Background
Evidence
favoring earlier HIV ART initiation at high CD4+ T-cell counts (CD4>350/uL)
has grown, and guidelines now recommend earlier HIV treatment. However, the
cost of providing ART to individuals with CD4>350 in Sub-Saharan Africa has
not been well estimated. This remains a major barrier to optimal global cost
projections for accelerating the scale-up of ART. Our objective was to compute
costs of ART delivery to high CD4+count individuals in a typical rural Ugandan
health center-based HIV clinic, and use these data to construct scenarios of
efficient ART scale-up.
Methods
Within
a clinical study evaluating streamlined ART delivery to 197 individuals with
CD4+ cell counts >350 cells/uL (EARLI Study: NCT01479634) in Mbarara,
Uganda, we performed a micro-costing analysis of administrative records, ART
prices, and time-and-motion analysis of staff work patterns. We computed
observed per-person-per-year (ppy) costs, and constructed models estimating
costs under several increasingly efficient ART scale-up scenarios using local
salaries, lowest drug prices, optimized patient loads, and inclusion of viral
load (VL) testing.
Findings
Among
197 individuals enrolled in the EARLI Study, median pre-ART CD4+ cell count was
569/uL (IQR 451–716). Observed ART delivery cost was $628 ppy at steady state.
Models using local salaries and only core laboratory tests estimated costs of
$529/$445 ppy (+/-VL testing, respectively). Models with lower salaries, lowest
ART prices, and optimized healthcare worker schedules reduced costs by $100–200
ppy. Costs in a maximally efficient scale-up model were $320/$236 ppy (+/- VL
testing). This included $39 for personnel, $106 for ART, $130/$46 for
laboratory tests, and $46 for administrative/other costs. A key limitation of
this study is its derivation and extrapolation of costs from one large rural
treatment program of high CD4+ count individuals.
Conclusions
In a Ugandan HIV clinic, ART delivery costs—including VL
testing—for individuals with CD4>350 were similar to estimates from
high-efficiency programs. In higher efficiency scale-up models, costs were
substantially lower. These favorable costs may be achieved because high CD4+
count patients are often asymptomatic, facilitating more efficient streamlined
ART delivery. Our work provides a framework for calculating costs of efficient
ART scale-up models using accessible data from specific programs and regions.
Below: Estimated ART Delivery Costs under Modeled Scenarios of
Efficient ART Scale-Up.
Costs for ART delivery under six modeled scenarios are
displayed inclusive of viral load testing. Model costs excluding viral load
testing are also shown. Model A: steady-state patient load, MJAP
program salary scale and standard core laboratory monitoring schedule. Model
B: model A + lowest available ARV drug costs. Model C: model B +
Uganda Ministry of Health 2013 salary scales. Model D: model C +
increased healthcare worker efficiency due to full use of workday.Model E: model
D + expansion of healthcare worker effort to full 8-hour workday. Model F: model
E + higher MJAP program salary scales.
Purchase full article at: http://goo.gl/aG6Lyj
By:
Vivek Jain, Douglas Black, Diane V. Havlir
HIV/AIDS Division, San Francisco
General Hospital, University of California San Francisco (UCSF), San Francisco,
CA, United States of America
Vivek Jain, Dathan M. Byonanebye, Asiphas Owaraganise, Ellon
Twinomuhwezi, Douglas Black, Moses R. Kamya, Diane V. Havlir
Makerere University-UCSF
(MU-UCSF) Research Collaboration, Kampala, Uganda
Wei Chang, James G. Kahn
Philip R. Lee Institute for
Health Policy Studies, UCSF, San Francisco, CA, United States of America
Gideon Amanyire
Makerere University Joint AIDS
Program (MJAP), Kampala, Uganda
Elliot Marseille
Health Strategies International,
Oakland, CA, United States of America
Moses R. Kamya
Department of Medicine, Makerere
University College of Health Sciences, Kampala, Uganda
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