Cost-effectiveness and feasibility of conditional economic incentives and motivational interviewing to improve HIV health outcomes of adolescents living with HIV in Anambra State, Nigeria

Abstract

Background In sub-Saharan Africa, there is increasing mortality and morbidity of adolescents due to poor linkage, retention in HIV care and adherence to antiretroviral therapy (ART). This is a result of limited adolescent-centred service delivery interventions. This cost-effectiveness and feasibility study were piggybacked on a cluster-randomized trial that assessed the impact of an adolescent-centred service delivery intervention. The service delivery intervention examined the impact of an incentive scheme consisting of conditional economic incentives and motivational interviewing on the health outcomes of adolescents living with HIV in Nigeria. Method A cost-effectiveness analysis from the healthcare provider’s perspective was performed to assess the cost per additional patient achieving undetected viral load through the proposed intervention. The cost-effectiveness of the incentive scheme over routine care was estimated using the incremental cost-effectiveness ratio (ICER), expressed as cost/patient who achieved an undetectable viral load. We performed a univariate sensitivity analysis to examine the effect of key parameters on the ICER. An in-depth interview was conducted on the healthcare personnel in the intervention arm to explore the feasibility of implementing the service delivery intervention in HIV treatment hospitals in Nigeria. Result The ICER of the Incentive Scheme intervention compared to routine care was US$1419 per additional patient with undetectable viral load. Going by the cost-effectiveness threshold of US$1137 per quality-adjusted life-years suggested by Woods et al., 2016, the intervention was not cost-effective. The sensitivity test showed that the intervention will be cost-effective if the frequency of CD4 count and viral load tests are reduced from quarterly to triannually. Healthcare professionals reported that patients’ acceptance of the intervention was very high. Conclusion The conditional economic incentives and motivational interviewing was not cost-effective, but can become cost-effective if the frequency of HIV quality of life indicator tests are performed 1–3 times per annum. Patients’ acceptance of the intervention was very high. However, healthcare professionals believed that sustaining the intervention may be difficult unless factors such as government commitment and healthcare provider diligence are duly addressed. Trial registration This trial is registered in the WHO International Clinical Trials Registry through the WHO International Registry Network (PACTR201806003040425).

Interventions to Improve Treatment Outcomes among Adolescents on Antiretroviral Therapy with Unsuppressed Viral Loads: A Systematic Review

“…The characteristics of the included studies are summarized in Table 1 . All included studies were published between 2018 and 2021; with one paper still in pre-print form [ 26 ]. All the included studies were conducted in sub-Saharan Africa (SSA): two in Zimbabwe [ 27 , 28 ] and in Uganda [ 29 , 30 ], and one in Nigeria [ 26 ].…”

“…All included studies were published between 2018 and 2021; with one paper still in pre-print form [ 26 ]. All the included studies were conducted in sub-Saharan Africa (SSA): two in Zimbabwe [ 27 , 28 ] and in Uganda [ 29 , 30 ], and one in Nigeria [ 26 ]. Four studies were parallel, or cluster randomized controlled trials [ 26 , 27 , 28 , 30 ], and one was a retrospective cohort study [ 29 ].…”

“…All the included studies were conducted in sub-Saharan Africa (SSA): two in Zimbabwe [ 27 , 28 ] and in Uganda [ 29 , 30 ], and one in Nigeria [ 26 ]. Four studies were parallel, or cluster randomized controlled trials [ 26 , 27 , 28 , 30 ], and one was a retrospective cohort study [ 29 ]. The sample sizes ranged from 134 to 479 participants.…”

“…Four types of interventions to improve viral suppression among ALHIV challenged with achieving viral suppression were identified: intensified adherence counselling (IAC) [ 29 ], differentiated service delivery (DSD) [ 27 , 28 ], family based economic empowerment [ 30 ], and conditional economic incentives with motivational interviewing [ 26 ].…”

“…The conditional economic incentives and motivational interviewing intervention was implemented in Nigeria to adolescents aged 10–19 years old who had unsuppressed viral loads [ 26 ]. Participants received US$ 5.6 if they achieved a viral load of less than 20 copies/mL for the first three months; then received US $2.8 if they maintained viral suppression for the next three months, and then again for the next six months.…”