Trend Analysis of Pepfar Funding and Patients on Art Treatment

Introduction

In 2008 alone over US$ 13.7 billion was spent on global HIV control ^[1], yet less than half of those who might benefit from antiretroviral therapy (Art) currently receive treatment ^[2]. As HIV treatment programs pursue universal admission goals ^[3], careful budgeting is needed to maintain admission to quality services over the long term.

Resources need projections for HIV treatment have been conducted at global ^[1,4] and country level ^[5,6], nonetheless these efforts are hampered past a lack of information. Some information on service commitment costs accept recently become available ^[7–12]. These studies generally adhere to methodological guidelines ^[13,14], even so differences in key areas – study perspective, inclusion/exclusion of administrative overheads, and handling of uppercase investments – brand comparisons difficult. Moreover, the studies written report data from a single or limited number of sites. It is unclear to what extent the wide range in costs reported by these studies – US$ 292–2830 (2009 U.s.$) for ART and US$ 131–457 for non-Fine art care – is due to real differences in clinical practice, price differentials, or differences in costing methodology. A recent S African written report ^[12] represents a promising exception to this tendency. Using a standardized methodology in four sites, the investigators found a much tighter range of per patient costs, from US$ 756 to 1126 for the first 12 months on ART.

The U.s. President's Emergency Plan for AIDS Relief (PEPFAR) supports HIV control in a number of high-prevalence countries. The PEPFAR Art Costing Project was initiated with the objective of estimating HIV handling costs in a sample of PEPFAR-supported countries and programs. Data were collected to estimate per patient treatment costs for pre-ART and ART patients, how costs are distributed across sources of support, input types, and programme activities, and how costs change every bit sites grow and mature. Economical theory suggests the possibility of falling per patient costs due to economies of calibration ^[xv], and there is bear witness of such a trend amongst HIV prevention programs ^[16]. Information on time trends in HIV treatment costs are scarce ^[17], though 1 study has shown decreasing per patient costs of HIV treatment over time ^[9]. As budgetary constraints increasingly limit program growth, the extent to which programs can reduce per patient costs may make up one's mind whether universal access goals can be achieved.

Empirical data on per patient treatment costs will also provide inputs for modeled analyses estimating costs and cost-effectiveness of competing programmatic approaches ^[18–22], providing a link between the minimal costing data collected through routine reporting systems and the intensive data requirements of cost-effectiveness analyses ^[23]. This study reports the data on HIV treatment costs collected by the PEPFAR ART Costing Projection.

Methods

Population and setting

The study included 45 HIV handling sites beyond five countries: Botswana, Ethiopia, Nigeria, Uganda and Vietnam, chosen to reverberate the range of the PEPFAR land programs. Sites were outpatient clinics providing gratuitous treatment for HIV-infected individuals and receiving direct or indirect PEPFAR back up. In each land a sample of 9 sites was purposively selected by local treatment program experts to reflect the range of publicly funded outpatient HIV treatment sites in the country, considering location, plan size (number of ART patients), and type of administration. The sample was restricted to sites that had been operating for more 12 months in order to reveal time trends; however, some newer sites (north = iii) were included in the sample when necessary to better reverberate current service delivery for a particular country. Of the original 45-site sample, 2 sites (in Uganda) were later on excluded from last analyses due to lack of adequate patient volume data. Final analyses included all patients receiving HIV handling at 43 written report sites. By the cease of the evaluation, a total of 106 906 individuals were currently receiving HIV treatment through the written report sites, comprising 62 512 patients receiving Fine art and 44 394 receiving pre-ART care.

