Economics: Costs, Cost-Effectiveness, and Benefits of HIV Treatment and Prevention
In the early years of the global rollout of HIV prevention interventions and antiretroviral treatment (ART) for HIV/AIDS, little attention was paid to the cost of the programs, the cost-effectiveness of different models of service delivery, or the value of the benefits generated. As national programs expanded and resources became scarcer, however, an urgent need for accurate, up-to-date data on the costs of care and prevention, for different populations and in different settings, arose. With it came demand for analyses of the cost-effectiveness of alternative approaches to providing services and, to a lesser extent, interest in measuring the benefits of the services.
Starting in 2005, CGHD researchers have been collecting and analyzing primary, patient-level data to estimate the costs, cost-effectiveness, and benefits of ART for adults and children in a range of countries and settings. Since then, results have been published of the cost of treatment per patient served, cost-effectiveness of different adult and pediatric treatment delivery models and drug regimens, and anticipated costs of changing treatment guidelines and numbers of patients served. This work has helped program managers and policy makers to understand the current costs of treatment, evaluate the economic implications of proposed treatment guideline changes, and identify areas for potential savings.
- Costs and Outcomes of HIV Treatment: When CGHD began its work on the economics of HIV in sub-Saharan Africa, few estimates were available of simple parameters such as the average cost of ART per patient treated. CGHD developed a methodology and model for using retrospective cohort data from local clinics and hospitals to estimate costs. When information about the outcomes of treatment was combined with these cost estimates, the results indicated the cost per patient retained in care and responding successfully to treatment—a “production cost” for HIV treatment. This approach has been applied to estimate treatment costs in South Africa, Zambia, Kenya, and Uganda, and for both adults and children. It has also been expanded to allow cost-effectiveness comparisons among different models of service delivery—such as ART managed by doctors at hospitals v. nurses at clinics—and between different antiretroviral drugs, such as tenofovir and stavudine.
- Costs of HIV Prevention: Although HIV prevention has not been a major area of research for CGHD’s health economics team, studies have been undertaken to estimate the costs of prevention of mother to child transmission (PMTCT) in Zambia and Kenya and of delivery of safe male circumcision in Uganda.
- Economic Outcomes of Treatment: By 2011, some 7.5 million people in sub-Saharan Africa were receiving antiretroviral therapy for HIV/AIDS. Within a few years, nearly 10% of working aged adults in South Africa will be on ART. Beginning in 2005, CGHD set out to assess the impact of treatment on patients’ economic activities, work productivity, quality of life, and other non-biomedical outcomes. Research has included a six-year prospective cohort study of adult patients in South Africa and a detailed analysis of the labor productivity of agricultural workers on ART in Kenya.
- Economics of Tuberculosis: Africa’s HIV epidemic has led to a parallel epidemic of tuberculosis and drug-resistant tuberculosis. Among the countries hardest hit is South Africa, where TB incidence is among the highest in the world and more than ten thousand cases of multidrug-resistant TB (MDR-TB) were diagnosed in 2012. CGHD’s work in this area is conducted in collaboration with HE2RO and focuses on the costs of treating and diagnosing TB and MDR-TB. Accomplishments include the development of the National TB Cost Model, used by the South African National Department of Health to estimate the costs of scaling up Xpert MTB/RIF diagnostic technologies country-wide.
- Modelling Future Costs: In 2009, the South African Department of Health and National Treasury asked a joint CGHD/HE2RO team to model the future size and costs of the national treatment effort. CGHD researchers built a model to estimate the annual expected costs of the program between 2010 and 2017 and evaluate proposed changes to treatment guidelines. The National ART Cost Model continues to be used to advise the South African Government on the expected costs of its treatment program, with additional modeling undertaken to understand the cost implications of treatment as prevention.
- AIDS and the Private Sector: As evidence of very high HIV infection rates among working-aged adults in sub-Saharan Africa accumulated in the late 1990s, concern mounted that employers, and in particular private companies participating in competitive export markets, would lose large numbers of skilled workers and face greatly increased labor costs. Among the CGHD’s earliest work on HIV/AIDS was a series of studies on the costs of HIV to private companies and government agencies in various African countries, including South Africa, Botswana, Zambia, Kenya, and Uganda. Most of this research pre-dated large-scale access to effective treatment for HIV/AIDS and examined the likely impact of the disease on employers and economies in the absence of treatment.
- Financing and Supply of Services: Several completed projects have examined the supply of HIV-related services, particularly treatment, and analyzed different ways of financing these services. Projects included work on employer provision of insurance in several countries and, in Namibia, public private partnerships, mobile service delivery, a partnership with the mining sector, and low-cost health insurance.
