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COST-EFFECTIVENESS OF HOME-BASED CHLORINATION AND SAFE WATER STORAGE IN REDUCING DIARRHEA AMONG HIV-AFFECTED HOUSEHOLDS IN RURAL UGANDA

Safe water systems (SWSs) have been shown to reduce diarrhea and death. We examined the cost-effectiveness of SWS for HIV-affected households using health outcomes and costs from a randomized controlled trial in Tororo, Uganda. SWS was part of a home-based health care package that included rapid diarrhea diagnosis and treatment of 196 households with relatively good water and sanitation coverage. SWS use averted 37 diarrhea episodes and 310 diarrhea-days, representing 0.155 disability-adjusted life year (DALY) gained per 100 person-years, but did not alter mortality. Net program costs were $5.21/episode averted, $0.62/diarrhea-day averted, and $1,252/DALY gained. If mortality reduction had equaled another SWS trial in Kenya, the cost would have been $11/DALY gained. The high SWS cost per DALY gained was probably caused by a lack of mortality benefit in a trial designed to rapidly treat diarrhea. SWS is an effective intervention whose cost-effectiveness is sensitive to diarrhea-related mortality, diarrhea incidence, and effective clinical management.

Received July 27, 2005. Accepted for publication January 2, 2006.

Acknowledgments: The authors thank Tororo Hospital administrative and clinical staff; the volunteers, staff, and clients of TASO; the US Embassy in Kampala; GAP headquarters; staff of CDC-Uganda, including the informatics, clinical, laboratory, and administrative units of CDC-Tororo.

Financial support: This study was funded by CDC and approved by the Science and Ethics Committee of the Uganda Virus Research Institute, the Uganda National Council of Science and Technology, and the Institutional Review Board of CDC.

^* Address correspondence to Ram Shrestha, Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS E-48, Atlanta, GA 30333. E-mail: rshrestha{at}cdc.gov

Authors’ addresses: Ram K. Shrestha and John M. Blandford, Global AIDS Program, National Center for HIV, STD and TB Prevention, Centers for Disease Control and Prevention (CDC), Atlanta, GA 30333, E-mails: rshrestha{at}cdc.gov and jblandford{at}cdc.gov; Elliot Marseille, Health Strategies International, Orinda, CA 94563, E-mail: emarseille{at}comcast.net. James G. Kahn, Institute for Health Policy Studies, University of California, San Francisco, CA 94143, E-mail: jgkahn{at}ucsf.edu. John R. Lule, Rebecca Bunnell, and Jonathan Mermin, CDC-Uganda, Global AIDS Program, National Center for HIV, STD and TB Prevention, and Uganda Virus Research Institute, Entebbe, Uganda, E-mails: nz14{at}ug.cdc.gov, rrb7{at}ug.cdc.gov, and jhm7{at}ug.cdc.gov. Christian Pitter, CDC-Uganda and Institute for Global Health and Department of Pediatrics, University of California, San Francisco, CA 94143, E-mail: christian{at}ug.cdc.gov. Alex Coutinho and Francis Kizito, The AIDS Support Organization, Entebbe, Uganda, E-mails: coutinhoa{at}tasouganda.org and afbkizito2002{at}yahoo.co.uk. Robert Quick, Foodborne and Diarrheal Diseases Branch, Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, CDC, Atlanta, GA 30329, E-mail: rquick{at}cdc.gov.