Intervention

Comprehensive HIV handling is comprised of Art and supportive care. The service mix included multiple discrete health interventions and was expected to vary across programs. Two chief patient types were identified: Art and pre-Art patients. In general, ART patients received a standardized antiretroviral regimen and regular clinical and laboratory monitoring to assess treatment response. Patients transitioned to alternating first-line or second-line antiretroviral regimens, as indicated by treatment failure or adverse reactions, or based on drug availability. Supportive care could include prophylaxis and treatment of opportunistic infections and other conditions; nutritional support; adherence interventions; and other clinic-based or community-based health interventions. Pre-Fine art patients more often than not received supportive care similar to Art patients, as well every bit regular clinical and laboratory monitoring, though potentially at a different frequency than Art patients. Pre-ART patients transitioned onto Art co-ordinate to affliction progression and site capacity for boosted ART patients. Art patient costs were subdivided according to whether patients were adult (>fifteen years old) or pediatric (0–15 years onetime), and whether they were newly initiated (≤6 months on ART) or established (>6 months on Art).

Perspective and costing methods

The written report adopted a programmatic perspective, considering all site-level costs of outpatient Fine art and supportive care. In addition to direct service provision costs, the study included site administration and management costs, as these can contribute essentially to total costs ^[24]. Medical costs incurred offsite were excluded, as were patient fourth dimension and travel costs and college-level program costs incurred past cardinal government and donor direction.

Analyses calculated both economic costs and fiscal costs. Economic costs gauge the opportunity price of resources devoted to an intervention, useful data for long-term resources allocation decisions. For economic costs, investments (renovation/construction, equipment, training, and antiretroviral buffer stock) were annualized over their useful life (30 years for renovation/construction, 5 years for equipment, two years for training, and perpetuity for buffer stock) using a iii% disbelieve rate ^[13,14]. Results were robust to changes in useful life and discount charge per unit values. Financial costs provide information on 'existent-fourth dimension' expenditures, with the toll of each investment included in the fourth dimension period when the expenditure occurred, and are useful for shorter-term fiscal planning. In both economic and financial cost analyses, donated resources were valued at marketplace prices, to capture the opportunity cost of all program contributions. For this reason the issue of donations and subsidies, usually considered part of the distinction between financial and economical costs, did not arise.

Overheads were allocated past direct allotment ^[13], and the opportunity cost of existing infrastructure was estimated as the equivalent rental cost. Antiretroviral buffer stock costs were calculated from the average number of months of antiretroviral drugs held in stock (typically half-dozen–12 months per ART patient), growth in Art patient volume, regimens distributions, and prevailing antiretroviral prices.

Cost data were labeled using three categorizations. 'Input type' categories comprised recurrent costs, including personnel, dispensed antiretroviral drugs, other drugs, laboratory supplies, other supplies, building apply, utilities, travel, and contracted services (such every bit contracted security); as well as investments, including renovation/structure, equipment, grooming, and antiretroviral buffer stock. 'Programmatic activity' categories included clinical intendance, laboratory services, training and supervision, supply chain management, 1000&E (monitoring and evaluation) and HMIS (wellness management information systems), and general administration/operations. 'Source of back up' categories included PEPFAR, national government, and other sources. As the written report identified sources of funding at the site level, it was non possible to place donor funding channeled through regime budgets (including Global Fund or World Bank funding). This funding is included in the authorities category.

Information collection

Data were nerveless at each site and its supporting organizations (i.e. preparation institutions, procurement agents) between April 2006 and March 2007. Data were collected on all services that met iii criteria: the service was primarily a wellness intervention, the primary recipient of the service was the HIV-infected individual, and the service was administered by the site. Data were nerveless through retrospective record review, including accounting records, prescribing logs, equipment inventories, and routine reports. Key informant interviews were conducted to identify program activities to which resource were devoted and develop a comprehensive description of HIV handling at the site. In Republic of botswana, data on antiretroviral usage could not be validated, and for this reason results reporting antiretroviral costs exclude Republic of botswana sites.

Data were organized into vi-calendar month periods, starting from the calibration-up of dedicated HIV treatment services at each site. Cost information were collected in original currency, converted to US dollars using prevailing inter-bank commutation rates, and inflated to constant 2009 dollars using the medical care component of the Us consumer price index. Routine reporting information were used to calculate the total patient years of treatment past patient blazon and time menstruum, then combined with cost data to guess annualized per patient costs. Unless specified, results are presented for the most contempo 6-calendar month period at each site. For fourth dimension trends over multiple periods, results are calculated as the median per patient costs (Fig. 2) or total costs (Fig. 3) across all sites at the get-go of the evaluation, adjusted for the average per centum change in costs between each subsequent period. The duration for which data were bachelor varied by site, from 6 to 36 months (median = 20 months). The percentage change in price between periods was calculated for all sites with data available in that period. Analyses were conducted using Stata SE 9 (StataCorp, College Station, Texas, U.s.a.).