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Costs and Outcomes of HIV Treatment
- Cost and outcomes of paediatric antiretroviral treatment in South Africa. Meyer-Rath G, Brennan A, Long L, Ndibongo B, Technau K, Moultrie H, Fairlie L, Coovadia A, Rosen S. AIDS 2012. 2013 Jan; 14(27):243-250.
- Uptake, outcomes, and costs of antenatal, well-baby, and prevention of mother-to-child transmission of HIV services under routine care conditions in Zambia. Scott CA, Iyer H, Bwalya DL, Bweupe M, Rosen S, Scott N, Larson B. PLoS ONE 2013; 8: e72444.
- Retention in care and outpatient costs for children receiving antiretroviral therapy in Zambia: A retrospective cohort analysis. Scott CA, Iyer H, Bwalya DL, McCoy K, Moyo C, Bolton-Moore C, Larson B, Rosen S. PLoS ONE 2013: 8(6): e67910.
- ART treatment costs and retention in care in Kenya: a cohort study in three rural outpatient clinics. Larson B, Bii M, Henly-Thomas S, McCoy K, Sawe F, Schaffer D, Rosen S. J Int AIDS Soc 2013; 6:18026. PMID: 23305696
- The net cost of incorporating resistance testing into HIV/AIDS treatment in South Africa: a Markov model with primary data. Rosen S, Long L, Sanne I, Stevens W, Fox MP. J Int AIDS Soc. 2011 Jul; 14(24):1-6.
- Treatment outcomes and cost-effectiveness of shifting management of stable ART patients to nurses in South Africa: an observational cohort. Long L, Brennan A, Fox MP, Ndibongo B, Jaffray I, Sanne I, Rosen S. PLOS Medicine. 2011 Jul; 8(7):1-10.
- The high cost of second-line antiretroviral therapy for HIV/AIDS in South Africa. Long L, Fox M, Sanne I, Rosen S. AIDS. 2010 Jan; 24(6):915-9.
- The outcomes and outpatient costs of different models of antiretroviral treatment delivery in South Africa. Rosen S, Long L, Sanne I. Trop Med Int Health. 2008 Jul; 13(8):1005-15.
- Cost and cost-effectiveness of switching from stavudine to tenofovir in first-line antiretroviral regimens in South Africa. Rosen S, Long L, Fox M, Sanne I. J Acquir Immune Defic Syndr. 2008 Jun; 48(3):334-44.
Economic Outcomes of Treatment
- Effect of antiretroviral therapy on patients’ economic well-being: five-year follow up in South Africa. Sydney Rosen; Bruce Larson; Julia Rohr; Ian Sanne; Constance Mongwenyana; Alana T. Brennan; Omar Galárraga. AIDS 2014; 28: 417-24
- Antiretroviral therapy, labor productivity, and gender: a longitudinal cohort study of tea pluckers in Kenya. Bruce.A. Larson, Matthew P. Fox, Margaret Bii, Sydney Rosen, Julia Rohr, Douglas Shaffer, Fredrick Sawe, Monique Wasunna and Jonathon L. Simon. AIDS 2012; 27: 115-23.
- HIV treatment produces economic returns through increased work and education, and warrants continued US support. Harsha Thirumurthy, Omar Galárraga, Bruce Larson, & Sydney Rosen. Health Affairs. 2012 Jul; 31(7):1470-1477.
- Economic outcomes of patients receiving antiretroviral therapy for HIV/AIDS in South Africa are sustained through three years on treatment. Rosen S., Larson B., Brennan A., Long L., Fox M., Mongwenyana C., Ketlhapile M., Sanne I. PLoS ONE. 2010 Jan; 5(9):e12731.
- Improvements in physical wellbeing over the first two years on antiretroviral therapy in western Kenya. Fox M. P., McCoy K., Larson B. A., Rosen S., Bii M., Sigei C., Shaffer D., Sawe F., Wasunna M., Simon J. L. AIDS Care. 2010 Apr; 22(2):137-45.
- Do the Socioeconomic Impacts of Antiretroviral Therapy Vary by Gender? A Longitudinal Study of Kenyan Agricultural Worker Employment Outcomes. Larson B. A., Fox M. P., Rosen S., Bii M., Sigei C., Shaffer D., Sawe F., McCoy K., Wasunna M., Simon J. L. BMC Public Health. 2009 Jul; 9:240.
- Economic and Quality of Life Outcomes of Antiretroviral Therapy for HIV/AIDS in Developing Countries: a Systematic Literature Review. Beard J., Feeley F., Rosen S. AIDS Care. 2009 Dec; 21(11):1343-56.
- Early Effects of Antiretroviral Therapy on Work Performance: Preliminary Results from a Cohort Study of Kenyan Agricultural Workers. Larson B. A., Fox M. P., Rosen S., Bii M., Sigei C., Shaffer D., Sawe F., Wasunna M., Simon J. L. AIDS. 2008 Jan; 22(3):421-5.
