BACKGROUND: Economic insecurity is associated with poor adherence to antiretroviral therapy (ART) among HIV-infected youth. Family-based economic empowerment (FEE) interventions, which aim to increase household financial stability, have the potential to mitigate the challenges in accessing treatment due to economic insecurity and improve adherence in this vulnerable population. We present efficacy and cost-effectiveness analyses of the Suubi Adherence study, a FEE intervention aiming to improve ART adherence among HIV-positive adolescents in southern Uganda.
METHODS: Intent-to-treat analyses using multilevel logistic regressions compared the effect of the intervention on participants receiving economic incentives and medical and psychosocial support-bolstered standard of care to those only receiving bolstered standard of care. The primary outcome was viral load suppression (< 40 copies/ml) at 24 months. Per-participant costs for each arm were calculated conservatively using the treatment-on-the-treated sample. Intervention effects and per-participant costs were used to compute incremental cost-effectiveness ratios from a provider perspective.
RESULTS: At 24 months, participants in the intervention arm exhibited higher odds of being virally suppressed (OR 2.15; 95% CI 1.12, 4.15; p = 0.022) and had higher mean difference in viral suppression compared to baseline (Percent change: 10.0% versus 1.1%; p = 0.032). Per-participant cost was US$109 for the intervention group, and US$27 for the control group. While the estimated cost of achieving 10% increase in the probability of being virally suppressed was US$71 (95% CI $30, $680), the cost per virally suppressed adolescent was estimated at $923 (95% CI $474, $2982).
CONCLUSIONS: Our findings indicate that the family-based economic empowerment intervention was effective in improving ART adherence among HIV-positive adolescents in Uganda. There is limited evidence regarding the cost-effectiveness of medication adherence for HIV in particular, and for chronic diseases in general. This study contributes with findings on ART adherence from low resource settings, that can aid policymakers in developing guidelines and programming for HIV care in such contexts.
Funding: National Institute of Child Health and Human Development at the National Institutes of Health (Grant #1 R01-HD074949-01, PI: FMS). Eunice Kennedy Shriver National Institute of Child Health and Human Development (PI: FMS).