Results

Characteristics of HIV treatment sites and patients

Of the 43 sites in the analysis, seven were primary health centers, 15 were secondary centers, and 21 were 3rd sites. Thirty-six sites were government-run facilities and seven were administered by nonprofit organizations. Three sites were in rural areas, nine in peri-urban areas, and 31 in urban areas. The hateful number of patients per site was 680 on Fine art and 494 on pre-Art at the get-go of the evaluation, rising to 1454 and 1032, respectively, by the end of the evaluation, with a mean scale-upwardly charge per unit of 39 Fine art and 28 pre-Fine art patients per site per month. Virtually sites had a bulk adult population, with pediatric patients representing 7.1% of all ART patients. Two dedicated pediatric sites were included in the study, treating a mean of 95.7% pediatric patients. In total, the costing included 62 512 ART patients and 44 394 pre-Art patients past the end of the evaluation, representing 54 519 and 38 581 patient-years of ART and pre-Art handling, respectively.

Total costs per patient

Table 1 presents summary data on full annual economical costs of HIV handling for different patient types. Antiretroviral drugs represented the major contributor to full costs. Antiretroviral costs are sensitive to price levels and changes in preferred regimens, and for this reason results are reported inclusive and exclusive of antiretroviral costs. Median almanac costs were U.s.$ 202 for pre-Art patients and U.s.$ 880 for ART patients. Excluding antiretrovirals, median annual costs for Fine art patients were US$ 298 (or US$ 287 excluding the Botswana sites). Countries with higher input prices (Nigeria, Botswana) tended to have college per patient costs. Annual per patient costs varied widely between sites, specially when antiretroviral costs are removed. The distribution of costs beyond sites was positively skewed (Fig. ane) with annual costs clustering around US$ 100–199 for pre-ART patients and US$ 600–999 for ART patients, with a small number of sites reporting much college costs. Per patient costs varied across countries, and too between patient types, with newly initiated Fine art patients (first half-dozen months of Art) costing 15–20% more than established ART patients (or approximately l% more when antiretroviral drugs are excluded), due to more than frequent clinical and laboratory follow-up during initial months on ART. Boilerplate per patient costs were college for pediatric patients compared to adults, though these patients more often than not represented a small fraction of full patients. In the 2 dedicated pediatric sites, the average almanac economic price per patient was United states$ 823 and 698 for newly initiated and established pediatric ART patients, respectively.

Table 1:

Annualized per patient costs for each patient type, past land and overall in 2006–2007 (Economic Costs, 2009 US$).

Fig. one:

Distribution of annualized per patient costs for ART and pre-Fine art patients across HIV treatment sites in 2006–2007 (economic costs, 2009 US$)^*.For both ART and pre-Art patients, the high price outlier was a site with comparatively low patient volume that was undergoing rapid expansion, having added 76% to its existing ART patient volume during the flow. ^*Fine art distribution graph excludes Botswana sites.

Distribution of costs

Table 2 shows the distribution of economical costs beyond input types and program activities, for both pre-Fine art and Art patients. Recurrent costs comprise the majority of all costs, 87.2% for pre-ART patients and 95.1% for ART patients. Personnel and laboratory supplies are the largest input-blazon categories for pre-ART patients, whereas antiretroviral drugs are the largest component for ART patients, followed past personnel and laboratory supplies. Contracted services were variable across sites and included a range of different activities, the virtually mutual of these being tests outsourced to external laboratories.

Table 2:

Mean distribution of per patient costs past input type, programmatic activity, and source of support in 2006–2007 (Last Period Economic Costs).

The second part of Table 2 shows the distribution of costs across program activities. Clinical care and laboratory services together represent the bulk of all costs for both pre-Fine art and Art patients (79.vii and xc.7%, respectively); still, other activities, taken together, stand for nontrivial additions to total service commitment costs.

