TitleTreatment Outcomes and Cost-Effectiveness of Shifting Management of Stable ART Patients to Nurses in South Africa: An Observational Cohort
AuthorsLong L., Brennan A., Fox M.P., Ndibongo B., Jaffray I., Sanne I., Rosen S.
PublicationPLOS Medicine. 2011 Jul; 8(7):1-10.


To address human resource and infrastructure shortages, resource-constrained countries are being encouraged to shift HIV care to lesser trained care providers and lower level health care facilities. This study evaluated the cost-effectiveness of down-referring stable antiretroviral therapy (ART) patients from a doctor managed, hospital-based ART clinic to a nurse-managed primary health care facility in Johannesburg, South Africa.

Methods and Findings:

Criteria for down-referral were stable ART ($11 mo), undetectable viral load within the previous 10 mo, CD4.200 cells/mm3, ,5% weight loss over the last three visits, and no opportunistic infections. All patients downreferred from the treatment-initiation site to the down-referral site between 1 February 2008 and 1 January 2009 were compared to a matched sample of patients eligible for down-referral but not down-referred. Outcomes were assigned based on vital and health status 12 mo after down-referral eligibility and the average cost per outcome estimated from patient medical record data. The down-referral site (n = 712) experienced less death and loss to follow up than the treatment-initiation site (n = 2,136) (1.7% versus 6.2%, relative risk = 0.27, 95% CI 0.15–0.49). The average cost per patientyear for those in care and responding at 12 mo was US$492 for down-referred patients and US$551 for patients remaining at the treatment-initiation site (p,0.0001), a savings of 11%. Down-referral was the cost-effective strategy for eligible patients.


Twelve-month outcomes of stable ART patients who are down-referred to a primary health clinic are as good as, or better than, the outcomes of similar patients who are maintained at a hospital-based ART clinic. The cost of treatment with down-referral is lower across all outcomes and would save 11% for patients who remain in care and respond to treatment. These results suggest that this strategy would increase treatment capacity and conserve resources without compromising patient outcomes.
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Related ProjectsEconomics and Epidemiology of HIV/AIDS, Tuberculosis, and Non-Communicable Diseases in Africa
Costs and Outcomes of HIV Treatment in South Africa