BACKGROUND: Lesotho, the country with the second highest HIV prevalence (23.6%) in the world, has made considerable progress towards achieving UNAIDS' '95-95-95' targets. Recent success in improving treatment access to all known HIV positive individuals has severely strained existing healthcare infrastructure and financial and human resources. Lesotho has a largely rural population, creating a significant burden to patients in terms of time and financial costs to visit healthcare facilities. With data from a cluster randomized non-inferiority trial of community-based differentiated models of multi-month ART delivery implemented in 2017-2019, we evaluated the impact of differentiated service delivery (DSD) models for ART delivery on costs to the provider and patient in Lesotho.
METHODS: For this analysis, we estimated the total cost per patient retained 12 months after entry into a DSD model. We evaluated the standard of care (SOC) (quarterly facility visits and ART dispensing), community adherence groups with 3-month dispensing (CAGs), and community ART distribution with 6-month dispensing. We calculated the cost per patient treated from provider and patient perspectives and the cost per patient retained from the provider perspective. Provider costs included medications, laboratory tests, clinical visits, and interactions with DSD models. Patient costs included transport time and opportunity costs to clinical visits and interactions with DSD models. Costs are reported in 2018 USD.
RESULTS: The 12-month retention and average annual cost of providing HIV care and treatment was comparable across all three study arms (Table 1). There was a strong reduction in patient costs, however, for both DSD arms: 63% reduction for CAGs compared to SOC and 58% reduction for 6-month community ART distribution compared to SOC.

CONCLUSIONS: In Lesotho, community-based DSD models for HIV treatment are not likely to reduce costs for providers. They offer a substantial savings to patients, however, and may thereby support long-term adherence and retention in care.