GAO report highlights complexities of analyzing PEPFAR treatment costs

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GAOCostCoverWith the groundwork for treatment provided through the President’s Emergency Plan For AIDS Relief having been laid in the first expensive years of country programs, with the purchases of generic antiretroviral drugs, and with economies of scale as the numbers of people enrolled in treatment increased, PEPFAR has reduced per patient treatment costs in recent years — but the information on costs that PEPFAR has gathered is incomplete, limiting its usefulness for planning.

That is the central finding of an April report from the U.S. General Accountability Office in response to a request from Republican Senators Lamar Alexander (R-TN), who is ranking member of the Senate Health, and Education Labor and Pensions Committee, Richard Burr (R -NC), Michael Enzi (R-WY) and Johnny Isakson (all ranking members of HELP subcommittees), and Tom Coburn (R-OK), ranking member of the Senate Committee on Homeland Security.

The report points out that while per patient treatment costs have dropped, programs will need to expand, requiring more resources than ever, if they are to address still vast currently unmet needs, and also provide treatment for those who will be eligible under new guidelines.

The report finds that PEPFAR has met the legislative requirement that more than half of its funds be spent to provide specific treatment and care for people living with HIV, but also finds numerous gaps that leave uncounted both total treatment costs and the impact of contributions from PEPFAR’s “Other” category, of spending on health system strengthening, to dropping treatment costs. According to the report, while PEPFAR’s budget for “treatment and care for people living with HIV” dropped from $1.8 billion to $1.4 billion from fiscal year 2008 to fiscal year 2012, the budget for “Other” rose from $574 million to $710 million. Other factors limiting treatment cost information compiled by PEPFAR were rapid changes in prices and program size, lack of timely data, and the small number and types of sites selected for data gathering that could not accurately represent costs and conditions in other settings, the GAO found. In addition, PEPFAR did not include costs covered by other sources, including partner country governments and the Global Fund to Fight AIDS, Tuberculosis and Malaria.

The report, written after a review of PEPFAR documents, interviews with PEPFAR officials and representatives from the program’s primary drug procurement contractor, and in-country interviews and document reviews in Kenya, South Africa and Uganda, concludes that more complete information on treatment costs will be necessary to planning and allocation decisions. The report notes, however, that “PEPFAR officials told us that conducting country treatment-cost studies more regularly has not been their highest priority,” leaving open the question of how that will change if the program’s resources are further reduced.

The report’s recommendations include that PEPFAR work with partner countries to capture treatment costs across all contributors and expand its treatment cost studies across more sites and countries. It concludes, “The current treatment spending requirement, however, is in effect only until September 30, 2013, when it expires.”

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