The relation of price of antiretroviral drugs and foreign assistance with coverage of HIV treatment in Africa: retrospective study

Abstract

Objective: To determine the association of reductions in price of antiretroviral drugs and foreign assistance for HIV with coverage of antiretroviral treatment.

Design: Retrospective study.

Setting: Africa.

Participants: 13 African countries, 2003-8.

Main outcome measures: A price index of first line antiretroviral therapy with data on foreign assistance for HIV was used to estimate the associations of prices and foreign assistance with antiretroviral coverage (percentage of people with advanced HIV infection receiving antiretroviral therapy), controlling for national public health spending, HIV prevalence, governance, and fixed effects for countries and years.

Results: Between 2003 and 2008 the annual price of first line antiretroviral therapy decreased from $1177 (£733; €844) to $96 and foreign assistance for HIV per capita increased from $0.4 to $13.8. At an annual price of $100, a $10 decrease was associated with a 0.16% adjusted increase in coverage (95% confidence interval 0.11% to 0.20%; 0.19% unadjusted, 0.14% to 0.24%). Each additional $1 per capita in foreign assistance for HIV was associated with a 1.0% adjusted increase in coverage (0.7% to 1.2%; 1.4% unadjusted, 1.1% to 1.6%). If the annual price of antiretroviral therapy stayed at $100, foreign assistance would need to quadruple to $64 per capita to be associated with universal coverage. Government effectiveness and national public health expenditures were also positively associated with increasing coverage.

Conclusions: Reductions in price of antiretroviral drugs were important in broadening coverage of HIV treatment in Africa from 2003 to 2008, but their future role may be limited. Foreign assistance and national public health expenditures for HIV seem more important in expanding future coverage.

Fig 1 Relation between price of first line antiretroviral therapy and coverage. Points represent country and year estimate of price of therapy in 2008 US dollars and antiretroviral coverage during that year. Markers are differentiated by year of observation to show price trends of therapy. Quadratic fit line suggests greater increases in coverage associated with price reductions at low prices, but coverage averaging just over 50% with lowest observed prices. In addition, prices appear to converge, so that by 2008 the prices are similar in most countries, suggesting a floor effect for price reductions

Fig 2 Relation between foreign assistance and coverage. Foreign assistance is in 2008 US dollars distributed for HIV by three major international donors (President’s Emergency Plan for AIDS Relief, Global Fund, and World Bank) per capita in each country during year of interest. Markers are differentiated by year of observation, and quadratic fit curve is shown

Fig 3 Resource requirements for universal coverage. Combination of foreign assistance for HIV per capita and national public health expenditures estimated to be sufficient for universal coverage at difference price points of first line antiretroviral therapy. As of 2008, public health expenditures in study countries were $40.9 per capita and foreign assistance for HIV $13.8 per capita