The cost and cost-effectiveness of alternative strategies to expand treatment to HIV-positive South Africans: scale economies and outreach costs

This repository item contains a single issue of the Health and Development Discussion Papers, an informal working paper series that began publishing in 2002 by the Boston University Center for Global Health and Development. It is intended to help the Center and individual authors to disseminate work that is being prepared for journal publication or that is not appropriate for journal publication but might still have value to readers.The South African government is currently discussing various alternative approaches to the further expansion of antiretroviral treatment (ART) in public-sector facilities. We used the EMOD-HIV model, a HIV transmission model which projects South African HIV incidence and prevalence and ARV treatment by age-group for alternative combinations of treatment eligibility criteria and testing, to generate 12 epidemiological scenarios. Using data from our own bottom-up cost analyses in South Africa, we separate outpatient cost into nonscale- dependent costs (drugs and laboratory tests) and scale-dependent cost (staff, space, equipment and overheads) and model the cost of production according to the expected future number and size of clinics. On the demand side, we include the cost of creating and sustaining the projected incremental demand for testing and treatment. Previous research with EMOD-HIV has shown that more vigorous recruitment of patients with CD4 counts less than 350 is an advantageous policy over a five-year horizon. Over 20 years, however, the model assumption that a person on treatment is 92% less infectious improves the cost-effectiveness of higher eligibility thresholds, averting HIV infections for between $1,700 and$2,800, while more vigorous expansion under the current guidelines would cost more than $7,500 per incremental HIV infection averted. Based on analysis of the sensitivity of the results to 1,728 alternative parameter combinations at each of four discount rates, we conclude that better knowledge of the behavioral elasticities could reduce the uncertainty of cost estimates by a factor of 4 to 10

The cost effectiveness of integrated care for people living with HIV including antiretroviral treatment in a primary health care centre in Bujumbura, Burundi

The incremental cost effectiveness of an integrated care package (i.e., medical care including antiretroviral therapy (ART) and other services such as psychological and social support) for people living with HIV/AIDS was calculated in a not-for-profit primary health care centre in Bujumbura run by Society of Women against AIDS-Burundi (SWAA-Burundi), an African non-governmental organisation (NGO). Results are expressed as cost-effectiveness ratio 2007, constant US$per disability-adjusted life year (DALY) averted. Unit costs are estimated from the NGO's accounting data and activity reports, healthcare utilisation is estimated from the medical records of a cohort of 149 patients. Effectiveness is modelled on the survival of this cohort, using standard calculation methods. The incremental cost of integrated care for people living with HIV/AIDS in the Bujumbura health centre of SWAA-Burundi is 258 US$ per DALY averted. The package of care provided by SWAA-Burundi is therefore a very cost-effective intervention in comparison with other interventions against HIV/AIDS that include ART. It is however, less cost effective than other types of interventions against HIV/AIDS, such as preventive activities

User fees, transport costs, and the ethics of exemption: how free is free ART?

The Southern African HIV Clinicians Society initiated an online discussion forum on ‘HIV Ethics and Policy' in 2007. The case study below concerns the ‘hidden' costs associated with access to antiretroviral therapy (ART), and discusses a number of proposed solutions to the problems faced by indigent patients with HIV/AIDS (to read the entire debate, see http://groups. google.com/group/policy-ethics/topics?start=10&sa=N). Southern African Journal of HIV Medicine Vol. 8 (2) 2007: pp. 52-5

OVC cost model

This item is archived in the repository for materials published for the USAID supported Orphans and Vulnerable Children Comprehensive Action Research Project (OVC-CARE) at the Boston University Center for Global Health and Development

A Compact Millimeter-Wavelength Fourier-Transform Spectrometer

We have constructed a Fourier-transform spectrometer (FTS) operating between 50 and 330 GHz with minimum volume (355 x260 x64 mm) and weight (13 lbs) while maximizing optical throughput (100 $\mathrm{mm}^2$ sr) and optimizing the spectral resolution (4 GHz). This FTS is designed as a polarizing Martin-Puplett interferometer with unobstructed input and output in which both input polarizations undergo interference. The instrument construction is simple with mirrors milled on the box walls and one motorized stage as the single moving element. We characterize the performance of the FTS, compare the measurements to an optical simulation, and discuss features that relate to details of the FTS design. The simulation is also used to determine the tolerance of optical alignments for the required specifications. We detail the FTS mechanical design and provide the control software as well as the analysis code online.Comment: Submitted to Applied Optics. [Copyright 2019 Optical Society of America]. Users may use, reuse, and build upon the article, or use the article for text or data mining, so long as such uses are for non-commercial purposes and appropriate attribution is maintained. All other rights are reserve

