Abstract
IMPORTANCE: The Daraja randomized clinical trial was a linkage case management intervention designed to improve HIV care engagement. Understanding the economic value of this type of case management intervention is essential to decision-makers in resource-constrained settings seeking to minimize HIV-related morbidity and mortality. OBJECTIVE: To evaluate the cost-effectiveness of Daraja compared with enhanced standard care from the Tanzania Ministry of Health and societal perspectives. DESIGN, SETTING, AND PARTICIPANTS: This prospective economic evaluation was conducted alongside the Daraja randomized clinical trial at 20 hospitals in Northwestern Tanzania from March 2019 to May 2023. Participants were patients hospitalized with HIV randomly assigned 1:1 to receive either the Daraja intervention or enhanced standard care and were followed up for 12 months through March 2023. Data were analyzed from May 2024 to March 2025. EXPOSURE: The Daraja intervention group received up to 5 sessions conducted by a social worker at the hospital, in the home, and in the HIV clinic over a 3-month period. The enhanced standard care group received predischarge HIV counseling and assistance in scheduling an HIV clinic appointment. MAIN OUTCOMES AND MEASURES: The primary outcome was the cost per disability-adjusted life-year (DALY) averted for Daraja vs standard care, assessed from Ministry of Health and societal perspectives at 3 months (intervention) and 12 months (intervention plus follow-up). RESULTS: Among 500 participants, the mean (SD) age was 37 [12] years, and 384 participants (77%) were female. Participants in the intervention group incurred more costs from the Tanzanian Ministry of Health perspective over the 3-month intervention period ($43.4 vs $24.0; difference, $19.4 [95% CI, $9.2 to $29.6]) and over the 12-month observation period ($101.6 vs $78.2; difference, $23.4 [95% CI, $8.0 to $38.9]). From the societal perspective, Daraja incurred more costs than standard care at 3 months ($72.4 vs $47.4; difference, $25.0 [95% CI, $2.0 to $48.0]) but not 12 months ($182.7 vs $160.5; difference, $22.2 [95% CI, -$16.4 to 60.8]). DALYs were lower for Daraja participants at both the 3-month (1.2 [95% CI, 1.1 to 1.2] DALYs averted, annualized) and 12-month (1.1 [95% CI, 1.3 to 3.7] DALYs averted) time points. CONCLUSIONS AND RELEVANCE: In this economic evaluation of the Daraja intervention, Daraja was more costly than standard care from both the Tanzanian Ministry of Health and societal perspectives; however, it was associated with improvements in DALYs. These findings suggest that Daraja has a high probability of being considered cost-effective from both economic perspectives.