Time trends in per patient costs

Whereas earlier figures and tables presented economic costs, Fig. two presents financial costs (including the cost of donated resources), showing the fourth dimension trends in average annual fiscal costs for Art and pre-Fine art patients from the start of program scale-up at each site. As the figure illustrates, per patient costs drop rapidly over the first year, with a 65.6% reduction in per patient costs for pre-ART patients and a 46.8% reduction for Fine art patients between first and second 6-month periods. Ongoing small-scale reductions are still evident afterwards this first year, with pre-ART and Art per patient costs dropping an average of 17.1 and 11.3%, respectively, in each successive 6-month period from months 6–11 to months 24–29. Excluding antiretroviral costs, per patient ART costs dropped 63.four% between first and 2nd 6-calendar month periods, and 18.4% in each successive half-dozen-month flow thereafter. Cost reductions were nigh pronounced for investment costs, which dropped by an average 61.8 and 37.8% in each successive vi-month flow for pre-Art and ART patients, respectively. Recurrent costs as well declined with time, though at lower rates than investments. This pattern – of large reductions in early periods followed by ongoing pocket-size reductions in later on periods – was seen in most individual cost categories, and was as well observed when sites were disaggregated into primary, secondary and tertiary sites.

Fig. ii:

Change in median per-patient fiscal costs in successive half dozen-calendar month periods, from start of HIV treatment calibration-upwardly in each site through 2006–2007 (2009 Us$).

Total site-level costs

Although per patient financial costs decreased over fourth dimension, total site-level financial costs continued to rising due to apace growing patient populations. Total site fiscal costs averaged United states$ 712 564 in the offset 6 months of calibration-up, and increased by an average of 28.5% in each successive 6-month period. The distribution across price categories too inverse, as shown in Fig. 3, with recurrent costs representing an increasingly larger share of total costs later on the get-go-up phase. This was particularly truthful of antiretroviral expenses, which grew from 25.2% of all spending in months 0–5 to 71.1% by months 24–29, with buffer stock expenditures representing a principal driver of financial costs due to the rapid scale-up of patient rolls.

Fig. iii:

Distribution of total financial costs in successive six-month periods, from start of HIV treatment calibration-up in each site through 2006–2007^δ.^*Other investments include construction/renovation, equipment and training. ^$Other recurrent costs include non-antiretroviral (ARV) medications, laboratory supplies, other supplies, building rental, travel expenses, utilities and contracted services. ^δFigure excludes Republic of botswana sites.

In the four countries excluding Botswana, PEPFAR contributed an boilerplate of 79.4% of all site back up, with national governments contributing 15.2%, and other funders the remaining 5.4%. It was not possible to calculate the distribution of costs across sources of support for Botswana given the difficulties confirming antiretroviral costs; however, it is clear that Botswana is atypical amongst sub-Saharan African countries, providing the large bulk of HIV treatment funding in national-level assessments ^[25]. Funders contributed in unlike ways, with PEPFAR mainly supporting antiretroviral drugs, equipment, and personnel (53.0, 8.1, and 7.7% of total PEPFAR back up, respectively). In contrast, national governments mainly supported personnel, buildings, and equipment (33.6, 21.4, and 17.ii% of full national government support, respectively), and other donors mainly supported equipment, antiretroviral drugs, and renovation/structure (19.one, 16.0, and 13.ii% of total other back up, respectively). It should be noted that, as the sample was limited to sites receiving PEPFAR support and college-level fundamental support costs were excluded, this breakup across sources of support may not be representative of total national HIV treatment spending.

Discussion

The study provides a detailed description of HIV treatment costs at PEPFAR-supported sites. In item, the report revealed progressive reductions in per patient financial costs as sites matured. For investment expenditures, it would be expected that per patient financial costs drop every bit sites mature – much of the site infrastructure and equipment must be nowadays before patients are enrolled, and expansion in patient numbers must be preceded past an expansion of dispensary capacity. Less apparent is why recurrent costs drop equally sites mature, but a like rationale – the need to develop capacity before bringing on additional patients – besides applies to a number of recurrent costs, such as personnel. Additionally, programs likely feel economies of calibration as patient numbers increase, and the accumulation of program feel may ameliorate efficiency. Reductions in per patient costs bode well for programme fiscal sustainability, suggesting that financial resources needed to support programs over the long term may exist less than suggested by the expenditures required over the start-up period.

