An Enhanced Retention Strategy to Prevent the Vertical Transmission of HIV in Uganda: A Budget Impact Analysis

Background Novel retention strategies have the potential to reduce vertical transmission of HIV and improve patient outcomes for women living with HIV (WLHIV) and their infants. We estimated the budget impact of the enhanced retention strategy (ERS) compared with the Ministry of Health strategy/standard of care (SOC) approach for preventing vertical transmission of HIV among women initiating antiretroviral therapy (ART) in late pregnancy in Uganda. Methods A budget impact analysis (BIA) was conducted from the payer (Uganda’s Ministry of Health) perspective with a 5-year time horizon. A Microsoft Excel-based BIA model was populated with HIV epidemiological data and expenditures from the literature and the clinical trial of dolutegravir in pregnant HIV mothers and their neonates. These cost projections accounted for various programmatic inputs, disease progression, differences in mortality based on treatment status, and subsequent pregnancies. The eligible population included all HIV-positive pregnant women currently receiving prevention of vertical transmission services in Uganda. The primary outcomes of the analysis were incremental budget costs, and infections averted over 5 years. Results Adopting the ERS would lead to a net cost increase of US$63.8 million over the next 5 years, or a net cost increase of US$12.7 million per year compared with the SOC. Newly enrolled WLHIV accounts for US$39.5 million of these marginal costs, while in-system patients account for US$24.2 million. Direct programmatic costs of the ERS only account for 13% of this additional cost, with 87% of the marginal increase coming from the cost of providing ART for WLHIV who would otherwise be lost to follow-up. The ERS would avert an additional 6933 infant infections compared with the SOC. Conclusion Implementing the ERS would significantly increase the Ugandan Ministry of Health's budget, but most additional costs would be accrued from the resulting expansion of ART client volume. The ERS is a relatively low-cost intervention to reduce loss to follow-up rates among marginalized and hard-to-reach populations.