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Barnaby Young Infectious Diseases registrar Communicable Diseases Centre,

The impact of a limited subsidy on access to antiretroviral therapy (ART) and patient outcomes in Singapore. Barnaby Young Infectious Diseases registrar Communicable Diseases Centre, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore. Overview.

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Barnaby Young Infectious Diseases registrar Communicable Diseases Centre,

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  1. The impact of a limited subsidy on access to antiretroviral therapy (ART) and patient outcomes in Singapore Barnaby Young Infectious Diseases registrar Communicable Diseases Centre, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore

  2. Overview • Financing of public healthcare in Singapore – and how HIV funding changed in early 2010 • ‘Before-and-after’ analysis • Examine the hypothesis that funding changes improved ART practice and patient outcomes • Some considerations for long-term affordability

  3. Singapore HIV prevalence in general pop 0.1-0.3%1 HIV prevalence in MSM 3-4%2 Healthcare performance ranked sixth globally3 GDP PPP, 60,410 Int$ per capita, ranked third 4 GINI co-efficient 0.459, second highest 5,6 1Chua 2012, 2Griensven 2010, 3WHO 2000,4IMF 2013, 5DSS 2012, 6OECD 2012,

  4. M & M & M cpf.gov.sg, accessed 18/6/13

  5. Limits of the 3 Ms cpf.gov.sg, accessed 18/6/13

  6. Methods • CDC  primary HIV treatment site in Singapore • HIV sentinel cohort database • Cohort of 50% of patients newly presenting for care at CDC from 2005 (randomly selected) • Extracted data for 1st year of care, divided into two cohorts • 2005-2008 • 2010-2011

  7. Proportion starting ART in 1st year

  8. Time to ART after a diagnosis of AIDS (CD4+ <200)

  9. Initial ART prescribed (for 2NRTI + NNRTI/PI combinations)

  10. Outcomes at 1 year

  11. Analysis of outcomes by year

  12. Income

  13. Proportion with AIDS who start ART *p<0.05

  14. Conclusion • Outcomes markedly improved between the two cohorts • This correlated with improved access to ART • Earlier initiation after AIDS diagnosis, and at higher CD4 counts • Timing and rapidity of changes suggests this was due to the increased funding available

  15. Conclusion • Improvements seen in both income groups – but greater magnitude in lower income due to late diagnosis • Patient data regarding Medifund, Medisaveutilisation and other financial sources in each cohort would be helpful • ?ART purchased locally or overseas

  16. Limitations • Retrospective study • Financial data based on a spot estimates of salary only (no income group heterogeneous) • Loss of income due to illness • Not known why some with low CD4+ counts did not start ART  standard practice (pre-Zolopa 2009), ?too ill, psychosocial or financial

  17. Future studies • Means testing thresholds for Medifund eligibility has not been made public • ART expensive, particularly for second-line therapies • Concern over a ‘sandwiched group’ who do not qualify for Medifund assistance, and need to pay a significant proportion of household income for medical bills

  18. Acknowledgments • Co-investigators: Dr Arlene Chua, Dr Ng OonTek, Ms Ho Lai Peng, Dr Lee Cheng Chuan, A/Prof Leo Yee Sin • Madeline Chua, Adriana, Chin Mei for data extraction • The medical social workers at CDC

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