unit cost for art delivery

Unit Costs for Delivery of AntiretroviralTreatment and Prevention of Mother-to-Child Transmission of HIVA Systematic Review for Low- and Middle-Income Countries

Omar Galarraga,1,2 Veronika J. Wirtz,3 Alejandro Figueroa-Lara,3 Yared Santa-Ana-Tellez,2

Ibrahima Coulibaly,4 Kirsi Viisainen,4 Antonieta Medina-Lara5 and Eline L. Korenromp4,6

1 Health Services, Policy and Practice (Health Economics), Brown University, Providence, Rhode Island,

USA

2 Center for Evaluation Research and Surveys, Division of Health Economics, National Institute of Public

Health (INSP)/Mexican School of Public Health, Cuernavaca, Mexico3 Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Mexico

4 The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland

5 Center for Research on Health and Social Care Management (CERGAS), Bocconi University, Milan, Italy

6 Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam,

the Netherlands

Contents

Abstract. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5801. Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 581

1.1 Search. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5811.1.1 Inclusion Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5811.1.2 Data Extraction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5821.1.3 Standardization of Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 582

1.2 Data Aggregation and Sensitivity Analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5831.3 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 583

2. Antiretroviral Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5832.1 Antiretroviral Medicines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5892.2 Laboratory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5892.3 Personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5892.4 Programme-Level Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5932.5 Paediatric Antiretroviral Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 593

3. Prevention of Mother-to-Child Transmission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5934. Sensitivity Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5945. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 594

5.1 Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5955.2 Future Work. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 596

6. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 597

REVIEWARTICLE Pharmacoeconomics 2011; 29 (7): 579-5991170-7690/11/0007-0579/$49.95/0 2011 Adis Data Information BV. All rights reserved.

Abstract As antiretroviral treatment (ART) for HIV/AIDS is scaled up globally,information on per-person costs is critical to improve efficiency in servicedelivery and to maximize coverage and health impact. The objective of thisstudy was to review studies on unit costs for delivery of adult and paediatricART per patient-year, and prevention of mother-to-child transmission(PMTCT) interventions per mother-infant pair screened or treated, in low-and middle-income countries. A systematic review was conducted of English,French and Spanish publications from 2001 to 2009, reporting empiricalcosting that accounted for at least antiretroviral (ARV)medicines, laboratorytesting and personnel. Expenditures were analysed by country-income leveland cost component. All costs were standardized to $US, year 2009 values.Several sensitivity analyses were conducted.

Analyses covered 29 eligible, comprehensive, costing studies. In the basecase, in low-income countries (LIC), median ART cost per patient-year was$US792 (mean: 839, range: 6821089); for lower-middle-income countries(LMIC), the median was $US932 (mean: 1246, range: 1563904); and, forupper-middle-income countries (UMIC), the median was $US1454 (mean:2783, range: 12305667). ARV drugs were the largest component of overallART costs in all settings (64%, 50% and 47% in LIC, LMIC and UMIC,respectively). Of 26 ART studies, 14 reported the drug regimes used, and onlyone study explicitly reported second-line treatment costs. The second costdriver was laboratory cost in LIC and LMIC (14% and 20%), and personnelcosts in UMIC (26%). Two ART studies specified the types of laboratorytests costed, and three studies specifically included above facility-level per-sonnel costs. Three studies reported detailed PMTCT costs, and three studiesreported on paediatric ART.

There is a paucity of data on the full unit costs for delivery of ART andPMTCT, particularly for LIC and middle-income countries. Heterogeneityin activities costed, and insufficient detail regarding components included inthe costing, hampers standardization of unit cost measures. Evaluation ofprogramme-level unit costs would benefit from international guidance on stan-dardized costing methods, and expenditure categories and definitions. Futurework should help elucidate the sources of the large variations in delivery unitcosts across settings with similar income and epidemiological characteristics.

As antiretroviral treatment (ART) for HIV/AIDS is scaled up globally, information on per-person costs is critical to improve efficiency inservice delivery and to maximize coverage andhealth impact. Cost evaluations support programmeplanning and budgeting, can help to ensure pro-gramme sustainability, and are a pre-requisite toidentifying opportunities for efficiency gains.[1,2]

As global health institutions strive to ensure valuefor money, they are committed to supportingcountries in the measurement of per-person de-livery costs of key services.[3-8] Since 2008, many

national HIV/AIDS programmes have made im-portant advances in complying with the bi-annualroutine reporting of nationally aggregated expen-ditures as stated in the 2001 Declaration of Com-mitment on HIV/AIDS (UNGASS) to UNAIDS(the Joint United Nations Programme on HIV/AIDS).[9] UNAIDS summaries of UNGASS datatry to standardize reported programme expendi-tures for ART and PMTCT as per-person costs,[10]

but do not request a comprehensive breakdown ofthe cost components included in each service area.As of 2011, most HIV/AIDS programmes do not

580 Galarraga et al.

2011 Adis Data Information BV. All rights reserved. Pharmacoeconomics 2011; 29 (7)

routinely assess their cost per person or per unitof service delivery, nor do they breakdown ex-penditure by cost components using standardizedmethods.

For antiretroviral treatment (ART), scale-upof treatment access in low- and middle-incomestudies started in 20045, when funding increasedsubstantially with new donor funding from theGlobal Fund to Fight AIDS, Tuberculosis andMalaria, and the US Presidents Emergency Planfor AIDS Relief (PEPFAR), among others. As atthe end of 2009, an estimated 5.2 million HIV-infected people were receiving ART globally.With the WHOs revised 2010 guidelines on HIVtreatment in resource-limited settings, the totalimmediate need is now estimated at 15 millioneligible people worldwide.[11] The ongoing scale-up and progress toward universal access willdepend on both total available funding and thedelivery cost per patient-year in countries withhigh HIV prevalence.

Previous reviews of facility-level or per-patientART costs found only a very small number ofstudies from low- andmiddle-income countries[12,13]

and estimated the cost of antiretroviral (ARV)medicines from manufacturers procurement pricelists, as an average per country-income group.[13]

For prevention of mother-to-child transmission(PMTCT) of HIV, (unit) delivery costs have notbeen reviewed since 2000.[14] Themost recent reviewof ART costs[15] included more studies from low-and middle-income countries and presented a scor-ing system to rate the methodological quality ofstudies without attempting a quantitative meta-analysis of cost results.

