Estimating the cost-effectiveness of nutrition supplementation for malnourished, HIV-infected adults starting antiretroviral therapy in a resource-constrained setting

Abstract

BackgroundLow body mass index (BMI) individuals starting antiretroviral therapy (ART) for HIV infection in sub-Saharan Africa have high rates of death and loss to follow-up in the first 6 months of treatment. Nutritional supplementation may improve health outcomes in this population, but the anticipated benefit of any intervention should be commensurate with the cost given resource limitations and the need to expand access to ART in the region.MethodsWe used Markov models incorporating historical data and program-wide estimates of treatment costs and health benefits from the Zambian national ART program to estimate the improvements in 6-month survival and program retention among malnourished adults necessary for a combined nutrition support and ART treatment program to maintain cost-effectiveness parity with ART treatment alone. Patients were stratified according to World Health Organization criteria for severe (BMI <16.0 kg/m2), moderate (16.00-16.99 kg/m2), and mild (17.00-18.49 kg/m2) malnutrition categories.Results19,247 patients contributed data between May 2004 and October 2010. Quarterly survival and retention were lowest in the BMI <16.0 kg/m2 category compared to higher BMI levels, and there was less variation in both measures across BMI strata after 180 days. ART treatment was estimated to cost $556 per year and averted 7.3 disability-adjusted life years. To maintain cost-effectiveness parity with ART alone, a supplement needed to cost $10.99 per quarter and confer a 20% reduction in both 6-month mortality and loss to follow-up among BMI <16.0 kg/m2 patients. Among BMI 17.00-18.49 kg/m2 patients, supplement costs accompanying a 20% reduction in mortality and loss to follow-up could not exceed $5.18 per quarter. In sensitivity analyses, the maximum permitted supplement cost increased if the ART program cost rose, and fell if patients classified as lost to follow-up at 6 months subsequently returned to care.ConclusionsLow BMI adults starting ART in sub-Saharan Africa are at high risk of early mortality and loss to follow-up. The expense of providing nutrition supplementation would require only modest improvements in survival and program retention to be cost-effective for the most severely malnourished individuals starting ART, but interventions are unlikely to be cost-effective among those in higher BMI strata.

Predictors of mortality within the first year of initiating antiretroviral therapy in urban and rural Kenya: A prospective cohort study

“…While nutritional supplementation and food assistance have effectively increased BMI in some [54–57], but not all studies [58], such interventions have not been shown to significantly decrease short-term mortality risk in HIV-infected adults [58, 59]. However, evidence is limited and nutritional supplementation has been shown to be cost-effective for reducing mortality in severely underweight individuals [60].…”

Managing Knowledge in Computational Models for Global Food, Nutrition and Health Technologies

“…[8,9] Food and nutrition therapy administration (FNTA) is important and integral in the management of HIV/AIDS patients in both self and managed care [10,11], especially in Developing Countries where weight loss is widespread due to malnutrition [12]. According to Koethe et al [13] and Martinez et al [14], in Sub-Saharan Africa and Honduras, there are high death rates and low health outcomes in HIV/AIDS patients who start anti-retroviral therapy (ART) with low body mass index (BMI), which mandates FNTA under severe personal and organisational resource limitations. Further to this, Cark and Cress [15] point out that FNTA should be personalised in order to be effective for HIV/AIDS patients, which requires any appropriate technologies to support customisation of incorporated knowledge.…”

Nutrition Therapy for HAART-Naïve HIV-Infected Patients

“…In the areas of food insecurity, this action is quite limited. Besides the food shortage in these regions, ensuring adequate food supply requires government strategic planning to better access to health networks and nutritionists, that is, it involves costs often unavailable in nutritional risk areas [31,66].…”