Gesine Meyer-Rath

The Impact and Cost of Scaling up GeneXpert MTB/RIF in South Africa

Objective We estimated the incremental cost and impact on diagnosis and treatment uptake of national rollout of Xpert MTB/RIF technology (Xpert) for the diagnosis of pulmonary TB above the cost of current guidelines for the years 2011 to 2016 in South Africa. Methods We parameterised a population-level decision model with data from national-level TB databases (nu200a=u200a199,511) and implementation studies. The model follows cohorts of TB suspects from diagnosis to treatment under current diagnostic guidelines or an algorithm that includes Xpert. Assumptions include the number of TB suspects, symptom prevalence of 5.5%, annual suspect growth rate of 10%, and 2010 public-sector salaries and drug and service delivery costs. Xpert test costs are based on data from an in-country pilot evaluation and assumptions about when global volumes allowing cartridge discounts will be reached. Results At full scale, Xpert will increase the number of TB cases diagnosed per year by 30%–37% and the number of MDR-TB cases diagnosed by 69%–71%. It will diagnose 81% of patients after the first visit, compared to 46% currently. The cost of TB diagnosis per suspect will increase by 55% to USD 60–61 and the cost of diagnosis and treatment per TB case treated by 8% to USD 797–873. The incremental capital cost of the Xpert scale-up will be USD 22 million and the incremental recurrent cost USD 287–316 million over six years. Conclusion Xpert will increase both the number of TB cases diagnosed and treated and the cost of TB diagnosis. These results do not include savings due to reduced transmission of TB as a result of earlier diagnosis and treatment initiation.

HIV Treatment as Prevention: Modelling the Cost of Antiretroviral Treatment—State of the Art and Future Directions

Policy discussions about the feasibility of massively scaling up antiretroviral therapy (ART) to reduce HIV transmission and incidence hinge on accurately projecting the cost of such scale-up in comparison to the benefits from reduced HIV incidence and mortality. We review the available literature on modelled estimates of the cost of providing ART to different populations around the world, and suggest alternative methods of characterising cost when modelling several decades into the future. In past economic analyses of ART provision, costs were often assumed to vary by disease stage and treatment regimen, but for treatment as prevention, in particular, most analyses assume a uniform cost per patient. This approach disregards variables that can affect unit cost, such as differences in factor prices (i.e., the prices of supplies and services) and the scale and scope of operations (i.e., the sizes and types of facilities providing ART). We discuss several of these variables, and then present a worked example of a flexible cost function used to determine the effect of scale on the cost of a proposed scale-up of treatment as prevention in South Africa. Adjusting previously estimated costs of universal testing and treatment in South Africa for diseconomies of small scale, i.e., more patients being treated in smaller facilities, adds 42% to the expected future cost of the intervention.

Scaling up Xpert MTB/RIF technology: the costs of laboratory- vs. clinic-based roll-out in South Africa

Objectiveu2002 The World Health Organization recommends using Xpert MTB/RIF for diagnosis of pulmonary tuberculosis (PTB), but there is little evidence on the optimal placement of Xpert instruments in public health systems. We used recent South African data to compare the cost of placing Xpert at points of TB treatment (all primary clinics and hospitals) with the cost of placement at sub‐district laboratories.

Feasibility, Yield, and Cost of Active Tuberculosis Case Finding Linked to a Mobile HIV Service in Cape Town, South Africa: A Cross-sectional Study

Katharina Kranzer and colleagues investigate the operational characteristics of an active tuberculosis case-finding service linked to a mobile HIV testing unit that operates in underserviced areas in Cape Town, South Africa.

Rates and Cost of Hospitalization Before and After Initiation of Antiretroviral Therapy in Urban and Rural Settings in South Africa

Abstract:Few studies have compared hospitalizations before and after antiretroviral therapy (ART) initiation in the same patients. We analyzed the cost of hospitalizations among 3906 adult patients in 2 South African hospitals, 30% of whom initiated ART. Hospitalizations were 50% and 40% more frequent and 1.5 and 2.6 times more costly at a CD4 cell count <100 cells/mm3 when compared with 200–350 cells/mm3 in the pre-ART and ART period, respectively. Mean inpatient cost per patient year was USD 117 (95% confidence interval, 85 to 158) for patients on ART and USD 72 (95% confidence interval, 56 to 89) for pre-ART patients. Raising ART eligibility thresholds could avoid the high cost of hospitalization before and immediately after ART initiation.

Cost and outcomes of paediatric antiretroviral treatment in South Africa

Objective:Little is known about the cost of paediatric antiretroviral treatment (ART) in low-income and middle-income countries. We analysed the average cost of providing paediatric ART in South Africa during the first 2 years after ART initiation, stratified by patient outcomes. Methods:We collected data on outpatient resource use and treatment outcomes of 288 children in two Johannesburg public clinics, Empilweni Services and Research Unit (ESRU) and Harriet Shezi Childrens Clinic (HSCC) from 2005 to 2009. Patient-level resource use was estimated from patient records. Unit cost data came from site accounts and public-sector sources. Patient outcomes at month 12 and 24 after initiation were defined based on patients’ weight CD4 cell counts/percentages, viral loads, and the presence of new WHO stage 3/4 conditions. Results:Median age/CD4 percentage at initiation was 4.03 years/12.40% in ESRU and 5.84 years/14.05% in HSCC, respectively. Sixty-two and 91% of patients remained in care and responding to treatment at month 12 in ESRU and HSCC, respectively, and 68 and 80% at month 24. The average cost per patient in care and responding was US

Retention in Care and Outpatient Costs for Children Receiving Antiretroviral Therapy in Zambia: A Retrospective Cohort Analysis

830 in year 1 and US

Cost-effectiveness of tenofovir gel in urban South Africa: model projections of HIV impact and threshold product prices

717 in year 2 in ESRU and US

Cost and resource use of patients on antiretroviral therapy in the urban and semiurban public sectors of South Africa.

678 and US

The cost-effectiveness of herpes simplex virus-2 suppressive therapy with daily aciclovir for delaying HIV disease progression among HIV-1-infected women in South Africa.

782 in HSCC. Antiretroviral drugs comprised 33–52% of total cost, clinic visits 23–31%, lab tests 12–16%, and fixed costs 8–18%. Conclusions:Costs varied between the two clinics but were comparable with those of adult ART. Few very young children accessed ART in either clinic and those who did were already very ill, emphasizing the importance of early infant treatment.