1. 1. Kheth’Impilo, Cape Town, South Africa
The Effectiveness and Cost-Effectiveness of Community-Based Support for Adolescents Receiving Antiretroviral Treatment
Geoffrey Fatti1, Debra Jackson2,3, Ameena Goga4,5, Najma Shaikh1, Brian Eley6, Jean B. Nachega7,8,9, Ashraf Grimwood1
1. Kheth’Impilo, Cape Town, South Africa
2. UNICEF, New York, NY, USA
3. School of Public Health, University of the Western Cape, Cape Town, South Africa
4. Health Systems Research Unit, South African Medical Research Council, South Africa
5. Department of Paediatrics, University of Pretoria, Pretoria, South Africa
6. Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, University of Cape Town, Cape Town, South Africa
7. Departments of Epidemiology, Infectious Diseases and Microbiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
8. Department of Medicine and Centre for Infectious Diseases, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
9. Departments of Epidemiology and International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA

2. Background
2000 YWG infected a week in SA, increasing the treatment burden
Adolescents on ART have increased attrition and poorer treatment outcomes
AIDS-related mortality amongst adolescents is increasing.
Effectiveness and cost-effectiveness evaluations of interventions improving ART outcomes are limited.
Aim: Measure the effectiveness and cost-effectiveness of a large community-based support program for adolescents and youth receiving ART in South Africa.
Study design: Cohort study including adolescents & youth initiating ART at 47 facilities.
Cost-effectiveness methods: Expenditure approach used to determine the incremental cost of CBS to usual care from a provider perspective. Incremental cost- effectiveness ratios calculated as annual cost/patient-loss (through death or LTFU) averted.

3. Results: Cumulative incidence of loss to follow-up and mortality after starting ART
6706 participants included, followed for 9215 person-years
Loss to follow-up Mortality
adjusted hazard ratio: 0.60 (95% CI: ); P<0.0001).
aHR: 0.52 (95% CI: ); P<0.0001).

4. Cost and cost-effectiveness of community-based support
Item
Average costs per patient-year supported, US$ (%)
Human Resources
$41.83 (84.4%)
Training
$5.97 (12.1%)
Infrastructure and equipment
$0.02 (0.05%)
Clothing for CBS-workers
$0.15 (0.3%)
Management and administration
$0.48 (1.0%)
Monitoring and evaluation
$0.10 (0.2%)
Overhead costs
$0.99 (2.0%)
Total cost per patient supported/ year
$49.5 (100.0%)
Duration of ART (years)
Effectiveness of intervention in reducing patient attrition (%)
Cost-effectiveness ratio (US$/patient-loss averted) 1
42.2%
$600.7 2
40.3%
$776.3 3
38.7%
$892.1 4
37%
$1007.7 5
35.9%
$1149.1

5. Conclusions
Community-based adherence support for adolescents and youth receiving ART was associated with substantially improved patient retention.
CBAS is a low-cost intervention, with reasonable cost- effectiveness.
Cost–effectiveness was maximal during first two years of treatment.
Policy that supports CBAS for adolescents and youth receiving ART may contribute to reducing AIDS-related mortality in the SA context.

6. Acknowledgements PEPFAR & USAID
Global Fund to Fight AIDS, Tuberculosis and Malaria
South African Department of Health
Funders and partners
This research has been supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) through USAID under the terms of AID-674-A This presentation and the data made herein was made possible through the generous support of our donors; the content of this presentation is a sole responsibility of Kheth’Impilo and do not necessarily reflect the views or opinions of our donors.