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Accessing Free Anti Retroviral Therapy (ART) Services is Expensive for PLHIV-A Costing Exercise from India (GHTM)*

Presented by

Dr Jammy Guru Rajesh

* Government Hospital of Thoracic Medicine, & ITECH Chennai, India

Co-Authors - S. Rajasekaran, T. Francis, P. Nadol, P. Naqui

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HIV/AIDS Scenario in India India has the third largest number

of people living with HIV/AIDS (2.27 million) (2008-09 provisional estimates)

Stable HIV epidemic, adult HIV prevalence rate is 0.29 percent (2008-09), 38% are women and 3.8% children

Concentrated epidemicHIV prevalence among different

population groups, (MSM- 9.2%, IDU – 7.3%, FSW – 4.9 %, STD- 2.5%, ANC- 0.49%) (2008-09 Provisional)

A 156: ANC Attendees >=1%

B 39: ANC Attendees <1%, HRG>=5%

C 296: HRG<5%

D 118: No Known Hot Spots/Poor Data

District Categorization based on HIVSentinel Surveillance (2004-06)

Source: NACO Annual Report, 2009-10 and UNGASS Report 2008

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Background

o ART reduces mortality of PLHIV .o Government of India (GOI) launched a free ART

program in 2004 with an aim of putting 300,000 PLHIV on ART by 2012.

o GHTM is the largest centre serving more than 20000 PLHIV

o By 2010 - 300,000 PLHIV on ARTo By 2008-09, second line ART criteria were

developed and initiated (10 centres) o There is a need for unit cost data to assess

financial implications for scale up

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To examine the unit cost of ART provision

To fill the gap in financial / cost information

This costing exercise of the ART services

was taken up at GHTM in 2007.

Purpose

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Methodology

Exploratory design for provider unit cost

Cost heads – Drugs, Lab, OP & IP

Data sources – Invoice (lab &drugs), ‘THIS’ and Discussions with staff & administrators

Cross sectional survey for patient costs

Direct & Indirect costs

200 PLHIV on ART aged 18-45 years & on ART for at least last 1 year.

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Results

P.S: All Cost are represented in USD $ (INR)

Conversion 1 USD = 45 INR

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Drugs cost

Drugs (ART + others) Initiation (15 days)

F/U (1 month)

AZT/3TC/NVP $7.49 (337.4) $12.60 (567.3)

AZT/3TC/EFV $12.88 (579.74) $23.60 (1062.3)

D4T/3TC/NVP $4.61(207.48) $6.60 (297.3)

D4T/3TC/EFV $9.99(449.82) $17.42 (783.9)

EFV > 7 x NVP

AZT > 3 x d4T

Provider cost

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Unit cost of laboratory tests

Capital cost of the machine, reagents, personnel,

stationery were included

Overhead costs were taken (10%)

CD4 CBCBlood sugar LFT RFT X ray

Sp. AFB

$9.78(440.4)

$0.97(43.7)

$0.5(22.7)

$0.94(42.7)

$0.52(23.4)

$1.10(49.8)

$0.31(14.3)

Provider cost

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ART provision at OPD costs

Personnel cost (cost of time) for ART services -

includes cost of Doctor, Counselor, Pharmacist,

nurse and support staff

For ART initiation – $1.48 (66.9) / patient

For ART follow up – $0.61 (27.6) / patient

Provider cost

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ART IPD hospitalization cost

Costs included were those for personnel, maintenance /

cleaning, laundry and food.

Overhead costs of 10% was added on to the total cost

IP cost / patient for ART initiation(15 days) =

$22.66 (1020)

IP cost per patient /day = $1.51 (68)

Provider cost

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Average cost for ART initiation

ART initiation cost = costs of drugs + labs (CD4, LFT, RFT, CBC, BS, X-ray, Sp) + OPD cost + IP (15 days)

  Total cost / patient

AZT/3TC/NVP $45.82 (2061.9)

AZT/3TC/EFV $51.20 (2304.24)

d4t/3TC/NVP $40.78 (1835.24)

d4t/3TC/EFV $48.31 (2174.32)

Weighted Average* cost of ART initiation at GHTM per

patient = $44.55 (2005)

* - Weighted average was taken based on the distribution of the regimens during the quarter (April-June 07).

