Académique Documents
Professionnel Documents
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Contents
Abstract. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1. Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.1 Search. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.1.1 Inclusion Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.1.2 Data Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.1.3 Standardization of Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.2 Data Aggregation and Sensitivity Analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.3 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. Antiretroviral Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.1 Antiretroviral Medicines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.2 Laboratory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.3 Personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.4 Programme-Level Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.5 Paediatric Antiretroviral Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. Prevention of Mother-to-Child Transmission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4. Sensitivity Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.1 Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.2 Future Work. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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589
589
593
593
593
594
594
595
596
597
Galarraga et al.
580
Abstract
national HIV/AIDS programmes have made important advances in complying with the bi-annual
routine reporting of nationally aggregated expenditures as stated in the 2001 Declaration of Commitment on HIV/AIDS (UNGASS) to UNAIDS
(the Joint United Nations Programme on HIV/
AIDS).[9] UNAIDS summaries of UNGASS data
try to standardize reported programme expenditures for ART and PMTCT as per-person costs,[10]
but do not request a comprehensive breakdown of
the cost components included in each service area.
As of 2011, most HIV/AIDS programmes do not
Pharmacoeconomics 2011; 29 (7)
581
quirements anticipated from national AIDS programmes from major global financiers of HIV/
AIDS programme scale-up.
1. Literature Review
1.1 Search
Galarraga et al.
582
Publications
identified through
PubMed
(n = 103)
Publications identified
through EconLit
(n = 30)
Additional records
identified through
POPLINE and other
sources1
(n = 34)
Articles screened
(n = 150)
Full-text articles
eligible for further analysis
(n = 139)
Editorials and
commentaries
(n = 11)
Full-text articles
excluded because they
did not fulfil inclusion
criteria2
(n = 110)
Fig. 1. Literature review on antiretroviral therapy and prevention of mother-to-child transmission per person-year delivery unit costs: flowchart
of search and review process. 1 Seven studies included for in-depth analysis were from the grey literature; 2 see Annex D in the Supplemental
Digital Content 1, http://links.adisonline.com/PCZ/A117, for a list of excluded studies.
583
Study, year of
publication
(country)
City/setting
Scope
facilitiesc
(provider type)
patients
ART regimenb
ART unit
costs
laboratory tests
overheads
584
Table I. Delivery unit costs ($US, year 2009 values) of antiretroviral treatment (ART), per patient-yeara
Low-income countries
Cotonou/U
1 (Nat/NGO/D)
122
outpts
681.9
500.5 (73.4)
51.4 (7.5)
99.5 (14.6)
21.1 (3.1)
NA
Bikilla et al.,[26]
2009e,f (Ethiopia)
Arba Minch/U
1 (Nat)
209
outpts
262.8
205 (78)
37.8 (14.4)
15.7 (6)
INU
(d4T/3TC + NVP)
or (AZT + 3TC + NVP)
or (d4T/3TC + EFV)
or (AZT + 3TC + EFV).
All regimens are
first-line
Kombe et al.,[27]
2004g (Ethiopia)
NA
804.1
548.3 (68.2)
PEPFAR ART
Costing Project
Team,[23] 2009h,i
(Ethiopia)
NA
outpts
741.7 (new
adult
patients)
428.3 (57.7)
21.8 (2.9)
191.1 (25.8)
59.9 (8)
NA
610.8
(established
adult
patients)
428.3 (70.1)
12 (2)
80.8 (13.2)
33.7 (5.5)
960.8 (new
paediatric
patients)
606.7 (63.1)
21.8 (2.2)
191.1 (19.9)
62.7 (6.5)
933.4
(established
paediatric
patients)
606.7 (65)
12.3 (1.3)
94.5 (10.1)
39.4 (4.2)
9 (Nat)
Koenig et al.,[28]
2008e (Haiti)
Port-au-Prince/U 1 (NGO)
218
in/outpts
1088.7
402.6 (37)
INU
147.4 (13.5)
129.6
(11.9)
NA
Jaffar et al.,[29]
2009e (Uganda)
Jinga/R
NA
outpts
789
416.6 (52.8)
181.5 (23)
INU
INU
NA
833.8
417.7 (50.1)
242.6 (29.1)
1 (NGO)
Galarraga et al.
