BACKGROUND: In 2018 Mozambique’s Ministry of Health launched a guideline to implement eight differentiated service delivery models (DSDMs) to optimize HIV service delivery, improve retention in care, and ultimately reduce HIV associated mortality. The models were:
(1) Fast-track (FT),
(2) Three-month Antiretrovirals Dispensing (3M),
(3) Community Antiretroviral Therapy (ART) Groups (CAGs),
(4) Adherence Clubs (AC),
(5) Family-approach (FA), and three one-stop shop models:
(6) adolescent-friendly health services (OSS-AFHS),
(7) maternal and child health (OSS-MCH), and
(8) tuberculosis (OSS-TB).
We conducted a cost-effectiveness analysis (CEA) and a budget impact analysis (BIA) comparing these DSDMs to conventional services.
METHODS: We constructed a decision tree model based on the percentage of enrolment on each DSDM and the probability of the outcome (12-months retention on ART), with and without DSDMs implementation, for each year of the study period; three for CEA (2019 to 2021), and three for BIA (2022 to 2024). The economic and financial costs for CEA and BIA, respectively, were estimated per client-year from the health system perspective, and included start-up, ARV drugs, laboratory tests, and clinical and pharmacy visits. Effectiveness was estimated using the Mozambique ART database, employing an uncontrolled interrupted time series analysis comparing the outcome before and during the implementation of DSDMs. A one-way sensitivity analysis was conducted to identify drivers of uncertainty.
RESULTS: During the three years of DSDMs implementation, there was a mean increase of 14.9 percentage points (95% Confidence Interval (CI): 12.2, 17.8) in 12-months retention comparing DSDMs implementation (62.5% [95%CI: 60.9, 64.1]) to conventional care (47.6% [95%CI: 44.9, 50.2]), and the mean base-case economic cost per person-year was estimated to be $253 and $359 for DSDMs and convention care, respectively; therefore, DSDMs dominated conventional care. The base-case 3-year financial costs associated with the DSDMs and the conventional care for a population of 1,535,575 were estimated to be $1,653,814,275 and $990,194,425, respectively. The results were most sensitive to clinical visits costs.
CONCLUSIONS: DSDMs were less expensive and more effective in retaining clients 12-months after ART initiation, and their implementation was estimated to save approximately $670 million to the health system from 2022 to 2024.