Email updates

Keep up to date with the latest news and content from BMC Public Health and BioMed Central.

Open Access Research article

Retention in care, resource utilization, and costs for adults receiving antiretroviral therapy in Zambia: a retrospective cohort study

Callie A Scott12, Hari S Iyer2, Kelly McCoy1, Crispin Moyo34, Lawrence Long5, Bruce A Larson16* and Sydney Rosen15

Author Affiliations

1 Center for Global Health and Development, Boston University, Crosstown Center, 3rd Floor, 801 Massachusetts Avenue, Boston, MA 02118, USA

2 Zambia Center for Applied Health Research and Development, Plot 4649 Beit Road, Rhodes Park, P.O. Box 30910, Lusaka 10101, Zambia

3 Zambian Ministry of Health, Ndeke House, P.O. Box 30205, Lusaka 10101, Zambia

4 Vanderbilt Institute of Global Health, Vanderbilt University, 2525 West End Avenue, Suite 750, Nashville, TN 37203, USA

5 Health Economics and Epidemiology Research Office, Wits Health Consortium, Department of Clinical Medicine, School of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Helen Joseph Hospital, Perth Road, Westdene, Johannesburg 2092, South Africa

6 Department of International Health, School of Public Health, Boston University, Crosstown Center, 3rd Floor, 801 Massachusetts Avenue, Boston, MA 02118, USA

For all author emails, please log on.

BMC Public Health 2014, 14:296  doi:10.1186/1471-2458-14-296

Published: 31 March 2014



Of the estimated 800,000 adults living with HIV in Zambia in 2011, roughly half were receiving antiretroviral therapy (ART). As treatment scale up continues, information on the care provided to patients after initiating ART can help guide decision-making. We estimated retention in care, the quantity of resources utilized, and costs for a retrospective cohort of adults initiating ART under routine clinical conditions in Zambia.


Data on resource utilization (antiretroviral [ARV] and non-ARV drugs, laboratory tests, outpatient clinic visits, and fixed resources) and retention in care were extracted from medical records for 846 patients who initiated ART at ≥15 years of age at six treatment sites between July 2007 and October 2008. Unit costs were estimated from the provider’s perspective using site- and country-level data and are reported in 2011 USD.


Patients initiated ART at a median CD4 cell count of 145 cells/μL. Fifty-nine percent of patients initiated on a tenofovir-containing regimen, ranging from 15% to 86% depending on site. One year after ART initiation, 75% of patients were retained in care. The average cost per patient retained in care one year after ART initiation was $243 (95% CI, $194-$293), ranging from $184 (95% CI, $172-$195) to $304 (95% CI, $290-$319) depending on site. Patients retained in care one year after ART initiation received, on average, 11.4 months’ worth of ARV drugs, 1.5 CD4 tests, 1.3 blood chemistry tests, 1.4 full blood count tests, and 6.5 clinic visits with a doctor or clinical officer. At all sites, ARV drugs were the largest cost component, ranging from 38% to 84% of total costs, depending on site.


Patients initiate ART late in the course of disease progression and a large proportion drop out of care after initiation. The quantity of resources utilized and costs vary widely by site, and patients utilize a different mix of resources under routine clinical conditions than if they were receiving fully guideline-concordant care. Improving retention in care and guideline concordance, including increasing the use of tenofovir in first-line ART regimens, may lead to increases in overall treatment costs.

HIV/AIDS; Adult; Antiretroviral therapy; Resource-limited setting; Costs; Outcomes; Zambia