Hounton et al.,[25]
2008d,e (Benin)
City/setting
ART regimenb
patients
ART unit
costs
laboratory tests
overheads
Chennai/U
1 (Nat)
2606
96.7
46.2 (47.8)
7.1 (7.3)
18.9 (19.5)
Not
included
Imphal/U
1 (Nat)
226
377.2
130.3 (34.5)
33.3 (8.8)
97.8 (25.9)
Ahmedabad/U
1 (Nat)
1210
133.2
60.7 (45.5)
8.5 (6.4)
42.4 (31.8)
New Delhi/U
2 (Nat)
1728
120
53.4 (44.5)
11.4 (9.5)
20.3 (16.9)
Trivandrum/U
1 (Nat)
498
217.9
118.3 (54.2)
12.8 (5.9)
60.3 (27.6)
Thrissur/U
1 (Nat)
308
155.5
101.4 (65.1)
8.7 (5.6)
0 (0)
John et al.,[31]
2006h,k (India)
Bangalore/U
1 (NGO)
25
in/outpts
461.8
257.7 (55.8)
17.4 (3.8)
INU project
coordinator, medical
officer, nurses,
laboratory
technician,
counsellors
INU
Cleary et al.,[19]
2007e,l (Lesotho)
Maseru/U
1 (Nat/NGO)
127.4 (78.8)
INU
15.3 (9.5)
INU
Loubiere et al.,[32]
2008e,m (Morocco)
Casa Blanca/U
1 (Nat)
167
in/outpts
1076.9
INU
INU
INU
INU
NA
Kombe et al.,[33]
2004e,n (Nigeria)
Lagos/U;
Abuja/U
5 (Nat)
NA
841
420.5 (50)
185 (22)
193.4 (23)
33.6 (4)
PHR,[34] 2004g,k,o
(Nigeria)
Anambra/U;
Bauchi/R;
Edo/U;
Federal Capital
Territory/U;
Kano/U;
Lagos/U;
Nassarawa/U;
Rivers/U
66
NA
(Nat/FBO/NGO) in/outpts
1023.3
362.1 (35.4)
391.2 (38.2)
237.5 (23.2)
18.6 (1.8)
Lower-middle-income countries
Gupta et al.,[30]
2009e,j,k (India)
585
Scope
facilitiesc
(provider type)
Study, year of
publication
(country)
Table I. Contd
Study, year of
publication
(country)
City/setting
Kitajima et al.,[35]
2003e,p (Thailand)
Khon Kaen/R
Scope
facilitiesc
(provider type)
2 (Nat)
ART regimenb
ART unit
costs
laboratory tests
overheads
106
outpts
3903.8
3415.1 (87.5)
INU
462 (11.8)
26.7 (0.7)
NA
157
adherent
patients
1454
1290.3 (88.7)
Not
included
NA
40 nonadherent
patients
1340.1
1290.3 (96.3)
patients
586
Table I. Contd
Upper-middle-income countries
Acurcio et al.,[36]
2006e,g,q (Brazil)
Sao Paulo/U
1 (Nat)
INU
INU
INU
INU
Aracena-Genao
et al.,[37] 2008e,r
(Mexico)
Mexico City/U
1 (Nat)
80
7688
INU
INU
INU
INU
NA
Bautista-Arredondo
et al.,[38] 2003;
Bautista-Arredondo
et al.,[39] 2008e,s
(Mexico)
Mexico City/U;
11 (Nat)
902
6651.3 first
year
6024.4 (90.6)
INU
223.4 (3.4)
INU
NA
Cuernavaca/U;
4256.8
second year
3809.4 (89.5)
165.8 (3.9)
Guadalajara/U
4682.9 third
year after
ART
initiation
3960.7 (84.6)
254.6 (5.4)
987.3
338.8 (34.3)
INU
1774.3
1108.3 (62.5)
Cleary et al.,[40]
2006e,t
(South Africa)
Cape Town/U
3 (Nat)
1729
INU
96 (9.7)
112 (6.3)
Galarraga et al.