To complement these reviews, we conducted asystematic literature review and a quantitativeanalysis of per-patient expenditure for adult andpaediatric ART, as well as ARV prophylaxis usedfor PMTCT, using explicit guidelines[16] for sys-tematic reviews, and standardizing data from eli-gible studies into common service delivery unitsand cost component categories. Per-patient costsare presented as median, arithmetic average andranges across eligible study sites, studies, countriesand country-income groupings, separately for themost important standardized cost components.We discuss results in the light of information re-

quirements anticipated from national AIDS pro-grammes from major global financiers of HIV/AIDS programme scale-up.

1. Literature Review

1.1 Search

The literature search followed the PRISMA(PreferredReporting Items for Systematic ReviewsandMeta-Analyses) guidelines (figure 1).[16] Orig-inal articles published in English, French andSpanish from January 2001 to October 2009were searched using PubMed, EconLit and theCochrane Library, and grey literature throughGoogle Scholar and POPLINE. In addition,websites of international donor organizations suchas UNAIDS, WHO, World Bank, PEPFAR andthe United Nations Childrens Fund (UNICEF)were searched. Abstracts from the InternationalAIDS Conferences 20018, International HealthEconomics Association 20068, American SocietyforHealth Economists 20068, International AIDSEconomics Network 2008 and PEPFAR Im-plementers meetings 20089 were also screened forcontextual information to the published data.References identified as relevant served to trackadditional studies of interest. Annex A details thesearch terms used on electronic databases; annexB shows the search commands and number ofstudies found (all annexes are available as Sup-plemental Digital Content only; http://links.adisonline.com/PCZ/A117).

1.1.1 Inclusion Criteria

The following inclusion criteria were applied.A list of excluded studies is available in Annex D. Country-specific, empirical measurement of

actual expenditure, from a micro-costing oringredients approach (if the study used solely astep-down approach, it was excluded).

Study (or study data point) included at least25 patients.

Low- and middle-income countries, accord-ing to the July 2009 World Bank list of econ-omies,[17] with both publication and datacollection between January 2001 and October2009.

Antiretroviral Treatment Unit Costs 581


Costing included at least ARVs, laboratoryexpenses and personnel, as three individuallyreported expenditure components, or as ex-plicitly named components of a comprehen-sive but unbundled overall expenditure.

Economic costs from the healthcare providerperspective; financial costs included if econom-ic costs were not available. Economic costsaccruing to patients, such as waiting and/ortransportation time and productivity losseswere not considered because of the inherentdifficulties associated with assigning opportu-nity costs in the absence of accurate data onwages and time costs.

1.1.2 Data Extraction

Eligible articles were reviewed for inclusion byat least two independent reviewers (OG and VWor AML), using a pre-determined data extractionform (see Annex C). When the decision was indoubt, a third or fourth reviewer (YST or AFL)analysed the article and inclusion was solved byconsensus. If the information contained in thefull-text article was incomplete, the authors werecontacted to obtain missing data.

1.1.3 Standardization of Data

ART delivery unit cost data were standardizedas estimates per patient-year, separately for first-and second-line ART, or weighed by the local mixof patients. Paediatric ARTwas distinguished fromadult ART, using an age cut-off of 15 years. Com-ponents of total costs were categorized as follows.

ARVs, including, if available, transport of drugsto point of care, and storage.

Personnel involved in delivering ART, includ-ing education and training, as well as supra-facility-level human resources, if specified (suchas personnel in distribution centres or district/provincial/national programme management,or monitoring and evaluation).

Laboratory tests, including CD4 cell countsand viral load, as well as other tests, if specificallymentioned. Overhead costs, including adminis-tration and utilities (electricity, water, phone,rent, maintenance costs, cleaning, security).

Other components considered and reported aspart of delivery unit costs, such as concomi-tant medications (for opportunistic infectionsor prophylaxis), other supplies (e.g. cotton, sy-ringes, gloves), staff transport for home visits

Records after removalof duplicates

(n = 17)

Articles screened(n = 150)

Publicationsidentified through

PubMed(n = 103)

Full-text articleseligible for further analysis

(n = 139)

Publications identifiedthrough EconLit

(n = 30)Additional recordsidentified through

POPLINE and othersources1

(n = 34)

Editorials andcommentaries

(n = 11)

Full-text articles eligiblefor in-depth analysis

(n = 29)

Full-text articlesexcluded because theydid not fulfil inclusion

criteria2 (n = 110)

Fig. 1. Literature review on antiretroviral therapy and prevention of mother-to-child transmission per person-year delivery unit costs: flowchartof search and review process. 1 Seven studies included for in-depth analysis were from the grey literature; 2 see Annex D in the SupplementalDigital Content 1, http://links.adisonline.com/PCZ/A117, for a list of excluded studies.



(i.e. trained field officers visit patients homesperiodically to deliver drugs, clinically moni-tor participants with a checklist on signs andsymptoms of drug toxicity or disease progres-sion and to provide adherence support) anddepreciated capital costs (medical and non-medical equipment), as well as other recurrentcosts when those breakdowns were available.For PMTCT, reported costs were either per

HIV-infected pregnant woman receiving ARVprophylaxis, or per pregnant woman initiallytested and counselled for HIV. In either case,costs covered the woman-neonate pair through-out the pregnancy/birth period. Cost componentswere categorized as follows. ARVs given before, during and/or shortly

after birth to mother and/or child to preventtransmission (including transport cost of ARVsto point of care and storage); personnel in-volved in delivering PMTCT, including educa-tion and training, as well as supra-facility-levelpersonnel, if specified.

Laboratory tests (including HIV testing, CD4cell counts and viral load).

Overhead costs, including administration andutilities (electricity, water, phone, rent, main-tenance costs, cleaning, security).

Other components, as listed by specific studies.All costs are presented as $US, October 2009

values, after foreign currency conversion usingaverage annual exchange rates provided by orig-inal study authors or from the InternationalMonetary Fund (IMF)[18] (except for a study ofART in Lesotho,[19] for which rates were directlyfrom a Central Bank[20] source, for lack of therelevant exchange rate from the IMF). Onceconverted into $US, costs were adjusted for in-flation using the US Consumer Price Index.[21]

1.2 Data Aggregation and Sensitivity Analysis

The analysis focused on economic costs fromthe perspective of the provider. Specified econ-omic costs to the patient were included only if amonetary transaction took place so that the ser-vice would occur (e.g. a co-payment or re-cuperation fee paid by the patient), in which casethey were added to the overall costs.