- Differences in Normal Activities, Job Performance and Symptom Prevalence between Patients Not Yet on Antiretroviral Therapy and Patients Initiating Therapy in South Africa. Rosen S., Ketlhapile M., Sanne I., DeSilva M. B.. AIDS. 2008 Aug; 22 Suppl 1:S131-9.
- Characteristics of patients accessing care and treatment for HIV/AIDS at public and nongovernmental sites in South Africa. Rosen S., Ketlhapile M., Sanne I., DeSilva M. B. J Int Assoc Physicians AIDS Care (Chic Ill). 2008 Jul; 7(4):200-7.
- Cost to patients of obtaining treatment for HIV/AIDS in South Africa. Rosen S., Ketlhapile M., Sanne I., DeSilva M. B. S Afr Med J. 2007 Sep; 97(7):524-9.
- The impact of HIV/AIDS on labour productivity in Kenya. Fox M. P., Rosen S., MacLeod W. B., Wasunna M., Bii M., Foglia G., Simon J. L. Trop Med Int Health. 2004 Mar; 9(3):318-24.
Economics of Tuberculosis
- Diagnosing Xpert MTB/RIF negative TB: impact and cost of alternative algorithms for South Africa. Schnippel K, Meyer-Rath G, Long L, Stevens W, Sanne I, Rosen S. S Afr Med J 2013: 103;101-106.
- Costs of inpatient treatment for multi-drug resistant tuberculosis in South Africa. Schnippel K, Rosen S, Shearer K, Martinson N, Long L, Sanne I, Variava E. Trop Med Int Health 2012; 18: 109-16.
- Scaling up Xpert MTB/RIF technology: the costs of laboratory- vs. clinic-based roll-out in South Africa. Schnippel K, Meyer-Rath G, Long L, Macleod W, Sanne I, Stevens W, Rosen S. Trop Med Int Health 2012; 17 (9):1142-51.
- The impact and cost of scaling up GeneXpert MTB/RIF in South Africa. Meyer-Rath G, Schnippel K, Long L, MacLeod W, Sanne I, Stevens W, Pillay S, Pillay Y, Rosen S. PLOS ONE 2012; 7(5): e36966.
Modeling Future Costs
- HIV treatment as prevention: modelling the cost of antiretroviral treatment—state of the art and future directions. Meyer-Rath G, Over M. PLOS ONE 2012; 9(7):1-10.
AIDS and the Private Sector
- Private Sector Provision and Financing of AIDS Treatment in Africa: Current Developments. Feeley F., Connelly P., Rosen S. Curr HIV/AIDS Rep. 2008 Mar; 4(4):192-200.
- The Private Sector and HIV/AIDS in Africa: Taking Stock of 6 Years of Applied Research. Rosen S., Feeley F., Connelly P., Simon J. AIDS. 2007 Aug; 21 Suppl 3:S41-51.
- The Impact of AIDS on Government Service Delivery: the Case of the Zambia Wildlife Authority. Rosen S., Hamazakaza P., Feeley F., Fox M. AIDS. 2007 Aug; 21 Suppl 3:S53-9.
- Treatment of HIV/AIDS at South Africa’s Largest Employers: Myth and Reality. Connelly P., Rosen S. S Afr Med J. 2006 Mar; 96(2):128-33.
- Provision of Antiretroviral Therapy by the Private Sector. Connelly P., Rosen S. Lancet. 2005 Jun; 365(9475):1925-6.
- The Cost of HIV/AIDS to Businesses in Southern Africa. Rosen S., Vincent J. R., MacLeod W., Fox M., Thea D. M., Simon J. L. AIDS. 2004 Apr; 18(2):317-24.
- Prevalence of HIV in Workforces in Southern Africa, 2000-2001. Evian C., Fox M., MacLeod W., Slotow S. J., Rosen S. S Afr Med J. 2004 Mar; 94(2):125-30.
- The Impact of HIV/AIDS on Labour Productivity in Kenya. Fox M. P., Rosen S., MacLeod W. B., Wasunna M., Bii M., Foglia G., Simon J. L. Trop Med Int Health. 2004 Mar; 9(3):318-24.
- Why do firms take action on HIV/AIDS? Evidence from Nigeria. Rosen S., Vincent J. R., MacLeod W., Thea D. M., Simon J. Journal of Business in Developing Countries. 2004 Jan; 8(1):1-38.
- Shifting the Burden: the Private Sector’s Response to the AIDS Epidemic in Africa. Rosen S., Simon J. L. Bull World Health Organ. 2003 May; 81(2):131-7.
- AIDS is Your Business. Rosen S., Simon J., Vincent J. R., MacLeod W., Fox M., Thea D. M. Harv Bus Rev. 2003 Feb; 81(2):80-7, 125.