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Presented by Dr Jammy Guru Rajesh

Accessing Free Anti Retroviral Therapy (ART) Services is Expensive for PLHIV -A Costing Exercise from India (GHTM) *. Presented by Dr Jammy Guru Rajesh. Co-Authors - S. Rajasekaran, T. Francis, P. Nadol, P. Naqui. * Government Hospital of Thoracic Medicine, & ITECH Chennai, India.

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Presented by Dr Jammy Guru Rajesh

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  1. Accessing Free Anti Retroviral Therapy (ART) Services is Expensive for PLHIV-A Costing Exercise from India (GHTM)* Presented by Dr Jammy Guru Rajesh Co-Authors - S. Rajasekaran, T. Francis, P. Nadol, P. Naqui * Government Hospital of Thoracic Medicine, & ITECH Chennai, India

  2. 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 epidemic HIV prevalence among different population groups, (MSM- 9.2%, IDU – 7.3%, FSW – 4.9 %, STD- 2.5%, ANC- 0.49%) (2008-09 Provisional) District Categorization based on HIV Sentinel Surveillance (2004-06) A 156: ANC Attendees >=1% B 39: ANC Attendees <1%, HRG>=5% C 296: HRG<5% D 118: No Known Hot Spots/Poor Data Source: NACO Annual Report, 2009-10 and UNGASS Report 2008

  3. Background • ART reduces mortality of PLHIV . • Government of India (GOI) launched a free ART program in 2004 with an aim of putting 300,000 PLHIV on ART by 2012. • GHTM is the largest centre serving more than 20000 PLHIV • By 2010 - 300,000 PLHIV on ART • By 2008-09, second line ART criteria were developed and initiated (10 centres) • There is a need for unit cost data to assess financial implications for scale up

  4. Purpose • 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.

  5. Methodology 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. Exploratory design for provider unit cost Cost heads – Drugs, Lab, OP & IP Data sources – Invoice (lab &drugs), ‘THIS’ and Discussions with staff & administrators

  6. Results P.S: All Cost are represented in USD $ (INR) Conversion 1 USD = 45 INR

  7. Provider cost Drugs cost EFV > 7 x NVP AZT > 3 x d4T

  8. Provider cost Unit cost of laboratory tests • Capital cost of the machine, reagents, personnel, stationery were included • Overhead costs were taken (10%)

  9. ART provision at OPD costs Provider cost 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

  10. ART IPD hospitalization cost Provider cost IP cost / patient for ART initiation(15 days) = $22.66 (1020) IP cost per patient /day = $1.51 (68) • Costs included were those for personnel, maintenance / cleaning, laundry and food. • Overhead costs of 10% was added on to the total cost

  11. Average cost for ART initiation Provider cost ART initiation cost = costs of drugs + labs (CD4, LFT, RFT, CBC, BS, X-ray, Sp) + OPD cost + IP (15 days) 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).

  12. Average cost for ART follow up Provider cost • 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)

  13. Cost Summary of provider cost 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 Major cost contributors – Drugs followed by labs

  14. Patient costs Patient costs Survey of 220 PLHA Direct costs – Travel and food Indirect cost – loss of wages, attendant cost

  15. Cost per patient / visit Direct costs Patient costs • 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)

  16. Patient costs Patient cost variation with distance

  17. Average Cost per patient Patient costs Cost / patient + attendant / visit = $12.4(558) Mean cost / patient / visit = $6.64 (299) (without attendant) Overall cost (wt. average) per patient / visit = $8.95 (403) (40% accompanied by attendants) Cost per patient / year – $107.35 (4,831)

  18. 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 )

  19. Conclusion • GOI 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.

  20. 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

  21. 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

  22. 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 up • Link 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

  23. 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

  24. Acknowledgements Dr. 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

  25. Extra slides

  26. Provider cost Example of a lab cost calculation for a CBC/CHG (i) Machine cost

  27. Provider cost Example of a lab cost calculation for a CBC/CHG… contd (ii) Personnel cost

  28. Provider cost Example of a lab cost calculation for a CBC/CHG… contd (iii) Total cost

  29. How far the patients come from? Patient costs Mean / Median Distance traveled = 200 kms

  30. Costs incurred by Patients Patient costs Mean travel cost per patient / visit = 140

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