Framework for determining the optimal course of action when efficiency and affordability measures differ by perspective in cost-effectiveness analysis—with an illustrative case of HIV treatment in Mozambique

Table 3 Cost-effectiveness of HIV treatment approaches in Mozambique (by perspective)

Intervention	Total cost per PLHIV	Total DALYs averted	Average survival	Average time on ART	Average annual cost on ART	Incremental cost^a	Incremental DALYs averted^a	ICER (cost per DALY averted)
Patient perspective
Clinical 6-month ARV distribution	$24.15	10.79	24.6 years	16.9 years	$2.16	Reference	Reference	Reference
Mixed community 3-month and clinical 6-month ARV distribution	$25.29	11.21	25.9 years	19.2 years	$2.08	$1.14	0.42	$2.71
Community 3-month ARV distribution	$26.82	11.74	27.6 years	22.5 years	$2.01	$1.53	0.53	$2.89
Clinical 3-month ARV distribution (status quo)	$33.49	9.86	21.9 years	12.2 years	$3.72	$6.67	−1.88	Dominated
Clinical 3-month ARV distribution with LTFU case management	$47.03	11.92	28.5 years	20.7 years	$3.69	$20.21	0.18	$112.28
Clinical 1-month ARV distribution	$77.92	9.37	20.5 years	10.3 years	$9.83	$30.89	−2.55	Dominated
Health sector perspective
Clinical 3-month ARV distribution (status quo)	$1284	9.87	21.9 years	12.2 years	$142	Reference	Reference	Reference
Clinical 6-month ARV distribution	$1405	10.80	24.6 years	16.8 years	$125	$121	0.93	$130
Clinical 1-month ARV distribution	$1548	9.39	20.6 years	10.4 years	$195	$143	−1.41	Dominated
Mixed community 3-month and clinical 6-month ARV distribution	$2073	11.22	25.9 years	19.2 years	$170	$668	0.42	$1590
Community 3-month ARV distribution	$2905	11.74	27.6 years	22.5 years	$218	$832	0.52	$1600
Clinical 3-month ARV distribution with LTFU case management	$6203	11.93	28.5 years	20.8 years	$486	$3298	0.19	$17,358

All values discounted 5% per year (except the average annual cost on ART), and all currency values are in 2020 USD. Slight differences in health outcomes for the same intervention were observed between the two different perspectives. This is due to first-order uncertainty in the model
ART antiretroviral therapy, ARV antiretroviral drug, DALY disability-adjusted life year, HIV human immunodeficiency virus, ICER incremental cost-effectiveness ratio, LTFU lost to follow-up, PLHIV person living with HIV
^aIncremental costs and incremental DALYs averted are calculated as the increment between an intervention and the next non-dominated intervention

ISSN: 1478-7547