accessing free anti retroviral therapy (art) services is expensive for plhiv -a costing exercise...
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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