Marques et al.,[24]
2007i (Brazil)
Study, year of
publication
(country)
City/setting
Deghaye et al.,[41]
2006e,u
(South Africa)
ART regimenb
Scope
facilitiesc
(provider type)
patients
ART unit
costs
laboratory tests
overheads
Durban/U
2 (Nat)
41
1022.3
411 (40.2)
330 (32.3)
218.8 (21.4)
16.4 (1.6)
Harling et al.,[42]
2007e,v
(South Africa)
Cape Town/U
1 (Nat/D)
NT
521.6
INU
INU
INU
NT
Harling et al.,[43]
2007e,u
(South Africa)
Cape Town/U
1 (Nat/NGO)
172
outpts
1296.5
535.9 (41.3)
203.3 (15.7)
341 (26.3)
25.2 (1.9)
535.9 (29.2)
545.5 (29.7)
442.1 (24.1)
212.7 (11.6)
Kevany et al.,[44]
2009w
(South Africa)
Cape Town/U
48 outpts 1795.8
103.9 (5.8)
478.1 (26.6)
988.6 (55.1)
consultant, medical
officer, nursing
sister, medical ward
staff
25 inpts
6579.5
271.7 (4.1)
2097.8 (31.9)
847.6 (12.9)
consultant, medical
officer, nursing
sister, medical ward
staff
591
2853.6 (new
ART
patients)
958 (33.6)
190.5
(10.8)
INU
INU
Martinson et al.,[45]
2009e,v
(South Africa)
Soweto/U
1 (Nat)
1 (D)
Gauteng/U
Rosen et al.,[46]
2008e (South Africa)
2 (Nat/NGO)
200
1122.5
(patient
responding)
INU
INU
1210.3
(patient not
responding)
Continued next page
587
958 (54.1)
1770.4
(establishedART
patients)
Not
included
Table I. Contd
Study, year of
publication
(country)
City/setting
Eastern Cape/U
Scope
facilitiesc
(provider type)
patients
1 (NGO)
100
ART unit
costs
ART regimenb
laboratory tests
overheads
500 (46.8)
236 (22.1)
16.6 (1.5)
588
Table I. Contd
1241.1
(patient
responding)
1177.3
(patient not
responding)
Mpumalanga/R
1 (NGO)
100
1229.4
(patient
responding)
1182.7
(patient not
responding)
Vella et al.,[22]
2008e,i
(South Africa)
a
KwaZulu-Natal/U 32 (Nat)
2835
1068.1
300 (28.1)
NA
Dollar amounts and proportions of overall costs may not add to 100% due to rounding and because some costs do not fit into the classifications used. For example, transportation
costs to visit patients homes, non-ARV medicines, opportunistic infections medicines and recurrent costs such as cotton, syringes, gloves, etc. are in the Other category, which
has been excluded from the table (but could be estimated by subtracting the current total from 100%). ARV medicine costs include only the costs of ARVs, mostly first-line
treatment unless otherwise noted in the Regimen column. Personnel costs include human resource expenses incurred in service delivery, including health workers doing patient
care and, in some studies, administrative personnel. Laboratory costs may include HIV testing, CD4 cell count and viral load measurement. Overheads may include capital costs
(e.g. medical equipment, computers) and/or recurrent costs (utilities: electricity, water, phone, rent, maintenance costs, storage, cleaning or security). If the study reviewed provided
details about what was included in each category, those details have been incorporated in the table. Costs were converted into $US, year 2009 values, using average exchange
rates during the study period (see sources in the Methods section). For further details see the Supplemental Digital Content (http://links.adisonline.com/PCZ/A117) versions of the table.
Costs calculated using patients retained at the end of the study as denominator.
Costs taken were for first-line, annually thereafter (i.e. first-line patients only, from their 6th month after ART initiation onwards).
Continued next page
Galarraga et al.
3TC = lamivudine; ARV = antiretroviral; AZT = zidovudine; d4T = stavudine; D = donor; DDL = didanosine; EFV = efavirenz; FBC = full blood count; FBO = faith-based organization;
IDV = indinavir; inpts = inpatients; INU = included but not unbundled; LPV = lopinavir; NA = not available; Nat = national (if Nat not mentioned it means that the provider is local);
NFV = nelfinavir; NGO = non-government organization; NVP = nevirapine; outpts = outpatients; PEPFAR = The Presidents Emergency Plan for AIDS Relief; R = rural; RTV = ritonavir;
tx = treatment(s); U = urban.