Another notable finding from this study is the wide range in per patient costs between sites. Whereas this variation may reverberate cost differentials and different stages of program development, differences in the package of services provided to patients may also be a cistron. Taken as a whole, the health improvements provided by HIV handling are well understood. Less well understood is the incremental value provided by individual components of the package of intendance. Given the varied service mix provided to patients, future plan improvements may be possible through identifying and promoting the most price-effective elements of the care package.

In focusing on programmatic costs, this study did not consider savings attributable to HIV treatment that result from less frequent illness and hospitalization. These cost savings may be considerable, and the net costs of handling programs would be lower if these cost savings were considered ^[18]. The beneficiaries of reduced healthcare usage and greater personal productivity are the broader healthcare arrangement and the patient, respectively. Whereas these gains do not reduce the funding required for HIV treatment programs, they represent benign spillovers for the wider wellness arrangement. Additionally, the study did non consider the costs of higher-level management and administration. Whereas not function of service delivery, these activities are important for supporting site development and should not be ignored in resource need projections.

The field of HIV treatment is evolving rapidly. Annual per patient antiretroviral regimen costs, averaging US$ 549 (2009 U.s.$) per patient in this study, were low compared to developed world prices, but high compared to at present prevailing antiretroviral costs, and were the major contributor to HIV treatment costs in mature sites. Major antiretroviral price reductions have occurred over recent years, with kickoff-line regimen prices dropping by fifteen% per year on boilerplate from 2004 to 2009 ^[26,27]; at the same time, ART guideline revisions ^[28] have recommended transition to more expensive regimens, with tenofovir preferred to stavudine in adult first-line regimens. As a consequence, projections of future HIV handling costs should consider the long-term trends in antiretroviral prices together with shifts in preferred antiretroviral regimens, in addition to the trends in service provision costs revealed by this study.

Whereas price reductions should permit continued program growth in the nigh term, resource constraints may limit scale-up before universal access targets are reached. Programs need to weigh the merchandise-offs between focusing resource on improved regimens and services for current patients and extending coverage to those non yet receiving intendance.

Acknowledgements

The PEPFAR Art Costing Project is a PEPFAR-funded public health evaluation (PHE) study led past the Us Centers for Disease Control and Prevention and implemented with ICF-Macro, in collaboration with USAID. J.One thousand.B., Northward.A.G., R.B., South.F., T.V.East. and R.F. contributed to protocol development and provided written report oversight. J.One thousand.B., Northward.A.M., A.A.B., S.F., and R.B. contributed to instrument design and fieldwork planning, and participated in fieldwork. A.A.B., N.A.M. and J.M.B. analyzed the data and drafted the manuscript. J.M.B., N.A.Grand., A.A.B., R.B., S.F., T.V.E. and R.F. reviewed and edited the manuscript. N.A.M. had full admission to all the data in the written report and takes responsibleness for the integrity of the data and the accuracy of the data assay. We would also like to acknowledge the time and endeavour of the PEPFAR country teams in Republic of botswana, Ethiopia, Nigeria, Uganda and Vietnam, likewise as collaborators and participants at wellness facilities and their supporting organizations. For more information on electric current PEPFAR evaluation activities, delight refer to the website http://www.cdc.gov/globalaids/.

Conflicts of interest

Funding sources: This study was conducted with funding from the Us President'due south Emergency Program for AIDS Relief.

Disclaimer: The findings and conclusions in this study are those of the authors and do not necessarily represent the views of the United states Centers for Disease Control and Prevention or USAID.

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Keywords:

AIDS; antiretroviral therapy; cost; developing countries; economics; HIV; resources-express settings

© 2011 Lippincott Williams & Wilkins, Inc.

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