 in the primary health centers

Touré, AIDS 2008
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Cost Data

• Aconda program
• ART regimens
• 60/year 1st-line NNRTI-based
• 670/year 2nd-line PI-based
• Mean medical cost/person/year on ART 820

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Four LTFU Prevention Interventions
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Results Projected Life Expectancy with HIV
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Results Projected Life Expectancy with HIV
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Results Projected Life Expectancy with HIV
6.36
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Results Years of Life Lost from LTFU in Aconda

• General health clinics
• 6,700 patients
• 18 LTFU at 1 year
• 6.36 years per person lost
• 6,700 X 18 X 6.36 years
• 7,670 years of life lost

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Results No ART co-payments, 22
reduction in LTFU at 1 year (baseline LTFU
18)
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Results Efficacy and Cost of the Interventions
Cost-effectiveness ratio (/YLS)
X
Reduction in LTFU
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Baseline Rates of LTFU

• Settings with highest rates of LTFU have the most
  to gain from effective interventions.
• Even in settings with moderate LTFU rates,
  interventions to decrease LTFU may be
  cost-effective.

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Limitations

• Costs were projected from estimates of
  interventions in Abidjan, not from tested
  interventions
• Analysis did not include
• LTFU after the 1st year
• Sustainability
• 3X GDP threshold
• International commitment and partnerships in HIV
  care and financing

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Conclusions

• Loss to follow-up from HIV treatment programs in
  resource-limited settings results in substantial
  decreases in life expectancy.
• Interventions to prevent LTFU in these settings,
  if moderately effective, would be cost-effective
  by international criteria.

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The ART-LINC Collaboration of IeDEA
PrincipaI investigators François Dabis, Matthias
Egger, Mauro Schechter Central Team Eric
Balestre, Martin Brinkhof, Claire Graber, Olivia
Keiser, Catherine Seyler, Hapsatou Touré,
Charlotte Lewden Steering Group Kathryn Anastos
(Kigali) David Bangsberg (Mbarara/ Kampala)
Andrew Boulle (Cape Town) Jennipher Chisanga
(Lusaka) Eric Delaporte (Dakar) Diana Dickinson
(Gaborone) Ernest Ekong (Lagos) Kamal Marhoum
El Filali (Casablanca) Mina Hosseinipour
(Lilongwe) Silvester Kimaiyo (Eldoret) Mana
Khongphatthanayothin (Bangkok) N Kumarasamy
(Chennai) Christian Laurent (Yaounde) Ruedi
Luthy (Harare) James McIntyre (Johannesburg)
Timothy Meade (Lusaka) Eugene Messou (Abidjan)
Denis Nash (New York) Winstone Nyandiko Mokaya
(Eldoret) Margaret Pascoe (Harare) Larry Pepper
(Mbarara) Papa Salif Sow (Dakar) Sam Phiri
(Lilongwe) Mauro Schechter (Rio de Janeiro)
John Sidle (Eldoret) Eduardo Sprinz (Porto
Alegre) Besigin Tonwe-Gold (Abidjan) Siaka
Touré (Abidjan) Stefaan Van der Borght
(Amsterdam) Ralf Weigel (Lilongwe) Robin Wood
(Cape Town)
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The CEPAC International Team
Côte dIvoire Xavier Anglaret, MD, PhD Eugène
Messou, MD Catherine Seyler, MD, MSc Christine
Danel, MD, PhD Eric Ouattara, MD, MPH Siaka
Touré, MD, MPH Hapsatou Touré, MD,
MPH France Yazdan Yazdanpanah, MD, PhD Sylvie
Deuffic-Burban, PhD Delphine Gabillard,
PhD South Africa Neil Martinson, MBBCh,
MPH Robin Wood, MD India Nagalingeswaran
Kumarasamy, MD Kenneth Mayer, MD Soumya
Swaminathan, MD

• United States
• Elena Losina, PhD
• Rochelle Walensky, MD, MPH
• Melissa Bender, MD
• John Chiosi, BS
• Andrea Ciaranello, MD, MPH
• Jennifer Chu, BSc
• Kenneth Freedberg, MD, MSc
• Sue Goldie, MD, MPH
• April Kimmel, MSc
• Julie Levison, MD, MPhil
• Bethany Morris, BA
• A. David Paltiel, PhD
• Mai Pho, MD
• Erin Rhode, MS
• Callie Scott, MSc
• George Seage, III, PhD
• Caroline Sloan, AB
• Adam Stoler, MA

Supported by NIAID and the ANRS
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Results Efficacy and Cost of the Interventions
Cost-effectiveness ratio (/YLS)
Reduction in LTFU
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Cost-effectiveness Analysis

• Two different outcome measures
• Cost , other currency
• Effectiveness years of life saved (YLS) or
  quality-adjusted life-years (QALYs)
• Cost-effectiveness ratio
• Additional Resource Use
• Additional Health Benefits
• Represents the value of resources spent (/YLS)