The economics of antiretroviral therapy in South Africa: The role of budget impact modelling in changing policy

South Africa is home to the largest number of people living with HIV in the world, as well as the world’s largest public-sector antiretroviral treatment (ART) programme. Despite the absolute majority of it being domestically funded, planning and budgeting for this programme has in the past been based on assumptions regarding target population and unit cost and on politically expedient coverage targets. The aim of this thesis was to improve on this situation by developing a budget impact model that could project the number of adults and children in treatment based on sound epidemiological methods, and calculate the cost of treating them based on the results of detailed bottom-up cost analyses at relevant clinics and hospitals in South Africa. The thesis describes the methods used in generating the inputs for the model, including the outpatient and inpatient cost of ART provision to adults and children of different ages, and the rates of CD4 cell count development, mortality, loss to follow-up, treatment failure, and regimen switches that were used in the model.The model was used to illustrate the budget impact of a number of guideline changes under discussion by the South African government in 2009/10, including 1.) expanding eligibility to all adults with CD4 cell counts <350 cells/microl, as well as to all TB co-infected and pregnant patients and all children under the age of 12 months regardless of immunological status, and 2.) replacing stavudine in first-line regimens with tenofovir for adults and with abacavir for children, with concomitant changes to second-line regimens. Both 1.) and 2.) had been suggested by the 2009 World Health Organization (WHO) guidelines (“Full WHO guidelines”). A second scenario was considered that expanded eligibility at 350 CD4 cells/microl only to those adults who were pregnant or had active TB at initiation while also replacing the current drug regimens as under 2.) (“New guidelines”). Additional factors with an impact on cost that were considered in the model were a) the introduction of a task-shifting policy that allowed antiretroviral drugs to be prescribed by nurses instead of doctors, and dispensed by pharmacy assistants instead of pharmacists, and b) replacing the existing system of antiretroviral drug procurement via government tenders that favour domestic production with drugs sourced globally at ceiling prices based on the cheapest internationally available price for each drug, including fixed-dose combinations (FDCs) wherever possible. Combining all the inputs, the model showed that while the Full WHO guidelines scenario would increase total cost over the next two mid-term expenditure framework periods (2010/11 to 2016/17) by 35% to USD 19.1 billion, and the New Guidelines scenario by 19%, this increase could be more than offset by introducing the two additional policies. In this case, the total cost of the ART programme under the New Guidelines would be 32% less than under the Old Guidelines without FDCs and task-shifting (taken as government’s revealed willingness-to-pay), while reaching 14% more patients, and implementing the Full WHO Guidelines would still be 23% less costly than continuing the Old Guidelines, while reaching 23% more patients. Based in part on this analysis, the South African government increased treatment eligibility in two steps in April 2010 and in August 2011, introduced the improved drug regimens, established task shifting, and, using the proposed reference price list, negotiated significant drug price reductions for both the December 2010 and the December 2012 ARV drug tender. The budget impact model, named the National ART Cost Model, has been used in budget planning processes for the last seven financial years and, based in part on it, the government’s Conditional Grant for HIV/AIDS, the main vehicle for ART funding, was more than doubled in real terms over this time period. The thesis ends by presenting the results of a cost-benefit analysis of an alternative funding mechanism to public-sector funding, the provision of ART at the workplace, which was found from the company perspective to be cost-saving over no provision of ART, reducing the total cost due to HIV by 5%, and the cost per HIV-infected employee by 14%, over 20 years

Five-year trends in antiretroviral usage and drug costs in HIV-infected children in Thailand.

