Estimating the Cost of Increasing Retention in Care for HIV-Infected Patients

Results of the CDC/HRSA Retention in Care Trial

Ram K. Shrestha, PhD; Lytt Gardner, PhD; Gary Marks, PhD; Jason Craw, MPH; Faye Malitz, MS; Thomas P. Giordano, MD, MPH; Meg Sullivan, MD; Jeanne Keruly, MS; Allan Rodriguez, MD; Tracey E. Wilson, PhD; Michael Mugavero, MD, MHSc


J Acquir Immune Defic Syndr. 2015;68(3):345-350. 

In This Article

Abstract and Introduction


Background Retaining HIV patients in medical care promotes access to antiretroviral therapy, viral load suppression, and reduced HIV transmission to partners. We estimate the programmatic costs of a US multisite randomized controlled trial of an intervention to retain HIV patients in care.

Methods Six academically affiliated HIV clinics randomized patients to intervention (enhanced personal contact with patients across time coupled with basic HIV education) and control [standard of care (SOC)] arms. Retention in care was defined as 4-month visit constancy, that is, at least 1 primary care visit in each 4-month interval over a 12-month period. We used microcosting methods to collect unit costs and measure the quantity of resources used to implement the intervention in each clinic. All fixed and variable labor and nonlabor costs of the intervention were included.

Results Visit constancy was achieved by 45.7% (280/613) of patients in the SOC arm and by 55.8% (343/615) of patients in the intervention arm, representing an increase of 63 patients (relative improvement 22.1%; 95% confidence interval: 9% to 36%; P < 0.01). The total annual cost of the intervention at the 6 clinics was $241,565, the average cost per patient was $393, and the estimated cost per additional patient retained in care beyond SOC was $3834.

Conclusions Our analyses showed that a retention in care intervention consisting of enhanced personal contact coupled with basic HIV education may be delivered at fairly low cost. These results provide useful information for guiding decisions about planning or scaling-up retention in care interventions for HIV-infected patients.


When taken as prescribed, antiretroviral therapy helps HIV-infected patients achieve and maintain viral suppression, which improves their health, and lowers their probability of transmitting HIV to others.[1,2] To receive the full benefits of antiretroviral therapy, HIV-infected patients must engage and remain in continuous care.[3–6] Some HIV-infected patients, however, delay entry into care, or fail to remain or re-engage in care.[7–9] In 2010, the National HIV/AIDS Strategy (NHAS) set a goal to improve retention in HIV care by retaining 80% of patients who are in the Ryan White HIV/AIDS Program.[10]

An estimated 1.1 million people are living with HIV in the United States, and approximately 964,000 of them have been diagnosed and are aware of their infection.[11] Recent studies have found that approximately 75% of HIV-infected patients were linked to HIV care within 3–4 months of diagnosis, but only 50%–60% of them were retained in care.[12,13] Mugavero et al[14] measured retention in 6 different ways, including a 4-month visit constancy measure, that is, at least 1 kept visit with an HIV primary care provider in each 4-month interval, and found that all 6 measures were significantly associated with viral load suppression.

In addition to observational studies of retention, several studies have reported results of interventions to improve retention in care.[15] However, there have been no cost or cost-effectiveness analyses of clinical trials on retention in HIV care. This study is a cost analysis of the programmatic aspects of delivering a clinic-based retention intervention that was part of a multisite randomized controlled trial in the United States.