The effectiveness and cost-effectiveness of community-based support for adolescents receiving antiretroviral treatment: An operational research study in South Africa

Abstract

Adolescents and youth receiving antiretroviral treatment (ART) in sub-Saharan Africa have high attrition andinadequate ART outcomes, and evaluations of interventions improving ART outcomes amongst adolescents are very limited.Sustainable Development Goal (SDG) target 3c is to substantially increase the health workforce in developing countries. Wemeasured the effectiveness and cost-effectiveness of community-based support (CBS) provided by lay health workers for ado-lescents and youth receiving ART in South Africa.A retrospective cohort study including adolescents and youth who initiated ART at 47 facilities. Previously unem-ployed CBS-workers provided home-based ART-related education, psychosocial support, symptom screening for opportunisticinfections and support to access government grants. Outcomes were compared between participants who received CBS plusstandard clinic-based care versus participants who received standard care only. Cumulative incidences of all-cause mortalityand loss to follow-up (LTFU), adherence measured using medication possession ratios (MPRs), CD4 count slope, and virologicalsuppression were analysed using multivariable Cox, competing-risks regression, generalized estimating equations and mixed-effects models over five years of ART. An expenditure approach was used to determine the incremental cost of CBS to usualcare from a provider perspective. Incremental cost-effectiveness ratios were calculated as annual cost per patient-loss(through death or LTFU) averted.