Research Article: Early and Late Direct Costs in a Southern African Antiretroviral Treatment Programme: A Retrospective Cohort Analysis

Date Published: December 1, 2009

Publisher: Public Library of Science

Author(s): Rory Leisegang, Susan Cleary, Michael Hislop, Alistair Davidse, Leon Regensberg, Francesca Little, Gary Maartens, Sydney Rosen

Abstract: Gary Maartens and colleagues describe the direct heath care costs and identify the drivers of cost over time in an HIV managed care program in Southern Africa.

Partial Text: Access to combination antiretroviral therapy (ART) is rapidly expanding in resource-limited settings. Data on the costs of providing HIV health care and how these change over time are important for guiding resource allocation. However, there are few good quality studies of the direct health care costs of HIV infection, as illustrated by a recent systematic review that found only nine studies from the ART era that fulfilled inclusion criteria [1]. Data on costs prior to starting ART are limited as most cost studies only report costs once ART has been commenced. A recent South African study reported that health care costs were almost twice as high in the first year on ART in comparison with the second year [2]. However, the sample size was small, patients had advanced disease, follow up was relatively short, and the period of higher costs in the first year on ART was not defined.

10,735 patients met our eligibility criteria. The characteristics of the cohort are described in Table 1. There were almost 600,000 patient months of observation, about half of which were on ART. Median follow-up on ART was 26 mo. Baseline body mass index (BMI) was only available for 4,416 of the patients: 13% were <18.5 kg/m2, 52% were ≥18.5 kg/m2 and <25 kg/m2, and 35% were ≥25 kg/m2. The most common first line and second line antiretroviral regimens were zidovudine, lamivudine, and efavirenz and lopinavir/ritonavir, zidovudine, and didanosine, respectively. CD4 and viral load monitoring were done 1.5 times per annum on average. Hospitalisation rates were 441 d per 100 patient years of observation (PYO) in the first 6 mo of ART and 179 d per 100 PYO subsequently. Hospitalisation incidence was highest in patients in the lowest CD4 count stratum. We analysed the direct health care costs of treating over 10,000 HIV-infected adults enrolled in a Southern African managed care ART programme with almost 600,000 patient months of follow-up, spanning 3 y before ART to 5 y on ART. We found a peak in costs in the period around the time of ART initiation, thereafter total mean costs dropped off to a plateau that persisted for 5 y. An important and novel feature of our study was the presentation of time-dependent associations between total mean costs and relevant variables. We identified lower baseline CD4+ cell count, higher baseline viral load, and shorter duration of CD4+ cell count monitoring before starting ART (as a proxy for HIV care) as being independently associated with higher costs in the early time periods. Lower ART adherence, being on second line ART, and starting ART at an younger age were most strongly associated with lower mean costs in later time periods, and the association with ART adherence became more marked over time. Source:


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