Sabin, Lora L.West, Rebecca Lynn2024-08-282024-08-282024https://hdl.handle.net/2144/49192BACKGROUND: Improving adherence to antiretroviral therapy (ART) is crucial for achieving HIV epidemic control in South Africa. The SUSTAIN trial aims to identify the most cost-effective package of evidence-based strategies for adherence monitoring (pharmacy refill monitoring (PRM), electronic adherence monitoring (EAM), viral load (VL) monitoring) and support (check-in texts (SMS), enhanced adherence counselling (EC)) for patients newly initiating ART. Participants were randomized to receive one of sixteen combinations of interventions using a multi-phase optimization strategy design. METHODS: First, a cost analysis of implementing SUSTAIN interventions for the first cohort (n=260) of participants was conducted from a health system perspective, using a micro-costing approach that employed three data collection methods: self-reported time and cost worksheets, independent staff observation, and discussions with staff during site visits. Second, a cost-effectiveness analysis was conducted using costing and adherence data from SUSTAIN participants to explore costs for achieving >80%, >90%, and >95% adherence for each intervention component. Third, a forward-looking costing model estimated costs for scaling up the interventions in a real-world setting (City of Cape Town) over a 10-year time horizon. All cost analyses were adjusted for inflation and discounted using an annual rate of 3%. RESULTS: The costs for one person-year of participation in SUSTAIN were $12 for PRM, $25 for VL monitoring, $162 for EAM, $16 for EC and $42 for SMS. Cost-effectiveness analyses showed PRM was cost-saving versus EAM and VL monitoring for achieving all categories of adherence. For support interventions, EC was cost-saving compared to SMS for achieving all categories of adherence. Estimated per annum future costs per patient ranged from $11–$25 for general program costs, $12–$20 for VL monitoring, $69–$122 for EAM, $3–$5 for PRM, $12–$14 for SMS, and $16–$31 for EC. A cost-effectiveness analysis of future costs found SMS would be more cost-saving than EC; the monitoring interventions remained the same. CONCLUSION: EAM was costliest due to high technology costs; however, these will decrease with mass production if scaled up. Pending final cost-effectiveness results from the main SUSTAIN trial, a differentiated approach based on cost and sensitivity of monitoring interventions could be considered for those restarting versus initiating ART. Support options require further investigation.  en-USPublic healthThesis/Dissertation2024-08-280000-0002-2958-0884