Unit costs and unit cost components weresummarized as mean, median and range acrosscountries studied (after aggregation across mul-tiple sites, or data points within each country)and country-income groups: low-income coun-tries (LIC), lower-middle-income countries (LMIC)and upper-middle-income countries (UMIC), ac-cording to the World Bank 2009 country classi-fication.[17] This method of aggregation preventedcountries with relatively large numbers of datapoints from skewing the results. In sensitivity anal-yses, we explored the robustness of results againstalternative ways of aggregating results across sites,countries and country-income groupings, and ro-bustness of different study inclusion criteria.

1.3 Results

Of 574 abstracts retrieved, 150 full-text studieswere assessed for eligibility; of those, 29 were in-cluded in the analysis: 26 on ART (23 on adultART, 2 on adult and paediatric ART[22,23] and 1on paediatric ART only)[24] (table I). Table II pro-vides estimates of ART cost per patient per yearaccording to country income level (base-case andsensitivity analyses), and figure 2 summarizes themost relevant findings. Three studies for PMTCTare detailed in table III (expanded versions of thetables, with additional information and annexes,are available in the Supplemental Digital Con-tent). The median year of reported cost data was2004 for ART and 2005 for PMTCT.

2. Antiretroviral Treatment

Six studies from four LIC were included(Benin, Ethiopia, Haiti and Uganda); the mediancost per patient-year of ART was $US792 (mean:839, range: 6821089) [table II].[23,25-29] Studiesfor LMIC were found for India,[30,31] Lesotho,[19]

Morocco,[32] Nigeria[33,34] and Thailand;[35] themedian cost of ART was $US932 (mean: 1246,range: 1563904) [table II]. In UMIC Brazil,[24,36]

Mexico[37-39] and SouthAfrica[22,40-46] themedianART cost was $US1454 (mean: 2783, range:12305667) [table II].

ART unit costs and their components variedconsiderably between both countries and studies



Table I. Delivery unit costs ($US, year 2009 values) of antiretroviral treatment (ART), per patient-yeara

Study, year of

publication

(country)

City/setting Scope ART unitcosts

Cost components (% of total cost) ART regimenb

facilitiesc

(provider type)

patients ARV

drugs

personnel laboratory tests overheads

Low-income countries

Hounton et al.,[25]

2008d,e (Benin)

Cotonou/U 1 (Nat/NGO/D) 122outpts

681.9 500.5 (73.4) 51.4 (7.5) 99.5 (14.6) 21.1 (3.1) NA

Bikilla et al.,[26]

2009e,f (Ethiopia)

Arba Minch/U 1 (Nat) 209outpts

262.8 205 (78) 37.8 (14.4) 15.7 (6) INU (d4T/3TC +NVP)or (AZT + 3TC+NVP)or (d4T/3TC +EFV)or (AZT + 3TC+EFV).All regimens are

first-line

Kombe et al.,[27]

2004g (Ethiopia)

Nazareth, Addis,

Bahir Dar/U6 (Nat) NA 804.1 548.3 (68.2) 14.2 (1.8) Dr,

nurse, counsellor,

pharmacist, lab

technician

241.5 (30) FBC,

blood chemistry,

blood sugar,

CD4 count, viral

load

Not

included

AZT +d4T +NVPfirst-line

PEPFAR ART

Costing Project

Team,[23] 2009h,i

(Ethiopia)

U 9 (Nat) NA

outpts

741.7 (new

adult

patients)

428.3 (57.7) 21.8 (2.9) 191.1 (25.8) 59.9 (8) NA

610.8

(established

adult

patients)

428.3 (70.1) 12 (2) 80.8 (13.2) 33.7 (5.5)

960.8 (new

paediatric

patients)

606.7 (63.1) 21.8 (2.2) 191.1 (19.9) 62.7 (6.5)

933.4

(established

paediatric

patients)

606.7 (65) 12.3 (1.3) 94.5 (10.1) 39.4 (4.2)

Koenig et al.,[28]

2008e (Haiti)

Port-au-Prince/U 1 (NGO) 218in/outpts

1088.7 402.6 (37) INU 147.4 (13.5) 129.6

(11.9)

NA

Jaffar et al.,[29]

2009e (Uganda)

Jinga/R 1 (NGO) NAoutpts

789 416.6 (52.8) 181.5 (23) INU INU NA

833.8 417.7 (50.1) 242.6 (29.1)

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Table I. Contd

Study, year of

publication

(country)



facilitiesc

(provider type)

patients ARV

drugs


Lower-middle-income countries

Gupta et al.,[30]

2009e,j,k (India)

Chennai/U 1 (Nat) 2606 96.7 46.2 (47.8) 7.1 (7.3) 18.9 (19.5) Notincluded

d4T +3TC +NVPFirst-line

Imphal/U 1 (Nat) 226 377.2 130.3 (34.5) 33.3 (8.8) 97.8 (25.9)

Ahmedabad/U 1 (Nat) 1210 133.2 60.7 (45.5) 8.5 (6.4) 42.4 (31.8)

New Delhi/U 2 (Nat) 1728 120 53.4 (44.5) 11.4 (9.5) 20.3 (16.9)

Trivandrum/U 1 (Nat) 498 217.9 118.3 (54.2) 12.8 (5.9) 60.3 (27.6)

Thrissur/U 1 (Nat) 308 155.5 101.4 (65.1) 8.7 (5.6) 0 (0)

John et al.,[31]

2006h,k (India)

Bangalore/U 1 (NGO) 25in/outpts

461.8 257.7 (55.8) INU project

coordinator, medical

officer, nurses,

laboratory

technician,

counsellors

17.4 (3.8) INU AZT/d4T + 3TC+NVPFirst-line

Cleary et al.,[19]

2007e,l (Lesotho)

Maseru/U 1 (Nat/NGO) 271 inpts 161.7 127.4 (78.8) INU 15.3 (9.5) INU 3TC+ d4T +NVPFirst-line

Loubiere et al.,[32]

2008e,m (Morocco)