Provider cost

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Average cost for ART follow up

As follow up differs for AZT and d4T regimens in

terms of lab tests, 3 months cost for follow up:

Weighted Average cost of

ART F/U/patient/ month – $14.04 (632)

Provider cost

 F/U cost / patient for 3

months % Regimens

AZT/3TC/NVP $48.49 (2182.2) 38

AZT/3TC/EFV $81.49 (3667.45) 11

d4t/3TC/NVP $24.60 (1107.2) 46

d4t/3TC/EFV $57.04 (2567.0) 6

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Cost Summary of provider cost

Year 1 of ART (includes initiation) =

$224.28 (10,093) per patient per year

Year 2 or each subsequent year =

$188.02 (8,461) per patient per year

Provider cost

Major cost contributors – Drugs followed by labs

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Patient costs Patient costs

Survey of 220 PLHA

Direct costs – Travel and food

Indirect cost – loss of wages,

attendant cost

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Cost per patient / visit

Median distance traveled = 200 kms (124.2 miles)

Mean Travel cost – $3.11 (140)

Mean food cost – $1.62 (73)

Mean daily wage loss – $1.91(86)

Mean cost / patient / visit = $6.64 (299)(without attendant)

Direct costs

Patient costs

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Patient cost variation with distance

Distance Travel cost

Food cost

Wage loss

Total cost

<200kms(52%)

$1.82 (82)

$1.22 (55)

$1.64 (74)

$4.68 (211)

>200Kms(48%)

$4.46 (201)

$2.06 (93)

$2.17 (98)

$8.71 (392)

Patient costs

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Average Cost per patient

Overall cost (wt. average) per patient / visit = $8.95 (403) (40% accompanied by attendants)

Cost per patient / year – $107.35 (4,831)

Patient costs

Mean cost / patient / visit = $6.64 (299)(without attendant)

Cost / patient + attendant / visit = $12.4(558)

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Cost Summary

Societal cost (Provider + Patient cost)

For Year 1 of ART (includes initiation) = $331.64 (14,924)

For Year 2 or each subsequent year = $295.37 (13,292 )

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ConclusionGOI sponsored ART is capital intensive

Drugs & Labs are the majority of cost

Surprisingly, patient costs are half that of the provider

Management of First Line therapy is somewhat affordable, but second line is expected to be much more expensive as both drug and lab costs would increase dramatically.

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Limitations

Economies of scale (GHTM a large provider)

would reduce the unit cost

Infrastructure cost of the ART services was

rounded off to overheads

Costing of the OI care was beyond the scope of

this study

Programmatic cost of the free ART services

was not calculated

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Recommendations / Call to action

Decentralization of ART provision

Increase the efficiency of labs to increase the

cost effectiveness

Public private partnership

Strengthening the ART referral Networks

User charges

Periodic unit cost calculation of services

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GOI initiatives which could influence the patient costs

Since the time study has been undertaken:

ART decentralized through ART centres scale up PLHIV on ART scaled upLink ART centres

Mainstreaming with rail and roadways departments for free transportation of PLHIV

Changing regimens (d4T reduced) and criteria for initiation

Cost of the ARV drugs

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Further research questions / needs

Programmatic costing of free ART program

Costing of HIV / OI care

Cost benefit analysis of the ART

Second line ART costs

Costing of mainstreaming HIV / ART care

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AcknowledgementsDr. S. Rajasekaran

Dr. Tara Francis

Mr. Patrick Nadol

Dr. Bimal Charles

Dr. Manoharan

Dr. Parveen Naqui

Ms. Bama (stores)

Mr. Yugendran

Ms. Kamali

Dr. Ashita

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Extra slides

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Example of a lab cost calculation for a CBC/CHG

Machine cost 350000

Depreciation @ breakeven by 5 years is 20%

So should get back per year 70000

Roughly doing max 150 test / day, tests per year with 25 working days a month 45000

Machine Cost per test with 150 tests / day to get back 70000 is 1.6

(i) Machine cost

Provider cost

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Cost of personnel per Month (salary) 8000

Per day salary 320

Per hour (for 6 hours work) 53.3

Per hour 45 CBC tests can be done so per 1 test 1.2

(ii) Personnel cost

Provider cost

Example of a lab cost calculation for a CBC/CHG… contd

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Cost of consumables per test 25

Blood collection 10

Stationary 2

Machine cost (ideally taking 150 tests) 1.6

Personnel cost per test 1.2

Cost per CBC 39.7

Overhead cost @ 10% 4

Total cost of CBC with overhead costs 43.7

(iii) Total cost

Provider cost

Example of a lab cost calculation for a CBC/CHG… contd

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How far the patients come from?

6

19

35

39

<150 Km 151-300 Km 301-500 Km 500+ Km

Distance travelled by PLHA to Reach GHTM

Mean / Median Distance traveled = 200 kms

Patient costs

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Costs incurred by Patients

49

39

9

2

<Rs.100 Rs. 101 to 250 Rs. 251 to 500 > Rs 500

Travel cost for reacing GHTM

Mean travel cost per patient / visit = 140

Patient costs