589
v Because the study reports the costs per month those costs were multiplied by 12 to have an annual parameter.
Costs concern ART given for tx occurring 612 months for first-line ART (pt specific) and separately for second-line tx.
t
Patients who, every month throughout the study period, received ART. Costs presented cover patients through 2006, with only 41% having started after the year 2000.
r
s Costs include pts who initiated ART in 2000, as it was not possible to single out those pts who started after 2001.
q Study does not specify what other specialists or laboratory tests were costed.
p The study reports the average cost. Because the investigation reports the cost per visit, cost were multiplied times the average number of visits per year to have an annual parameter.
Because the hospital charges an extra 15%, we multiplied by 85% to obtain the actual cost of the ART delivery.
o Public sector only, with patients paying a fixed portion of ART (included in the costs listed).
m Including patients who started visiting the hospital in 1997, as it was not possible to single out those patients who initiated ART after 2001.
Table I. Contd
Galarraga et al.
590
Table II. Base-case and sensitivity analyses: delivery unit cost ($US, year 2009 values) of antiretroviral treatment (ART) per patient per year,
by country income levela
Low
income
Lower-middle
income
Upper-middle
income
All
Mean
839
1246
2783
1494
Median
792
932
1454
1005
SD
175
1546
2500
1628
Range
6821089
Base case
1563904
12305667
1565667
Countries
12
Studies (n)
13
26
10
12
24
46
1588
770
714
2366
Median
797
298
1397
1073
SD
226
1067
2034
1754
Range
2631089
973904
5227688
977688
Countries
12
Studies (n)
13
26
10
12
24
46
2. Adding studies reporting total unit cost without ARV/laboratory/human resource breakdown
Mean
713
1314
Unchanged from
base case
1422
Median
773
932
932
SD
319
1637
1639
Range
2111089
1624212
1625667
Countries
13
Studies (n)
29
11
14
48
565
1683
3068
Median
646
1454
1241
1073
SD
346
886
2537
1754
5223904
10687688
Range
971089
1588
977688
Countries
Studies (n)
11
26
20
13
13
46
12
The base case and scenario 2 aggregate total ART unit costs per person per year by first taking the median within each country. Sensitivity
analyses are as follows: 1. All study sites weighted equally, regardless of country or number of sites per country. 2. Expanded dataset to include
studies that did not include a breakdown of cost components, but had data on total ART costs. 3. Use World Bank gross national income per
capita data at the time of the study costing, instead of 2009 gross national income, to classify countries according to income level. Baseline
estimates based on more than 14 765 patients from 26 studies, plus additional studies that did not disaggregate costs by cost component.
Twelve studies specifically reported costs for first-line treatment; one study[40] specifically included second-line treatment but those specific
costs were excluded. See table I, text and Supplemental Digital Content, 1 (http://links.adisonline.com/PCZ/A117) for further details.
b The total number of countries in scenario 3 adds to 12 only because, given the timing of the costing, and the countrys economic development,
South Africa is in both the lower-middle-income and the upper-middle-income categories.
ARV = antiretroviral.
8000
Mexico
7000
6000
South Africa
5000
ARV drugs
Laboratory tests
Personnel
Other costs
Costs not unbundled
Thailand
4000
3000
Brazil
*
2000
1000
Ethiopia
**
Haiti
Uganda
Nigeria
Benin
Morocco
*
India
Aracena-Genao, 2008
Fig. 2. Unit costs for delivery of antiretroviral treatment (ART), per patient-year, by cost component, country and site.[19,22-31,33-38,40-46] Countries are ranked from left to right according
to increasing per capita gross national income (GNI) and then by year of study publication. Studies including (or limited to) paediatric ART are indicated with an asterisk (*) over the bar.