Casa Blanca/U 1 (Nat) 167in/outpts

1076.9 INU INU INU INU NA

Kombe et al.,[33]

2004e,n (Nigeria)

Lagos/U;Abuja/U

5 (Nat) NA 841 420.5 (50) 185 (22) 193.4 (23) 33.6 (4) d4T +3TC +NVPFirst-line

PHR,[34] 2004g,k,o

(Nigeria)

Anambra/U;Bauchi/R;Edo/U;Federal Capital

Territory/U;Kano/U;Lagos/U;Nassarawa/U;Rivers/U

66

(Nat/FBO/NGO)NA

in/outpts1023.3 362.1 (35.4) 391.2 (38.2) 237.5 (23.2) 18.6 (1.8) 3TC+ d4T +NVP

First-line

Continued next page

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Treatm

entUnitCosts

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Table I. Contd

Study, year of

publication

(country)



facilitiesc

(provider type)

patients ARV

drugs


Kitajima et al.,[35]

2003e,p (Thailand)

Khon Kaen/R 2 (Nat) 106outpts

3903.8 3415.1 (87.5) INU 462 (11.8) 26.7 (0.7) NA

Upper-middle-income countries

Acurcio et al.,[36]

2006e,g,q (Brazil)

Belo Horizonte/U 2 (Nat) 157adherent

patients

1454 1290.3 (88.7) 6.2 (0.4) infectious

diseases specialist

and other specialists

45 (3)

lymphocyte

CD4/CD8, viralload test, other

tests

Not

included

NA

40 non-

adherent

patients

1340.1 1290.3 (96.3) 8.7 (0.6) infectious

diseases specialist

and other specialists

39.9 (2.9)

lymphocyte

CD4/CD8, viralload test, other

tests

Marques et al.,[24]

2007i (Brazil)

Sao Paulo/U 1 (Nat) 140 outptchildren

2038.8 INU INU INU INU RTV+NFV +3CT +AZT +DDL + IDV

Aracena-Genao

et al.,[37] 2008e,r

(Mexico)

Mexico City/U 1 (Nat) 80 7688 INU INU INU INU NA

Bautista-Arredondo

et al.,[38] 2003;

Bautista-Arredondo

et al.,[39] 2008e,s

(Mexico)

Mexico City/U; 11 (Nat) 902 6651.3 firstyear

6024.4 (90.6) INU 223.4 (3.4) INU NA

Cuernavaca/U; 4256.8second year

3809.4 (89.5) 165.8 (3.9)

Guadalajara/U 4682.9 thirdyear after

ART

initiation

3960.7 (84.6) 254.6 (5.4)

Cleary et al.,[40]

2006e,t

(South Africa)

Cape Town/U 3 (Nat) 1729 987.3 338.8 (34.3) INU 96 (9.7) INU AZT +3TC +NVP/EFV first-line

1774.3 1108.3 (62.5) 112 (6.3) AZT +DDL +LPV/RTV second-line

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Table I. Contd

Study, year of

publication

(country)



facilitiesc

(provider type)

patients ARV

drugs


Deghaye et al.,[41]

2006e,u

(South Africa)

Durban/U 2 (Nat) 41 1022.3 411 (40.2) 330 (32.3) 218.8 (21.4) 16.4 (1.6) d4T +3TC +EFVfirst-line

Harling et al.,[42]

2007e,v

(South Africa)

Cape Town/U 1 (Nat/D) NT 521.6 INU INU Dr, nurse,counsellor,

pharmacist

INU INU NT

Harling et al.,[43]

2007e,u

(South Africa)

Cape Town/U 1 (Nat/NGO) 172outpts

1296.5 535.9 (41.3) 203.3 (15.7) 341 (26.3) 25.2 (1.9) d4T +3TC +EFVfirst-line

129 inpts 1834.3 535.9 (29.2) 545.5 (29.7) 442.1 (24.1) 212.7 (11.6)

Kevany et al.,[44]

2009w

(South Africa)

Cape Town/U 1 (Nat) 48 outpts 1795.8 103.9 (5.8) 988.6 (55.1)consultant, medical

officer, nursing

sister, medical ward

staff

478.1 (26.6) Not

included

3TC+ d4T +NVPfirst-line

25 inpts 6579.5 271.7 (4.1) 2097.8 (31.9)

consultant, medical

officer, nursing

sister, medical ward

staff

847.6 (12.9)

Martinson et al.,[45]

2009e,v

(South Africa)

Soweto/U 1 (D) 591 2853.6 (newART

patients)

958 (33.6) 435.5 (15.3) primary

health care nurse,

pharmacist, medical

officer

1174.4 (41.2) 190.5 (6.7) d4T +3TC +NVPfirst-line

1770.4

(established-

ART

patients)

958 (54.1) 435.5 (24.6) primary

health care nurse,

pharmacist, medical

officer

114.5 (6.5) 190.5

(10.8)

Rosen et al.,[46]

2008e (South Africa)

Gauteng/U 2 (Nat/NGO) 200 1122.5(patient

responding)

INU INU INU INU 3TC+ d4T +EFVfirst-line

1210.3

(patient not

responding)

Continued next page

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Table I. Contd

Study, year of

publication

(country)



facilitiesc

(provider type)

patients ARV

drugs


Eastern Cape/U 1 (NGO) 100 1241.1(patient

responding)

1177.3

(patient not

responding)

Mpumalanga/R 1 (NGO) 100 1229.4(patient

responding)

1182.7

(patient not

responding)

Vella et al.,[22]

2008e,i

(South Africa)

KwaZulu-Natal/U 32 (Nat) 2835 1068.1 500 (46.8) 300 (28.1) 236 (22.1) 16.6 (1.5) NA

a Dollar amounts and proportions of overall costs may not add to 100% due to rounding and because some costs do not fit into the classifications used. For example, transportationcosts to visit patients homes, non-ARV medicines, opportunistic infections medicines and recurrent costs such as cotton, syringes, gloves, etc. are in the Other category, which

has been excluded from the table (but could be estimated by subtracting the current total from 100%). ARV medicine costs include only the costs of ARVs, mostly first-linetreatment unless otherwise noted in the Regimen column. Personnel costs include human resource expenses incurred in service delivery, including health workers doing patient

care and, in some studies, administrative personnel. Laboratory costs may include HIV testing, CD4 cell count and viral load measurement. Overheads may include capital costs

