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Gesine Meyer-Rath 1,2,3 ,

The cost of early versus deferred paediatric antiretroviral treatment in South Africa A comparative cost analysis of the first year of the Children with HIV Early Antiretroviral Therapy (CHER) trial . Gesine Meyer-Rath 1,2,3 ,

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Gesine Meyer-Rath 1,2,3 ,

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  1. The cost of early versus deferred paediatric antiretroviral treatment in South Africa A comparative cost analysis of the first year of the Children with HIV Early Antiretroviral Therapy (CHER) trial Gesine Meyer-Rath1,2,3, Avy Violari4, Mark Cotton5, Buyiswa Ndibongo2, Alana Brennan1,2,3, Lawrence Long2,3, Ravindre Panchia4, Ashraf Coovadia6, Diana M Gibb7, Sydney Rosen1,2 1 Center for Global Health and Development, Boston University, US 2 Health Economics and Epidemiology Research Office (HE2RO), Wits Health Consortium, South Africa 3 Faculty of Health Sciences, University of the Witwatersrand, South Africa 4 Perinatal HIV Research Unit, University of the Witwatersrand, South Africa 5Children’s Infectious Diseases Clinical Research Unit, Stellenbosch University, South Africa 6 Department of Paediatrics and Child Health, University of the Witwatersrand, South Africa 7 Medical Research Council Clinical Trials Unit, UK

  2. Background Children with HIV Early Antiretroviral Therapy (CHER) trial (Violari NEJM 2008): • Effectiveness of early ART initiation (6-12 weeks of age), regardless of CD4 cell percentage or CDC stage (Early Paediatric Treatment) • Hazard ratio for death: 0.24 (95% CI 0.11 to 0.51; P<0.001) • Hazard ratio for disease progression: 0.25(95% CI 0.15 to 0.41; P<0.001) Main obstacles to implementation: • Cost of early treatment • Affordability of full coverage with paediatric treatment

  3. Economic evaluation: Scenarios Analysis of full cost of care during first year of life from provider perspective 27 weeks 20 weeks 10 weeks MEAN AGE AT INITIATION Diagnosis ART initiation Trial arm 2/3 (n=284) Early treatment Pre-ART care Trial arm 1 (n=89) Deferred treatment Diagnosis ART initiation ART initiation Routine care (n=143) Pre-ART care Diagnosis

  4. Economic evaluation: Methods • Full cost analysis of CHER trial arms • Resource use from trial data, including inpatient care • Unit cost (drugs, labs, staff, space, equipment) from public sector data • Full cost analysis of Routine care of children initiating ART in standard HIV clinic in first year of life • Resource use and unit costs from Empilweni Clinic, Johannesburg, including inpatient care

  5. Economic evaluation: Data sources • Patient-level resource use data (Patient files): • Antiretroviral drugs dispensed • Laboratory test and other diagnostics • Number of clinic consultations • Inpatient days • Unit costs (Mixed sources): • Drugs: Government drug depot • Laboratory tests: National Health Laboratory Service • Staff salaries (incl. benefits): Hospital accounts • Equipment, supplies, overheads: Clinic/ hospital accounts • Inpatient days: Hospital cost per patient-day equivalent

  6. Results: Cost per child [2009 USD] • Cost difference mostly due to difference in frequency of hospitalisations: • Early therapy: 2 days/ child (max: 68 days) • Deferred therapy: 7 days/ child (max: 84 days) • Routine care: 13 days/ child (max: 121 days)

  7. Budget implications: South AfricaNational ART Cost Model (NACM)/Budget Review 2010, National Treasury Early Paediatric Treatment at 90% coverage • The cost of the paediatric ART programme will always be dwarfed by • the cost of the adult programme, regardless of eligibility criterion

  8. Limitations of analysis • Cost per inpatient day = Average cost per inpatient day across all wards  Conservative cost estimate • Cost of screening of all HIV-exposed children not included; would add about $300 per child • Early treatment arm different from early treatment in practice (better follow-up; LPV/r-containing regimen) • All arms limited to children surviving to ART initiation • Difference in cost depends on children being presented for hospital admission

  9. Conclusions • Cost per child during first year of life is lower under Early therapy than under Deferred therapy OR Routine care • This is mostly due to cost savings from a decrease in hospitalisations • “Routine” care with delayed access to ART is exceptionally expensive • Since survival is also higher under Early Therapy, this strategy is likely to be cost-effective • South Africa has adopted Early Paediatric Treatment in its new guidelines from April 2010.

  10. Acknowledgements • Research assistance: Busisiwe Sithole • Data management (PHRU SDMC): Kennedy Otwombe, Handrè Truter • Empilweni clinic: Karl Technau, Annie Jordan, Vincent Kgakgadi • USAID South Africa: Melinda Wilson, Clint Cavanaugh, Roxana Rogers • GSK plc

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