The determinants of HIV treatment costs in resource limited settings

Abstract

Background: Governments and international donors have partnered to provide free HIV treatment to over 6 million individuals in low and middle-income countries. Understanding the determinants of HIV treatment costs will help improve efficiency and provide greater certainty about future resource needs.

Methods and findings: We collected data on HIV treatment costs from 54 clinical sites in Botswana, Ethiopia, Mozambique, Nigeria, Uganda, and Vietnam. Sites provided free HIV treatment funded by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), national governments, and other partners. Service delivery costs were categorized into successive six-month periods from the date when each site began HIV treatment scale-up. A generalized linear mixed model was used to investigate relationships between site characteristics and per-patient costs, excluding ARV expenses. With predictors at their mean values, average annual per-patient costs were $177 (95% CI: 127-235) for pre-ART patients, $353 (255-468) for adult patients in the first 6 months of ART, and $222 (161-296) for adult patients on ART for >6 months (excludes ARV costs). Patient volume (no. patients receiving treatment) and site maturity (months since clinic began providing treatment services) were both strong independent predictors of per-patient costs. Controlling for other factors, costs declined by 43% (18-63) as patient volume increased from 500 to 5,000 patients, and by 28% (6-47) from 5,000 to 10,000 patients. For site maturity, costs dropped 41% (28-52) between months 0-12 and 25% (15-35) between months 12-24. Price levels (proxied by per-capita GDP) were also influential, with costs increasing by 22% (4-41) for each doubling in per-capita GDP. Additionally, the frequency of clinical follow-up, frequency of laboratory monitoring, and clinician-patient ratio were significant independent predictors of per-patient costs.

Conclusions: Substantial reductions in per-patient service delivery costs occur as sites mature and patient cohorts increase in size. Other predictors suggest possible strategies to reduce per-patient costs.

Figure 1. Change in annual per-patient cost for established adult ART patients as a function of site maturity and patient volume.

Panel A shows annual HIV treatment cost as a function of site maturity. Panel B shows annual HIV treatment cost as a function of patient volume. HIV treatment costs represent annual economic costs of site-level service delivery in 2010 US dollars, excluding ARVs and national/regional overhead costs. Changes in per-patient costs calculated from a regression of per-patient costs against proximal cost determinants. Each panel shows the consequence of change in a single determinant, holding all other determinants at their mean values.

Figure 2. Change in annual per-patient cost for established adult ART patients as a function of per-capita GDP.

HIV treatment costs represent economic costs of site-level service delivery in 2010 US dollars, excluding ARVs and national/regional overhead costs. Changes in per-patient costs calculated from a regression of per-patient costs against proximal cost determinants. The plot shows the consequence of changes in per-capita GDP, holding all other determinants at their mean values. Overplotted country-level estimates: ETH = Ethiopia, MOZ = Mozambique, UGA = Uganda, VIE = Vietnam, NIG = Nigeria, BOT = Botswana.

Figure 3. Average annual per-patient HIV treatment costs, by patient type.

HIV treatment costs represent economic costs of site-level service delivery in 2010 US dollars, excluding ARVs and national/regional overhead costs. Cost estimates calculated from a regression of per-patient costs against proximal cost determinants. In figure, diamond signifies point estimate, length of bars signifies 95% confidence interval.