Other costs refer to components of ART other than antiretroviral (ARV) medicines, laboratory and personnel costs; other costs are not comparable across studies because they do
not contain the same elements. Unbundled costs refer to the overall cost of ART in case the study did not report the separate cost components but these still included at least the three
main components under review. Each bar represents a separate data point within each country or study (e.g. different region, health facility/site, patient type, delivery modality,
temporality, etc.). GNI per capita (year 2009 values): Ethiopia $US280, Uganda $US420, Haiti $US660, Benin $US690, India $US1070, Lesotho $US1080, Nigeria $US1160, Thailand
$US2840, South Africa $US5820, Brazil $US7350, Mexico $US9980. See table I for additional details. PEPFAR = US Presidents Emergency Plan for AIDS Relief; PHR = The Partners
for Health Reformplus.
591
Rosen, 2008
PHR, 2004
Lesotho
0
Study, year of
publication
(country)
City/settingb
(costing yearc)
Scope
facilitiesd
Provider
typef
patientse
Dandona
et al.,[48] 2008
(India)
Andhra Pradesh/U
(20056)
16
1212
Nat
2.4 (post-test
counselling)
Desmond
et al.,[49] 2004
(South Africa)
Durban/U, Paarl/U,
Siloam/R, Frankfort/R
(2002)
McMennamin
et al.,[50] 2007
(Rwanda)
laboratory
tests
overheads
INU
INU
0.35 (14.7)
Gicumbi/R (2005)
709 (pre-test
counselling)
Nat/D
42.4
570 testing
32.5
532 (post-test
counselling)
23.8
208.8i
63 (motherneonate pair
follow-up)
327.2j
NA
Nat/FBO
6.42 specific
intervention
Costs were converted into $US, year 2009 values, using average exchange rates during the study period.
Regimeng
592
Table III. Delivery unit cost ($US, year 2009 valuesa) of prevention of mother-to-child transmission (PMTCT) of HIV
NVP
36.9 (14.7)
INU
INU
INU
Not
included
NVP + CTX
INU
INU
INU
INU
Not reported
c Refers to the year for which the study reported the costs.
Refers to the number of facilities in which the costs were collected.
The mother was given one tablet of NVP 200 mg at the onset of labour and the neonate was given NVP 2 mg/kg bodyweight within 72 hours of birth.
This cost includes re-issue of NVP to mothers, and provision of NVP suspension to the child and any formula milk for the duration of the hospital stay.
PMTCT activities delivered after the mother and infant are discharged from hospital after delivery, including CTX and the provision of formula feeding. It does not include infant HIV
testing.
ARV = antiretroviral; CTX = cotrimoxazole; D = donor; FBO = faith-based organization; INU = included but not unbundled; NA = not available in the study; Nat = National (if Nat not
mentioned it means that the provider is local); NGO = non-government organization; NVP = nevirapine; R = rural; U = urban.
Galarraga et al.
593
Galarraga et al.
594
in part explained by Rwandas much lower percapita income level and health worker salaries.
Equally important, this unit cost was achieved in
a large-scale programme in a high HIV-prevalence
setting, with the six health centres covering a
catchment population of 148 151 individuals, with
a high PMTCT uptake rate of 71.6%, which likely
achieved significant economies of scale. However, the study does not specify number of pregnant women screened for PMTCT, the number of
HIV-infected women or the number of motherinfant pairs given nevirapine.
4. Sensitivity Analyses
A first sensitivity analysis assessed the effect of
aggregating unit cost within country-income groups
by weighing all data points and sites across studies and countries equally, instead of the base-case
model (presented above), which weighed all
countries equally, irrespective of their number of
data points. In this variant model, median unit
costs for ART were nearly unchanged for LIC
and UMIC: in LIC, the median was $US797
(vs $US792 in the base-case model) and 1397
in UMIC (vs $US1454 in the base-case model;
table II). However, for LMIC, this alternative
aggregation method resulted in a 3-fold reduced
median cost estimate per patient-year: $US298
compared with $US932 in the base case. This
difference reflects an over-representation of study
sites and data points from India among LMIC,
with exceptionally low unit costs reflecting Indias
uniquely low ARV prices due to the countrys
important generic ARV industry and resulting
strong pharmaceutical negotiation capacity.