(e.g. medical equipment, computers) and/or recurrent costs (utilities: electricity, water, phone, rent, maintenance costs, storage, cleaning or security). If the study reviewed provideddetails about what was included in each category, those details have been incorporated in the table. Costs were converted into $US, year 2009 values, using average exchange

rates during the study period (see sources in theMethods section). For further details see the Supplemental Digital Content (http://links.adisonline.com/PCZ/A117) versions of the table.

b Refers to the ARV line costed by the study.

c Refers to the number of facilities in which the costs were collected; whether the programme was national or local; and whether the provider was different from public/local government(i.e. NGO, FBO or D).

d International dollars converted into $US using the purchase power parity conversion factor provided by the UN Statistical Office.[47]

e The study reports the average costs.

f Outpts only (includes patients aged 15 years).

g The costs collected are financial costs.

h The study reports the median costs.

i Includes children (

(such as South Africa[22,40-46]) and between siteswithin one study (e.g. Gupta et al.,[30]) [figure 2].While variations between studies may in partreflect differences in costing methods and defini-tions, variations within studies point to the ex-istence of real differences in actual cost betweensites and/or patient populations.

2.1 Antiretroviral Medicines

In all three income groups, ARV medicineswere the largest cost component. In LIC, theyrepresented 64% of the overall costs, at a median$US428 per patient-year (mean: 456 [62%], range:205607 [3778%]) [summary of table I is availablein the Supplemental Digital Content only]. InLMIC, ARVmedicines represented 50% of overallcosts (median: $US127, mean: 463 [54%], range:463415 [3588%]) [see the Supplemental digitalContent]. In UMIC, ARV medicines covered47% of costs: median $US958 per patient-year,mean: 1473 (53%), range: 1046024 (496%)[table I].

2.2 Laboratory

In LIC and LMIC, laboratory costs werethe second most important cost component. InLIC they accounted for 14% of overall costs(median: $US123; mean: 133 [17%], range: 16242[630%]) [see table I in the Supplemental DigitalContent]. In LMIC, laboratory costs correspondedto 20% of overall costs (median: $US42; mean:106 [18%], range:

were the second most important cost component,at 26% of overall cost (median: $US383, mean:535 [24%], range: 62098 [0.455%]) [table I].

Most (23 of 26) studies included the costof personnel only at the facility level. While typesof services costed varied, only seven studies re-

Table II. Base-case and sensitivity analyses: delivery unit cost ($US, year 2009 values) of antiretroviral treatment (ART) per patient per year,

by country income levela

Low

income

Lower-middle

income

Upper-middle

income

All

Base case

Mean 839 1246 2783 1494

Median 792 932 1454 1005

SD 175 1546 2500 1628

Range 6821089 1563904 12305667 1565667

Countries 4 5 3 12

Studies (n) 6 7 13 26

Data points/sites (N) 10 12 24 461. Weighing all study sites, instead of all countries equally

Mean 770 714 2366 1588

Median 797 298 1397 1073

SD 226 1067 2034 1754

Range 2631089 973904 5227688 977688

Countries 4 5 3 12

Studies (n) 6 7 13 26

Data points/sites (N) 10 12 24 462. Adding studies reporting total unit cost without ARV/laboratory/human resource breakdownMean 713 1314 Unchanged from

base case

1422

Median 773 932 932

SD 319 1637 1639

Range 2111089 1624212 1625667

Countries 5 5 13

Studies (n) 7 9 29

Data points/sites (N) 11 14 483. Country income level according to costing yearb

Mean 565 1683 3068 1588

Median 646 1454 1241 1073

SD 346 886 2537 1754

Range 971089 5223904 10687688 977688

Countries 7 4 2 12

Studies (n) 11 9 6 26

Data points/sites (N) 20 13 13 46a The base case and scenario 2 aggregate total ART unit costs per person per year by first taking the median within each country. Sensitivity

analyses are as follows: 1. All study sitesweighted equally, regardless of country or number of sites per country. 2. Expandeddataset to include

studies that did not include a breakdown of cost components, but had data on total ART costs. 3. Use World Bank gross national income per

capita data at the time of the study costing, instead of 2009 gross national income, to classify countries according to income level. Baseline

estimates based on more than 14765 patients from 26 studies, plus additional studies that did not disaggregate costs by cost component.

Twelve studies specifically reported costs for first-line treatment; one study[40] specifically included second-line treatment but those specific

costs were excluded. See table I, text and Supplemental Digital Content, 1 (http://links.adisonline.com/PCZ/A117) for further details.

b The total number of countries in scenario 3 adds to 12 only because, given the timing of the costing, and the countrys economic development,

South Africa is in both the lower-middle-income and the upper-middle-income categories.

ARV= antiretroviral.



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8

Ethiopia* *

UgandaHaiti

Benin India

ARV drugsLaboratory testsPersonnelOther costsCosts not unbundled

Lesotho

Nigeria Morocco

Thailand

South Africa

*

*

Brazil

Mexico

0

Fig. 2. Unit costs for delivery of antiretroviral treatment (ART), per patient-year, by cost component, country and site.[19,22-31,33-38,40-46] Countries are ranked from left to right accordingto increasing per capita gross national income (GNI) and then by year of study publication. Studies including (or limited to) paediatric ART are indicated with an asterisk (*) over the bar.Other costs refer to components of ART other than antiretroviral (ARV) medicines, laboratory and personnel costs; other costs are not comparable across studies because they donot contain the same elements. Unbundled costs refer to the overall cost of ART in case the study did not report the separate cost components but these still included at least the threemain components under review. Each bar represents a separate data point within each country or study (e.g. different region, health facility/site, patient type, delivery modality,temporality, etc.). GNI per capita (year 2009 values): Ethiopia $US280, Uganda $US420, Haiti $US660, Benin $US690, India $US1070, Lesotho $US1080, Nigeria $US1160, Thailand$US2840, South Africa $US5820, Brazil $US7350, Mexico $US9980. See table I for additional details. PEPFAR =US Presidents Emergency Plan for AIDS Relief; PHR =The Partnersfor Health Reformplus.

