Abstract Background Differentiated service delivery (DSD) is increasingly available for HIV treatment. DSD has been shown to improve treatment retention, but DSD modalities incur higher costs than the clinic-based standard-of-care (SoC). We conducted a cost-effectiveness (CE) analysis to assess what DSD modalities, in what settings, would constitute an efficient use of limited HIV program resources. Methods We adapted two validated mathematical models (EMOD-HIV and HIV Synthesis) to project HIV trends (incidence, prevalence, mortality), disability-adjusted life years (DALYs), and costs (2021 USD) arising from DSD versus SoC over 2022–2062 in four settings: South Africa, Malawi, Zambia, and a collective representation of African low- and middle-income countries (LMICs). We compared three DSD modalities: healthcare worker-managed community adherence groups (CAG), client-managed urban adherence group (UAG), and home ART delivery (HomeART). We calculated incremental cost-effectiveness ratios (ICERs) of DSD versus SoC from the health system perspective using country-specific CE thresholds, and performed one-way sensitivity analyses for key assumptions. Results Community adherence groups (ICER: 274–604/DALY averted) and UAG (ICER: 590–720/DALY averted) were cost-effective for all country/model settings. HomeART was dominated by UAG in all settings. In nearly all settings, CE estimates of CAG were robust to uncertainty in DSD effectiveness (except Zambia), DSD costs, CE threshold (except South Africa), HIV-associated disability weights, and discount rates. Cost-effectiveness of UAG was highly sensitive to uncertainty in DSD effectiveness in all settings. Conclusions Community adherence groups and UAG can provide cost-effective alternatives to the clinic-based SoC in multiple African settings.
You et al. (Mon,) studied this question.