HIV treatment engagement interventions for men in Malawi: a mixed-methods economic evaluation

BACKGROUND: Men in sub-Saharan Africa have lower rates of HIV treatment initiation and retention than women. In this mixed-methods study, we created a structured decision-making framework comparing the three interventions tested in the Identifying Efficient Linkage Strategies for Men (IDEaL) trial in Malawi: 1) home-based counseling with lay cadre healthcare workers (HCWs); 2) home-based counseling with lay cadre HCWs plus home-based ART initiation; and 3) stepped interventions deployed sequentially until ART initiation occurred (home-based lay cadre counseling, motivational interviewing with a psychosocial counselor, and home-based ART initiation). METHODS: This study was guided by the Assessing Cost-Effectiveness (ACE) framework. First, we conducted in-depth interviews with high-level international and Malawi-based stakeholders to understand their perceptions and priorities. We analyzed transcripts using thematic content analysis. Next, we conducted an incremental cost-effectiveness analysis of the IDEaL interventions. Finally, we created a decision-making framework for stakeholders deciding whether to adopt and implement the IDEaL interventions. The framework included trial data on the following criteria: effectiveness, intervention cost, feasibility, equity, acceptability, sustainability, and “other considerations.” RESULTS: Both international and Malawi-based stakeholders prioritized client acceptability but diverged elsewhere: international stakeholders prioritized effectiveness while Malawi-based stakeholders prioritized long-term costs, feasibility, and sustainability. Both groups prioritized facility-based interventions and highly valued person-centered care. Average incremental costs per client were higher for the home-based ART ($44) and stepped ($35) interventions than for the counseling-only intervention ($28). The most expensive aspect of the interventions was HCW travel to community-based settings. All three interventions performed better than a standard of care comparison on 6-month retention in HIV care; differences in retention across arms were not statistically significant. The incremental cost-effectiveness ratio (ICER) for the stepped arm compared to the counseling-only arm was $101/participant with a successful outcome (95% CI: -$219, $1,284). The lay cadre counseling-only intervention was the most acceptable, feasible and sustainable option. CONCLUSION: Person-centered, male-tailored counseling with HCWs contributed to the success of the IDEaL interventions and was highly valued by clients and healthcare workers. Counseling with lay cadre HCWs should be prioritized over more expensive interventions, such as community-based psychosocial counseling and ART dispensation for increasing men’s engagement in HIV care.

Author dc:creator

• Hariprasad, Santhi

Advisor dc:contributor.advisor

• Sabin, Lora L.

• Public health

Language dc:language.iso

en_US

Handle dc:identifier.uri

https://hdl.handle.net/2144/48754

OAI identifier oai:identifier

oai:open.bu.edu:2144/48754