Antiretro

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Table III. Delivery unit cost ($US, year 2009 valuesa) of prevention of mother-to-child transmission (PMTCT) of HIV

Study, year of

publication

(country)

City/settingb

(costing yearc)

Scope Provider

typefPMTCT unit cost Cost (% of total cost) Regimeng

facilitiesd patientse ARV

drugs

personnel laboratory

tests

overheads

Dandona

et al.,[48] 2008

(India)

Andhra Pradesh/U(20056)

16 1212 Nat 2.4 (post-test

counselling)

INU 1.1 (47.3) INU 0.35 (14.7) NVP

251.1h (mother-

neonate pair

receiving NVP)

118.7 (47.3) 36.9 (14.7)

Desmond

et al.,[49] 2004

(South Africa)

Durban/U, Paarl/U,Siloam/R, Frankfort/R(2002)

9 709 (pre-test

counselling)

Nat/D 42.4 INU INU INU Notincluded

NVP +CTX

570 testing 32.5

532 (post-test

counselling)

23.8

117 (mother-

neonate pair

receiving NVP)

208.8i

63 (mother-

neonate pair

follow-up)

327.2j

McMennamin

et al.,[50] 2007

(Rwanda)

Gicumbi/R (2005) 6 NA Nat/FBO 6.42 specificintervention

INU INU INU INU Not reported

a Costs were converted into $US, year 2009 values, using average exchange rates during the study period.

b Refers to the city and the type of location.

c Refers to the year for which the study reported the costs.

d Refers to the number of facilities in which the costs were collected.

e Refers to the number of patients studied to cost the ART delivery.

f Refers to the type of ART provider.

g ARV line costed by the study.

h The mother was given one tablet of NVP 200mg at the onset of labour and the neonate was given NVP 2mg/kg bodyweight within 72 hours of birth.

i This cost includes re-issue of NVP to mothers, and provision of NVP suspension to the child and any formula milk for the duration of the hospital stay.

j PMTCT activities delivered after the mother and infant are discharged from hospital after delivery, including CTX and the provision of formula feeding. It does not include infant HIV

testing.

ARV = antiretroviral; CTX = cotrimoxazole; D =donor; FBO = faith-based organization; INU = included but not unbundled; NA= not available in the study; Nat =National (if Nat notmentioned it means that the provider is local); NGO =non-government organization; NVP = nevirapine; R = rural; U =urban.

592Galarraga

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ported details of the types of personnel in-cluded.[27,31,36,40,42,44,45] Of these, three includedabove-facility-level personnel such as humanresources at distribution centres or district/provincial/national programme management, ormonitoring and evaluation in the personnel costcomponent[30,31,34] (see section 2.4).

2.4 Programme-Level Costs

Three studies included programme-level costsassociated with ART delivery.[30,31,34] Across twourban sites in India,[30] programme-level costs onmedical and administrative personnel other thanthose directly involved in ART delivery to patientswere reported to be about 16% of per patient-yearrecurrent costs during the first year of the pro-gramme, falling to about 7% in the second year.Another study in India[31] included a project co-ordinator working across different health facilitiesunder personnel cost. In urban Nigeria,[34] reportedabove-facility expenses included transport of drugsfrom federal central facilities to the ARV centres.

2.5 Paediatric Antiretroviral Treatment

We identified three studies reporting costs ofART for patients aged 60% of totalcost), and laboratory tests $US191 (20%) in new or$US94 (10%) in established patients.

3. Prevention of Mother-to-ChildTransmission

Three eligible PMTCT costing studies wereanalysed. The cost per mother-neonate pair re-ceiving nevirapine around child delivery was$US251.1 in India,[48] $US208.8 in SouthAfrica[49]

(both middle-income countries), but only $US6.4in Rwanda,[50] an LIC (table III). The large dif-ference in costs suggests that these studies includeddifferent packages of PMTCT services and/or different cost components (see Discussionsection).

The SouthAfrican study[49] presented a thoroughcosting in already existing facilities, focusing onthe added financial costs utilized specifically bythe PMTCT programme. Across four facilities,the average unit cost per HIV-infected mother-neonate pair receiving prophylactic nevirapineservices was $US208.8. This cost included nevi-rapine to mothers at delivery, as well as provisionof nevirapine suspension to the infant and for-mula milk for the duration of the hospital stay.Additional costs estimated in the study were$US42.4 for the pre-test counselling and $US32.5for testing costs. The study reported a substan-tially higher cost for post-discharge follow-upcare, at $US327.2 per HIV-infected mother/infantpair covering cotrimoxazole and provision of in-fant formula after birth for the duration of thehospital stay (table III). The unit costs varied ac-cording to the denominator unit used (pregnantwomen screened, or HIV-infected women andneonate pair receiving ARV prophylaxis) as wellas between the four locations according to theireconomic and epidemiological differences, e.g. ahigh HIV prevalence and resource-poor setting(Frankfort, Free State) compared with a lowHIVprevalence and better resourced setting (Paarl,Western Cape).

In Andhra Pradesh, India,[48] across 16 PMTCTcentres, 1212 HIV-infected pregnant women re-ceived PMTCT, of 125 073 counselled and testedpregnant women. The average economic cost perHIV-infected woman receiving nevirapine aroundchild delivery was $US251. Average unit cost,expressed per pregnant woman counselled andtested, irrespective of HIV status, was $US2.40.Given the low price of nevirapine, personnel wasthe major cost component, at $US119 or 47% ofoverall cost per HIV-infected woman, followedby $US37 (15%) on overheads.

In Rwanda,[50] the PMTCT unit cost per spe-cific package was much lower, at $US6.42. Themarked contrast with India and South Africa is



in part explained by Rwandas much lower per-capita income level and health worker salaries.Equally important, this unit cost was achieved ina large-scale programme in a high HIV-prevalencesetting, with the six health centres covering acatchment population of 148 151 individuals, witha high PMTCT uptake rate of 71.6%, which likelyachieved significant economies of scale. How-ever, the study does not specify number of preg-nant women screened for PMTCT, the number ofHIV-infected women or the number of mother-infant pairs given nevirapine.

