Kate Condliffe from the Clinton Health Access Initiative (CHAI) presented a very interesting costing study at the International HIV Treatment as Prevention meeting in Vancouver Monday. The study analyzed the cost of providing antiretroviral therapy (ART) at the facility level at 161 representative facilities in Ethiopia, Malawi, Rwanda, South Africa and Zambia. This was a top-down study that assessed the total costs of ART at the facility divided by the total patient years, to arrive at an average cost per patient-year.
The facility costs were much lower than expected, ranging from $136 per patient per year in Malawi to $692 per patient per year in South Africa. Costs are higher in South Africa due to higher salaries and more lab testing. Antiretrovirals (ARVs) constituted about 50 percent of the total costs and ARVS plus personnel contributed to 70 percent of total costs. Lab spending was generally low with an average of only 1.2 to 1.5 CD4 tests per year per patient. ARV costs are driven by regimen choice, but prices are declining and the increases in cost associated with the movement away from D4T will not be as great as expected given the falling price of tenofovir, according to the study authors. Personnel costs were generally low and driven by staff mix. The total amount of annual resources expended in these countries for treatment at the facility level was less than $1 billion. (This figure does not include facility treatment expenditures for South Africa).
Utilization rates for HIV treatment services were low in many sites, suggesting the potential to scale up without increasing costs significantly at existing facilities. Attrition rates were better than expected with a range of two percent in Rwanda to eight percent in South Africa at 12 months. Rwanda was the clear stand out in successfully managing new patients and retaining them in care.
The bottom line according to Condliffe – “There are not significant savings opportunities to be had in the cost of HIV treatment at the facility level outside of South Africa.” There are opportunities to improve outcomes by identifying HIV-infected patients sooner and initiating ART earlier. One quarter of the facilities were initiating treatment in most patients at CD4 counts below 100.
Given low cost levels, aggressive HIV treatment scale up should be possible, Condlifee said. There is a need to optimize spending above the facility level and to optimize spending on non-treatment costs. In a later presentation by Stephen Becker from the Bill & Melinda Gates Foundation, the funder of this CHAI study, he noted that work is continuing to analyze costs “above the facility level.” Inquiring minds look forward to that analysis.