A second sensitivity analysis, to further check on
representativeness, expanded the data set to include
a number of studies that did not include a breakdown of cost components, but had data on total
ART costs. With the addition of one study from
Kenya,[51] the LIC median cost per patient per year
became $US773 (mean: 713, range: 2111089), similar to the original estimate of $US792. Among
LMIC, adding data points from Thailand and
India[52-54] did not alter the median cost per patient
per year from the default of $US932 (but the mean
increased to 1314, range: 1624212).
2011 Adis Data Information BV. All rights reserved.
Third, we replaced the country-income classification according to each countrys 2009 income
level by a classification using each countrys income level in the year of cost data collection
(while in both cases applying World Bank 2009
income thresholds). This shifted five countries
that had grown richer between the costing study
year and 2009 (Brazil, India, Lesotho, Nigeria
and South Africa) into a lower income category.
This country regrouping reduced the median
ART per-patient cost among LIC (from $US792
to $US646), increased the estimate for LMIC
(from $US932 to $US1454) and decreased the
estimate for UMIC (from $US1454 to $US1241).
5. Discussion
Empirical data on ART delivery unit costs in
low- and middle-income countries has increased
significantly in recent years, as access to ART has
expanded. The current review identifies several
more good-quality costing studies of both outpatient and home-based ART than earlier reviews,[12,13,15] and provides separate cost estimates
for the components ARVs, personnel and laboratory costs.
The results have several implications for
programme planning and budgeting, and for seeking efficiency improvement. For ART, the key cost
drivers within health facilities are ARV procurement, laboratory tests and personnel. ARV prices
have declined substantially over the last decade,
with average declines of 1239% over 20069 for
the first-line regimens most commonly used in
low- and middle-income countries.[55] Lacking
specification of regimens and drug sources in sites
studied, it was not possible to adjust cost estimates
for price declines. Only six of the 24 ART costing
studies reported whether the programme used
generic or innovator drugs (see the expanded versions of table I in the Supplemental Digital Content). Of 14 studies that specified ARV regimens,
the majority used lamivudine (3TC) + nevirapine +
stavudine (d4T) as the most common first-line
regimen, the regimen for which recent price declines have been smallest: 912% per year.[55] The
predominance of this regimen may explain why,
over 20049, the average proportion of overall
Pharmacoeconomics 2011; 29 (7)
595
5.1 Limitations
Galarraga et al.
596
nominator definitions will have on unit cost estimates, especially in programmes with low patient
retention and/or rapid scale-up, with many new
patients initiating ART.
5.2 Future Work
The limitations in availability and comparability of existing cost data described above
highlight an urgent need for development and
dissemination of standardized cost-measurement
methodologies and for capacity building. Awaiting such guidance and improved data quality and
standardization, any cost comparisons between
sites and studies should be carried out with extreme caution and attention to methodological
differences; interpretations on relative efficiency
will typically be limited to within-study determinants. Future strategic use of cost data for improving the efficiency of ART delivery will, in
particular, benefit from more careful costing and
reporting of ARV drug sources and regimens,
laboratory costs by type and frequency of tests,
and staff costs by type of personnel, including
those above the health-facility level.
Future assessments should link costs to health
outcomes, including cost differentials associated
with clinical response,[46] drug toxicity and resistance.[44] This is ever more important in view of
the WHO revised 2010 guidelines for adult ART
in resource-limited settings, which recommended
an expanded access to ART, starting at CD4 cell
count <350/uL instead of the former 200/uL. In
addition, a gradual phasing-out is now recommended of stavudine (d4T) in first-line regimens,
to be replaced by less toxic but more costly efavirenz and/or tenofovir-based first-line regimens.[62]
As countries gradually adopt and implement the
new treatment guidelines over coming years, it is
imperative that costing studies document the mix
of patients evaluated in terms of CD4 cell counts
at treatment initiation and regimens used, to facilitate interpretation of cost findings and cost
determinants.
To improve the knowledge base on efficient
ART and PMTCT delivery, collaboration between countries could be very important. First, to
increase costing capacity and resources, and
Pharmacoeconomics 2011; 29 (7)
597
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