4. Sensitivity Analyses

A first sensitivity analysis assessed the effect ofaggregating unit cost within country-income groupsby weighing all data points and sites across stud-ies and countries equally, instead of the base-casemodel (presented above), which weighed allcountries equally, irrespective of their number ofdata points. In this variant model, median unitcosts for ART were nearly unchanged for LICand UMIC: in LIC, the median was $US797(vs $US792 in the base-case model) and 1397in UMIC (vs $US1454 in the base-case model;table II). However, for LMIC, this alternativeaggregation method resulted in a 3-fold reducedmedian cost estimate per patient-year: $US298compared with $US932 in the base case. Thisdifference reflects an over-representation of studysites and data points from India among LMIC,with exceptionally low unit costs reflecting Indiasuniquely low ARV prices due to the countrysimportant generic ARV industry and resultingstrong pharmaceutical negotiation capacity.

A second sensitivity analysis, to further check onrepresentativeness, expanded the data set to includea number of studies that did not include a break-down of cost components, but had data on totalART costs. With the addition of one study fromKenya,[51] the LICmedian cost per patient per yearbecame $US773 (mean: 713, range: 2111089), sim-ilar to the original estimate of $US792. AmongLMIC, adding data points from Thailand andIndia[52-54] did not alter the median cost per patientper year from the default of $US932 (but the meanincreased to 1314, range: 1624212).

Third, we replaced the country-income classi-fication according to each countrys 2009 incomelevel by a classification using each countrys in-come level in the year of cost data collection(while in both cases applying World Bank 2009income thresholds). This shifted five countriesthat had grown richer between the costing studyyear and 2009 (Brazil, India, Lesotho, Nigeriaand South Africa) into a lower income category.This country regrouping reduced the medianART per-patient cost among LIC (from $US792to $US646), increased the estimate for LMIC(from $US932 to $US1454) and decreased theestimate for UMIC (from $US1454 to $US1241).

5. Discussion

Empirical data on ART delivery unit costs inlow- and middle-income countries has increasedsignificantly in recent years, as access to ART hasexpanded. The current review identifies severalmore good-quality costing studies of both out-patient and home-based ART than earlier re-views,[12,13,15] and provides separate cost estimatesfor the components ARVs, personnel and labor-atory costs.

The results have several implications forprogramme planning and budgeting, and for seek-ing efficiency improvement. For ART, the key costdrivers within health facilities are ARV procure-ment, laboratory tests and personnel. ARV priceshave declined substantially over the last decade,with average declines of 1239% over 20069 forthe first-line regimens most commonly used inlow- and middle-income countries.[55] Lackingspecification of regimens and drug sources in sitesstudied, it was not possible to adjust cost estimatesfor price declines. Only six of the 24 ART costingstudies reported whether the programme usedgeneric or innovator drugs (see the expanded ver-sions of table I in the Supplemental Digital Con-tent). Of 14 studies that specified ARV regimens,the majority used lamivudine (3TC)+ nevirapine+stavudine (d4T) as the most common first-lineregimen, the regimen for which recent price de-clines have been smallest: 912% per year.[55] Thepredominance of this regimen may explain why,over 20049, the average proportion of overall



ART cost covered by ARV drugs was relativelystable, at 4852% every year, rather than declining.

The observed large variations in laboratorycosts between countries and sites indicate possibleopportunities for efficiency gains. Variations maypartly relate to patients differing clinical stages andresponses to treatment,[46] with laboratory costsbeing higher during the first 6 months after ARTinitiation.[23] Furthermore, laboratory costs tend tobe lower in established programmes or in hospitals,for example, $US15.7 or 6% of overall cost inEthiopia in 20045,[26] compared with programmesor clinics that are starting up and therefore invest-ing more in laboratory equipment.[27]

Available data (table I) were limited in thespecification of laboratory tests performed, test-specific costs and precise laboratory testingpractices and frequencies. We could therefore notanalyse whether sites with routine, systematicCD4 and viral load monitoring were more ex-pensive than sites with selective viral load mon-itoring, sites with only (or less frequent) CD4testing, or sites with just clinical monitoring, andcannot estimate the possible savings from shiftingtesting patterns. In the DART (Development ofAntiRetroviral Therapy in Africa) trial of clinicallydriven versus laboratory-guided ART in Ugandaand Zimbabwe, haematology and biochemistryadded little benefit. Twelve-weekly CD4 monitor-ing improved clinical outcomes from the 2nd yearfrom treatment initiation onwards. However, thecost of CD4 testing would have to drop to $US3.8(from current $US175) in order to make this mon-itoring practice cost effective.[56-58]

Another approach to improving the efficiencyof ART programmes may be personnel taskshifting.[59-61] In a non-Government Organiza-tion-led programme in rural Uganda, costs to theprovider were similar for clinic-based and home-based ART ($US834 and $US789 per patient-year, respectively), at comparable patient retentionand clinical outcomes.[29] The study suggests anopportunity to increase ART access in settingswith restrained health system capacity. The mark-edly higher cost of inpatient versus outpatientART (two studies in South Africa[43,44] [table I])further demonstrates the financial importance ofpreventing hospitalizations.

5.1 Limitations

This review reflects the state of evidence inthe first decade of global ART scale-up. Giventhe small number of studies and settings, the avail-able data can hardly claim global representative-ness. Despite the recent increase in good-qualitystudies (as defined in our inclusion criteria),costing information from South Asia (2 studies),Latin America and the Caribbean (5) and EastAsia and the Pacific (1) remains extremely lim-ited. Furthermore, in sub-Saharan Africa, 8 ofthe 16 studies were conducted in South Africa,which, with its relatively high income level, is thecountry least representative of the region. Thelack of regional representativeness is one reasonthat our first sensitivity analysis found highermedian ART costs in LIC than in LMIC, a resultthat seems contrary to intuition and to observedpatterns in ARV prices.[55] Despite the inclusionof studies from the grey literature (of which sevenwere eligible[19,22,23,27,33,34,38]), we cannot excludethe possibility of publication bias in availablecosting studies. Several recent, well executedART and PMTCT cost studies that are re-cognized for influencing donor funding policieshave not been published in books, peer-reviewedjournals or made otherwise publically available,so were unfortunately not included in our meta-analyses.

Innovative monitoring and evaluation strategiesare needed to address the gaps in good-qualityevidence, especially concerning above-facilityand programme-level costs. We intended toanalyse all relevant cost components, includingprogramme-level (above facility-level) activitiesand expenses, including managerial overheads,administration, monitoring and evaluation andtraining borne at district, province and nationallevels. However, only three ART studies[30,31,34]

provided such programmatic costs, without suf-ficient description of the relevant activities orcost items to analyse the determinants of thesepotentially significant contributions to overalldelivery cost.

