collecting costs at the country level ppt, 608kb

Antiretroviral Treatment Costs in Mexico

WHO/UNAIDS Workshop on Strategic Information for Anti-Retroviral Therapy Programmes

30 June to 2 July, 2003Assessment of programme outcomes (economic)

Sergio Bautista, Tania Dmytraczenko, Gilbert Kombe and Stefano Bertozzi

Presentation prepared by INSP, 30 June 2003

Purpose of the Study

To document—using a consistent methodology—the Mexican experience in HIV/AIDS treatment in 3 health subsystems– Ministry of Health (SSA)– Mexican Social Security Institutes (IMSS/ISSSTE)– National Institutes of Health (INS)


Specific Objectives of the Study

Identify patterns of HIV/AIDS care and treatment and related costs by type of therapy received– ARV triple therapy or not

To estimate the annual care costs per patient by

•Subsystems SSA, IMSS/ISSSTE,

INS•Care setting Inpatient, outpatient

•Level of care Specialized clinics, secondary

and tertiary hospitals•Disease stage CDC classification CD4


Study Approach: Site selection

11 health facilities were selected– SSA sites (5)– IMSS/ISSSTE sites (4)– INS sites (2)

Geographic Location– Mexico City (6)– Guadalajara (2)– Cuernavaca (2)

Level of Care– Highly specialized tertiary care

facilities (3)– Secondary care facilities (7)– Specialized HIV clinic (1)


Study Approach: Sample size and eligibility

Convenience sample to reflect clinical and treatment criteria of interest:– ARV recipients (75%)– Not on ARVs (15%)– Deceased (10%)– 1062 patients randomly selected, with sample stratification

Patients eligibility criteria– 18 years or older at first consultation– Diagnosed with HIV and confirmed by Western, Elisa or laboratory

culture, or symptomatic AIDS– Documented visit at a study site between 1/1/2000- 12/31/2001


Data Collection Instruments

Utilization (patient chart review)– Socio-demographic characteristics– Clinical events including outpatient, inpatient, labs,

drugs, surgical procedures and interventions

Unit costs (facility questionnaire)– Existing unit cost data

• Facility- or subsystem-specific– Micro-costing of AIDS-specific diagnostic tests and drugs– Recurrent costs (except for AIDS-specific tests)


Data Collection Process

5 trained teams, each composed of an economist and a MD/nurse

Data were captured retrospectively for a period of 3 years from the date of last consultation in the study period

Accuracy and reliability of data collection was strengthened with real-time data entry in the field and error checking interface


SSA IMSS/ISSSTE INS Education (n=506) (n=144) (n=87)

Primary or less 30.0% 9.0% 26.4% Secondary+ 54.0% 52.8% 55.2% Higher 16.0% 38.2% 18.4%

Mode of Transmission (n=496) (n=175) (n=69) Unsafe injection 1.2% -- -- Transfusion 3.0% 5.7% 2.9% Occupational risk -- -- 1.5% Sexual 95.8% 94.3% 95.7%

Sexual Preference (n=404) (n=127) (n=44) Heterosexual, male 40.3% 62.2% 40.9% Homosexual, male 45.5% 29.9% 43.2% Bisexual, male 14.1% 7.8% 15.9%

Characteristics of the Sample (n=1062)


Key Finding #1: There has been a progressive and rapid uptake of HAART

0%10%20%30%40%50%60%70%80%90%

100%

1997 1998 1999 2000 2001

MonoDoubleTriple

(n = 49) (n = 138) (n = 326) (n = 567) (n = 496)

Distribution of Patients by Type of Therapy


Key finding #2: Patients start treatment in advanced stages, improvement is gradual

.003

.002

.001

0

2000150010005000

year –1 (n = 319)year 1 (n = 712)year 3 (n = 140)

Distribution of CD4 Count


Key Finding #3: Total costs are substantially higher under HAART

0500

10001500200025003000350040004500

-3 -2 -1 1 2 3

Years pre- and post-HAART

US$

HospitalizationOutpatient visitsLab testsOI drugs + proceduresARV drugs

(n = 45) (n = 153) (n = 612) (n = 792) (n = 459) (n = 201)

Average Annual per Patient Cost of Treatment


Key Finding #4: Lab tests and Outpatient visits are the largest contributors to treatment costs,

excluding ARVs

0100200300400500600700800900

-3 -2 -1 1 2 3

Years pre- and post-HAART

US$

HospitalizationOutpatient visitsOI drug + proceduresLab tests

(n = 45) (n = 153) (n = 612) (n = 792) (n = 459) (n = 201)

Average Annual per Patient Cost of Treatment, Excl. ARVs


Key Finding #5: Treatment costs are higher for patients in advanced stages of illness

CD4 RangeOutpatient

visitsHospital

daysLab tests

OI drugs+ procedures

Total

0-199 (n = 1016)

190 104 759 91 1144

200-349(n = 484)

205 36 603 30 874

350-499(n = 270)

279 23 566 21 888

>500(n = 306)

271 8 496 61 836

Avg Annual per Patient Cost of Treatment Excl. ARVs, by CD4 count


Summary

Our findings are consistent with studies done in other countries– ARV comprises >75% of total treatment costs– Outpatient and monitoring costs increase as patients start

triple therapy Unlike Sub-Saharan African countries, hospitalization is not a big

factor in Mexico Costs associated with late initiation of treatment and during last

year of life


Policy Recommendations I

Governments should be realistic about resource requirements of starting and scaling-up ARV treatment– Lab capacity– Human resource training

Countries should be prepared for the shift in care and treatment patterns of patients on HAART especially from inpatient to outpatient

Clinicians should clearly understand when to initiate and how to monitor patients on therapy


Policy Recommendations II

Estimating total cost of ARV treatment can significantly help countries plan for scaling-up– Negotiating drug prices

Medium to long-term prospective is needed for a full evaluation of program costs

collecting costs at the country level ppt, 608kb

Documents