Mead Over

The economics of effective AIDS treatment : evaluating policy options for Thailand

The purpose of this report is to advise the Thai government and Thai society at large about the full range of benefits, costs, and consequences that are likely to result from the decision to expand public provision of antiretroviral therapy (ART) through National Access to Antiretroviral Program for People Living with HIV/AIDS (NAPHA) and to assist with the design of implementation policies that will achieve maximum treatment benefits, while promoting prevention of HIV/AIDS and maintaining financial sustainability within Thailand. The study has several significant findings: NAPHA with first-line regimen only is the most cost-effective policy option of those studied; NAPHA with second-line therapy is still affordable and yields large benefits in terms of life-years saved; policy options to enhance adherence and to recruit patients earlier are a good public investment; public financing will help ensure equitable access; public financing can strengthen positive spillovers and can limit negative spillovers of ART; if the success of ART rollout makes people or the government complacent about prevention, future costs could rise substantially; and future government expenditures on ART, and the lives it will save are highly sensitive to negotiated agreements on the intellectual property rights for pharmaceuticals. In its current form, Thailands NAPHA program is affordable. Under the models assumptions, it is also cost-effective relative to the baseline scenario. Furthermore, although the two enhanced policies we suggest early recruitment through expanded voluntary counseling and testing (VCT) and improved adherence through Person living with HIV/AIDS (PHA) groups are less cost-effective, they are still a good bargain, particularly if both are enacted.

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.

Multi-Country Analysis of Treatment Costs for HIV/AIDS (MATCH): Facility-Level ART Unit Cost Analysis in Ethiopia, Malawi, Rwanda, South Africa and Zambia

Background Todays uncertain HIV funding landscape threatens to slow progress towards treatment goals. Understanding the costs of antiretroviral therapy (ART) will be essential for governments to make informed policy decisions about the pace of scale-up under the 2013 WHO HIV Treatment Guidelines, which increase the number of people eligible for treatment from 17.6 million to 28.6 million. The study presented here is one of the largest of its kind and the first to describe the facility-level cost of ART in a random sample of facilities in Ethiopia, Malawi, Rwanda, South Africa and Zambia. Methods & Findings In 2010–2011, comprehensive data on one year of facility-level ART costs and patient outcomes were collected from 161 facilities, selected using stratified random sampling. Overall, facility-level ART costs were significantly lower than expected in four of the five countries, with a simple average of

Taking ART to scale: determinants of the cost and cost-effectiveness of antiretroviral therapy in 45 clinical sites in Zambia.

208 per patient-year (ppy) across Ethiopia, Malawi, Rwanda and Zambia. Costs were higher in South Africa, at

HIV/AIDS treatment and prevention in India : modeling the cost and consequences

682 ppy. This included medications, laboratory services, direct and indirect personnel, patient support, equipment and administrative services. Facilities demonstrated the ability to retain patients alive and on treatment at these costs, although outcomes for established patients (2–8% annual loss to follow-up or death) were better than outcomes for new patients in their first year of ART (77–95% alive and on treatment). Conclusions This study illustrated that the facility-level costs of ART are lower than previously understood in these five countries. While limitations must be considered, and costs will vary across countries, this suggests that expanded treatment coverage may be affordable. Further research is needed to understand investment costs of treatment scale-up, non-facility costs and opportunities for more efficient resource allocation.

Antiretroviral therapy and HIV prevention in India: Modeling costs and consequences of policy options

Background We estimated the unit costs and cost-effectiveness of a government ART program in 45 sites in Zambia supported by the Centre for Infectious Disease Research Zambia (CIDRZ). Methods We estimated per person-year costs at the facility level, and support costs incurred above the facility level and used multiple regression to estimate variation in these costs. To estimate ART effectiveness, we compared mortality in this Zambian population to that of a cohort of rural Ugandan HIV patients receiving co-trimoxazole (CTX) prophylaxis. We used micro-costing techniques to estimate incremental unit costs, and calculated cost-effectiveness ratios with a computer model which projected results to 10 years. Results The program cost

The economics of effective AIDS treatment in Thailand

69.7 million for 125,436 person-years of ART, or

Cost and efficiency of public sector sexually transmitted infection clinics in Andhra Pradesh, India

556 per ART-year. Compared to CTX prophylaxis alone, the program averted 33.3 deaths or 244.5 disability adjusted life-years (DALYs) per 100 person-years of ART. In the base-case analysis, the net cost per DALY averted was

Evidence for scaling up HIV treatment in sub-Saharan Africa: A call for incorporating health system constraints

833 compared to CTX alone. More than two-thirds of the variation in average incremental total and on-site cost per patient-year of treatment is explained by eight determinants, including the complexity of the patient-case load, the degree of adherence among the patients, and institutional characteristics including, experience, scale, scope, setting and sector. Conclusions and Significance The 45 sites exhibited substantial variation in unit costs and cost-effectiveness and are in the mid-range of cost-effectiveness when compared to other ART programs studied in southern Africa. Early treatment initiation, large scale, and hospital setting, are associated with statistically significantly lower costs, while others (rural location, private sector) are associated with shifting cost from on- to off-site. This study shows that ART programs can be significantly less costly or more cost-effective when they exploit economies of scale and scope, and initiate patients at higher CD4 counts.

Antiretroviral Therapy Perceived Efficacy and Risky Sexual Behaviors: Evidence from Mozambique

How should governments respond to the increasing domestic and international pressures to finance antiretroviral therapy for AIDS patients? Once prohibitively expensive outside rich countries, antiretroviral therapy is now increasingly affordable, especially in India where patent laws and a dynamic pharmaceutical industry have facilitated the production and marketing of some of the best available drug combinations at prices below a dollar a day. This title projects the future implications of three alternative AIDS treatment financing policies for the health burden of AIDS in India and for its overall health expenditures. The Indian governments 2004 treatment initiative contains elements of all three of these options. Written by an interdisciplinary team of AIDS experts, the book presents new data on the supply and demand for antiretroviral treatment in India and new models of the epidemiological effects and the financial costs of alternative policies. The book shows that the lower prices of antiretroviral therapy, plus the fact that therapy can reduce transmission by the treated patient, imply that such therapy could save healthy years of life at a cost of between