BACKGROUND: As antiretroviral treatment (ART) programs mature, data on drug utilization and costs are needed to assess durability of treatments and inform program planning. METHODS: Children initiating ART were followed up in an observational cohort in Thailand. Treatment histories from 1999 to 2009 were reviewed. Treatment changes were categorized as: drug substitution (within class), switch across drug class (non nucleoside reverse-transcriptase inhibitors (NNRTI) to/from protease inhibitor (PI)), and to salvage therapy (dual PI or PI and NNRTI). Antiretroviral drug costs were calculated in 6-month cycles (US$2009 prices). Predictors of high drug cost including characteristics at start of ART (baseline), initial regimen, treatment change, and duration on ART were assessed using mixed-effects regression models. RESULTS: Five hundred seven children initiated ART with a median 54 (interquartile range, 36-72) months of follow-up. Fifty-two percent had a drug substitution, 21$251 to $428 per child per year in the first and fifth year of therapy, respectively. PI-based and salvage regimens accounted for 16% and 2% of treatments prescribed and 33% and 5% of total costs, respectively. Predictors of high cost include baseline age ≥ 8 years, non nevirapine-based initial regimen, switch across drug class, and to salvage regimen (P < 0.005). CONCLUSIONS: At 5 years, 21% of children switched across drug class and 2% received salvage therapy. The mean drug cost increased by 70%. Access to affordable second- and third-line drugs is essential for the sustainability of treatment programs

Diagnosing Xpert MTB/RIF-negative TB: Impact and cost of alternative algorithms for South Africa

Background. Use of Xpert MTB/RIF is being scaled up throughout South Africa for improved diagnosis of tuberculosis (TB). A large proportion of HIV-infected patients with possible TB are Xpert-negative on their initial test, and the existing diagnostic algorithm calls for these patients to have sputum culture (Xpert followed by culture (X/C)). We modelled the costs and impact of an alternative diagnostic algorithm in which these cultures are replaced with a second Xpert test (Xpert followed by Xpert (X/X)).Methods. An existing population-level decision model was used. Costs were estimated from Xpert implementation studies and public sectorprice and salary data. The number of patients requiring diagnosis was estimated from the literature, as were rates of TB treatment uptakeand loss to follow-up. TB and HIV positivity rates were estimated from the national TB register and laboratory databases.Results. At national programme scale in 2014, X/X (R969 million/year) is less expensive than X/C R1 095 million/year), potentially saving R126million/year (US$17.4 million). However, because Xpert is less sensitive than culture, X/X diagnoses 2% fewer TB cases. This is partly offset byhigher expected treatment uptake with X/X due to the faster availability of results, resulting in 1% more patients initiating treatment under X/Xthan X/C. The cost per TB patient initiated on treatment under X/X is R2 682, which is 12% less than under X/C (R3 046).Conclusions. Modifying the diagnostic algorithm from X/C to X/X could provide rapid results, simplify diagnostic processes, improve HIV/TB treatment outcomes, and generate cost savings

Designing an optimal HIV programme for South Africa: Does the optimal package change when diminishing returns are considered?

Abstract Background South Africa has a large domestically funded HIV programme with highly saturated coverage levels for most prevention and treatment interventions. To further optimise its allocative efficiency, we designed a novel optimisation method and examined whether the optimal package of interventions changes when interaction and non-linear scale-up effects are incorporated into cost-effectiveness analysis. Methods The conventional league table method in cost-effectiveness analysis relies on the assumption of independence between interventions. We added methodology that allowed the simultaneous consideration of a large number of HIV interventions and their potentially diminishing marginal returns to scale. We analysed the incremental cost effectiveness ratio (ICER) of 16 HIV interventions based on a well-calibrated epidemiological model that accounted for interaction and non-linear scale-up effects, a custom cost model, and an optimisation routine that iteratively added the most cost-effective intervention onto a rolling baseline before evaluating all remaining options. We compared our results with those based on a league table. Results The rank order of interventions did not differ substantially between the two methods- in each, increasing condom availability and male medical circumcision were found to be most cost-effective, followed by anti-retroviral therapy at current guidelines. However, interventions were less cost-effective throughout when evaluated under the optimisation method, indicating substantial diminishing marginal returns, with ICERs being on average 437% higher under our optimisation routine. Conclusions Conventional league tables may exaggerate the cost-effectiveness of interventions when programmes are implemented at scale. Accounting for interaction and non-linear scale-up effects provides more realistic estimates in highly saturated real-world settings