Cost-Saving Measures Can Offset Increasing ART Costs.

Increases in antiretroviral treatment costs for HIV/AIDS patients in South Africa could be offset by the introduction of cost-saving measures, according to a new study led by a School of Public Health researcher.

The study, published in PLOS­–ONE, analyzed the cost of the current national South African HIV treatment program and estimated the expected cost and impact of treatment guidelines issued by the World Health Organization (WHO) between 2009 and 2016. Those guidelines aimed to steadily raise the threshold of eligibility for antiretroviral treatment (ART) while also providing better drugs for patients.

The researchers found that the annual cost for ART would continue to increase until universal treatment was introduced. They predicted a reduction of the annual cost of the treatment program under universal treatment from 2024 onward. Universal HIV treatment became policy in South Africa in September 2016, in part based on the model findings.

“The paper summarizes our close collaboration with the South African Department of Health and Treasury over the last eight years, which resulted in us helping to change public policy—an unusual situation for an academic,” says lead author Gesine Meyer-Rath, research assistant professor of global health. “While many factors have contributed to the remarkable expansion of HIV treatment in South Africa over the last decade, with the political will demonstrated by the current minister of health being the most important one, our model supported the process by allowing the Department of Health to submit budget bids to treasury that were based on precise estimates of patients in need of treatment and overall costs.”

The South African national ART program is the largest HIV/AIDS treatment program in the world, currently reaching almost 4 million patients. The program is one of the few in Africa that is funded by the government rather than international donors; the costs of the program have been increasing since its establishment.

“The cost of this program, which has risen steadily since its inception in 2004, has been and remains one of the major challenges confronting the South African government as it seeks to expand access to treatment and sustain or improve quality of service delivery,” the researchers wrote. “The National South African Department of Health (NDOH) faces the double challenge of expanding eligibility for and coverage of the HIV treatment program while simultaneously reducing the per-person cost of treatment.”

The researchers worked with the South African government to analyze the costs and impacts of the program since 2009. They constructed the National ART Cost Model (NACM), a population-level budget impact model, to capture guideline changes by the WHO and to calculate how to offset the additional costs of the changing guidelines through implementing procurement, health systems, and technical improvements to the program. The NACM model allowed the researchers to provide estimates to the NDOH of the costs and impacts of incorporating changes recommended by the WHO between 2009 and 2015 into national guidelines.

The researchers found that certain cost-saving measures, such as introducing task-shifting and opening the drug tenders for international competition, would more than offset the increases in treatment costs under the 2009 WHO guidelines, and the introduction of adherence clubs for stable patients on ART would offset some of the costs of introducing universal treatment. The researchers predicted a reduction in the annual costs by 2024 as the program reaches universal coverage.

“Annual budgetary requirements for ART will continue to increase in South Africa until universal treatment is taken to full scale.” the authors wrote. “Model results were instrumental in changing South African ART guidelines, more than tripling the population on treatment between 2009 and 2017, and reducing the per-patient cost of treatment by 64 percent.”

Other authors from authors from SPH were Alana Brennan, global health instructor, Lawrence Long, research assistant professor, Matthew P. Fox, professor of epidemiology, and Sydney Rosen, research professor of global health. Other co-authors included: Leigh F. Johnson, epidemiologist at the University of Cape Town; Yogan Pillay, deputy director general for special programmes at the National Department of Health, South Africa; Mark Blecher, chief director for health and social development at the South African National Treasury; Harry Moultrie, senior researcher at the University of the Witwatersrand; and Ian Sanne, associate professor of internal medicine and infectious diseases at the University of the Witwatersrand.

—Salma Abdalla