Liang Annie, Wilson-Barthes Marta, Galárraga Omar
Brown University School of Public Health, Providence, RI, USA.
Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA.
Cost Eff Resour Alloc. 2024 May 24;22(1):46. doi: 10.1186/s12962-024-00557-w.
There is some evidence that differentiated service delivery (DSD) models, which use a client-centered approach to simplify and increase access to care, improve clinical outcomes among people living with HIV (PLHIV) in high HIV prevalence countries. Integrating economic strengthening tools (e.g., microcredit, cash transfers, food assistance) within DSD models can help address the poverty-related barriers to HIV antiretroviral therapy (ART). Yet there is minimal evidence of the cost-effectiveness of these types of multilevel care delivery models, which potentially prohibits their wider implementation.
Using a qualitative systematic review, this article synthesizes the literature surrounding the cost-effectiveness of differentiated service delivery models that employ economic strengthening initiatives to improve HIV treatment adherence in low- and middle-income countries. We searched three academic databases for randomized controlled trials and observational studies published from January 2000 through March 2024 in Sub-Saharan Africa. The quality of each study was scored using a validated appraisal system.
Eighty-nine full texts were reviewed and 3 met all eligibility criteria. Two of the three included articles were specific to adolescents living with HIV. Economic strengthening opportunities varied by care model, and included developmental savings accounts, microenterprise workshops, and cash and non-cash conditional incentives. The main drivers of programmatic and per-patient costs were ART medications, CD4 cell count testing, and economic strengthening activities.
All economic evaluations in this review found that including economic strengthening as part of comprehensive differentiated service delivery was cost-effective at a willingness to pay threshold of at least 2 times the national per capita gross domestic product. Two of the three studies in this review focused on adolescents, suggesting that these types of care models may be especially cost-effective for youth entering adulthood. All studies were from the provider perspective, indicating that additional evidence is needed to inform the potential cost-savings of DSD and economic strengthening interventions to patients and society. Randomized trials testing the effectiveness of DSD models that integrate economic strengthening should place greater emphasis on costing these types of programs to inform the potential for bringing these types of multilevel interventions to scale.
有证据表明，差异化服务提供（DSD）模式采用以客户为中心的方法来简化并增加医疗服务的可及性，在高艾滋病毒流行率国家改善了艾滋病毒感染者（PLHIV）的临床结局。在DSD模式中整合经济强化工具（如小额信贷、现金转移、食品援助）有助于消除与贫困相关的艾滋病毒抗逆转录病毒疗法（ART）障碍。然而，关于这些多层次医疗服务提供模式的成本效益的证据极少，这可能阻碍了它们的更广泛实施。
本文采用定性系统评价方法，综合了围绕采用经济强化举措以提高低收入和中等收入国家艾滋病毒治疗依从性的差异化服务提供模式的成本效益的文献。我们在三个学术数据库中检索了2000年1月至2024年3月在撒哈拉以南非洲发表的随机对照试验和观察性研究。使用经过验证的评估系统对每项研究的质量进行评分。
共审查了89篇全文，其中3篇符合所有纳入标准。纳入的三篇文章中有两篇专门针对感染艾滋病毒的青少年。经济强化机会因护理模式而异，包括发展储蓄账户、微型企业讲习班以及现金和非现金有条件激励措施。项目成本和人均成本的主要驱动因素是抗逆转录病毒药物、CD4细胞计数检测和经济强化活动。
本综述中的所有经济评估均发现，将经济强化作为综合差异化服务提供的一部分，在支付意愿阈值至少为国家人均国内生产总值2倍时具有成本效益。本综述中的三项研究中有两项聚焦于青少年，这表明这些类型的护理模式对进入成年期的年轻人可能特别具有成本效益。所有研究均从提供者角度进行，这表明需要更多证据来了解DSD和经济强化干预措施对患者和社会的潜在成本节约情况。测试整合经济强化的DSD模式有效性的随机试验应更加强调对这些类型项目进行成本核算，以了解将这些多层次干预措施扩大规模的可能性。