Quality and completeness of available cost-ing studies varied. Many did not explicitly re-port all cost components, missing information



on such important cost determinants as ARVdrugs, regimens, or type and frequency of la-boratory testing used. Most studies also lackeddetails about variation in costs between differenttypes of facilities and patient populations stud-ied (in terms of, for example, age and CD4 cellcount at treatment initiation).[23] Basic infor-mation on cost components was lacking in manystudies; often either capital costs (such as thoserelated to setting up laboratory equipment) orselected recurrent costs (such as utilities) wereomitted. In particular, definitions of overheadcosts varied, with some studies not even includ-ing any overheads. Only three studies[33,34,36]

mentioned explicitly that their data collectioninstruments had been validated or piloted be-fore application. The best studies reviewed useda micro-costing approach, where expenditureson each component of providing ART orPMTCT delivery were separately listed and val-ued. Even when an ingredients approach wasutilized, most studies in the last decade did notprovide the type of ART used (not even gener-ic vs patent, or first- vs second-line). In manystudies, sample sizes appear to have been drivenby clinical outcomes, rather than by costing-related statistical considerations. Sample sizesvaried between 209 (median for LIC, range122218) and 430 (median for UMIC, range222835) patients, which may be consideredappropriate for an overall estimate from onesingle locality. However, convenience samplinglimits the precision and power to evaluate costsfor relevant strata of sites, patient age groups,treatment regimens and modality and phasesof treatment.

Heterogeneity in unit denominators, notablythe calculation of patient-years, further compli-cates comparisons among studies. For illustra-tion, a study in India[30] reported 1094 clients whoever started ART (as average across sites),939 clients at the end of study and 503 clientswho had been on therapy for the entire studyperiod. These authors selected the corresponding9460 client-months of ART as an appropriatedenominator unit; however, the large differencesbetween patients starting and patients retainedillustrates the critical influence that varying de-

nominator definitions will have on unit cost esti-mates, especially in programmes with low patientretention and/or rapid scale-up, with many newpatients initiating ART.

5.2 Future Work

The limitations in availability and compar-ability of existing cost data described abovehighlight an urgent need for development anddissemination of standardized cost-measurementmethodologies and for capacity building. Await-ing such guidance and improved data quality andstandardization, any cost comparisons betweensites and studies should be carried out with ex-treme caution and attention to methodologicaldifferences; interpretations on relative efficiencywill typically be limited to within-study determi-nants. Future strategic use of cost data for im-proving the efficiency of ART delivery will, inparticular, benefit from more careful costing andreporting of ARV drug sources and regimens,laboratory costs by type and frequency of tests,and staff costs by type of personnel, includingthose above the health-facility level.

Future assessments should link costs to healthoutcomes, including cost differentials associatedwith clinical response,[46] drug toxicity and resis-tance.[44] This is ever more important in view ofthe WHO revised 2010 guidelines for adult ARTin resource-limited settings, which recommendedan expanded access to ART, starting at CD4 cellcount

second, to exchange experiences in increasingservice efficiency. Multi-country exercises shouldhelp to improve and standardize costing meth-odologies and tools for comprehensive data col-lection. Economies of scale, as apparent in somesettings,[30] are worth investigating to establishmore clearly if these are achieved merely by allo-cating fixed costs over a larger number of pa-tients, or by improved technical efficiency (i.e.transformation of inputs to outputs) associatedwith programme maturation and learning.

Whenever possible (conditional on the avail-ability of data on patient wages and other oppor-tunity costs), both financial and economic costsshould be collected. Financial costs are relevantfor budgeting, while economic costs (includingopportunity costs, productivity losses, transportand out-of-pocket expenditure by patients) willdetermine cost effectiveness and prioritization ofresource allocations. For example, if an ART ser-vice package includes in-kind contributions suchas food subsidies or other resources donated fromexternal funding sources, these will influence fu-ture planning and sustainability. Ignoring suchexternal assistance would distort the picture ofoverall costs and incentive structures in which anART programme operates.

6. Conclusions

There is a paucity of information about unitcosts for delivery of ART and PMTCT in differ-ent HIV/AIDS programmes, particularly in LIC.Future evaluations of programme-level ART andPMTCT unit costs will benefit from internation-al guidance on standardized expenditure defini-tions and categories, standardized formats forspecifying ARV regimen mixes, laboratory test-ing practices (including type of tests and frequency)and human resource disaggregation (facility levelvs above-facility and programme level); as well asstandardized service unit denominators (possiblyincluding a component of service quality or pa-tient retention). The large differences in ARTunit costs observed in settings with similar epi-demiological and economic characteristics deserveadditional assessments focusing on cost deter-minants and opportunities for efficiency gain

in programme implementation and scale-up. Toscale-up ART and PMTCT to global universalaccess, innovative options are needed to containcosts while maintaining or improving quality andhealth gain.

Acknowledgements

The authors thank Daniel Acuna, who conducted the ini-tial bibliographic search, as well as Lazarus Muchabaiwa andJesse Kigozi for their research assistance. The authors alsoacknowledge Sergio Bautista-Arredondo, Lisa DeMaria,Steven Forsythe, Lori Bollinger, Megan OBrien and variousparticipants at the first Latin America & the Caribbean Con-ference on Global Health in Cuernavaca, Mexico and at theXVIII International AIDS Conference in Vienna, Austria, forhelpful comments. The research was partially funded by theGlobal Fund to Fight AIDS, Tuberculosis and Malaria(PO#2008301) through the National Institute of Public Health(INSP)/Consortium for Research on HIV/AIDS and Tu-berculosis (CISIDAT[63]). Additional funding for OmarGalarraga was provided by the US National Institutes ofHealth (NIH)/Fogarty International Center (K01-TW008016-02)through the Institute of Business andEconomicResearch (IBER)at theUniversity of California, Berkeley, CA,USA. The opinionsexpressed in the review do not reflect the views of any of thefunding or other organizations that supported or facilitated thestudy. The authors are solely responsible for the contents; theyreport no conflicts of interest.

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Correspondence: Dr Veronika J. Wirtz, Av. Universidad 655,Cuernavaca, CP 62100, Mexico.E-mail: [email protected]



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