# Economic evaluation of digital health interventions to improve quality-adjusted life years in adolescents living with HIV in Ethiopia

## TL;DR

This study shows that SMS reminders improve health outcomes for HIV-positive adolescents in Ethiopia at a low cost.

## Contribution

The study provides new evidence on the cost-effectiveness of SMS interventions for improving QALYs in adolescents with HIV in Ethiopia.

## Key findings

- SMS reminders were cost-effective with an ICER of $1,037 per QALY gained.
- Participants with SMS reminders had higher utility scores and QALYs compared to controls.
- Anxiety/depression and pain/discomfort were key factors influencing QALYs.

## Abstract

The rapid expansion of mobile phone access has enabled low-cost SMS interventions to support adherence to antiretroviral therapy (ART). Although text messaging improves adherence and retention in HIV care, its cost-effectiveness for enhancing quality of life remains uncertain, particularly among adolescents in resource-limited settings. This study evaluated whether SMS reminders improve retention in care and quality-adjusted life years (QALYs) among adolescents living with HIV in Ethiopia. We hypothesized that SMS reminders would increase adherence and retention, leading to measurable gains in quality of life.

A 6-month economic evaluation was conducted from the health system perspective, comparing daily SMS reminders plus standard care vs. standard care alone. HRQoL was measured using the EuroQol EQ-5D-3L instrument, which includes five domains: mobility, self-care, usual activity, pain/discomfort, and anxiety/depression. Utility values were derived using the Zimbabwean EQ-5D-3L value set as a proxy for Ethiopia and converted into QALYs. Costs were categorized as fixed (planning, system development, training) and variable (personnel, SMS communication, equipment, and overhead), valued in 2023 US dollars (USD; 1 USD = 54.7442 ETB). The Incremental Cost-Effectiveness Ratio (ICER) was calculated as ΔCost/ΔQALY. The WHO-CHOICE cost-effectiveness threshold (<3 × GDP per capita; $3,636 for Ethiopia, 2023) guided interpretation.

Daily SMS reminders were cost-effective according to WHO thresholds, with an ICER of $1,037.00 per QALY gained. Accounting for potential retention improvements, the ICER decreased to $864.00 per QALY gained. Intervention participants had higher utility scores (0.9515 vs. 0.9030) and QALYs (0.4760 vs. 0.4510) compared to controls.

SMS-based adherence interventions offer a cost-efficient approach to improving ART outcomes by enhancing adherence and retention. Anxiety/depression and pain/discomfort were key determinants of QALYs. Future research should assess long-term cost-effectiveness and scalability in resource-limited settings.

PACTR202107638293593.