|POLICY AND PRACTICE
|Year : 2017 | Volume
| Issue : 1 | Page : 94-98
Delivery of antiretroviral treatment services in India: Estimated costs incurred under the National AIDS Control Programme
Reshu Agarwal1, Bharat Bhushan Rewari2, Suresh Shastri3, Sharath Burugina Nagaraja4, Abhilakh Singh Rathore5
1 Formerly National AIDS Control Organisation, New Delhi, India
2 World Health Organization Country Office for India, New Delhi, India
3 State TB Cell, Revised National Tuberculosis Control Programme, Bangalore, India
4 Employees' State Insurance Corporation Medical College and PGIMSR, Bangalore, India
5 National AIDS Control Organisation, New Delhi, India
|Date of Web Publication||12-May-2017|
Sharath Burugina Nagaraja
Employees' State Insurance Corporation Medical College and PGIMSR, Bangalore
Competing domestic health priorities and shrinking financial support from external agencies necessitates that India’s National AIDS Control Programme (NACP) brings in cost efficiencies to sustain the programme. In addition, current plans to expand the criteria for eligibility for antiretroviral therapy (ART) in India will have significant financial implications in the near future. ART centres in India provide comprehensive services to people living with HIV (PLHIV): those fulfilling national eligibility criteria and receiving ART and those on pre-ART care, i.e. not on ART. ART centres are financially supported
(i) directly by the NACP; and (ii) indirectly by general health systems. This study was conducted to determine (i) the cost incurred per patient per year of pre-ART and ART services at ART centres; and (ii) the proportion of this cost incurred by the NACP and by general health systems. The study used national data from April 2013 to March 2014, on ART costs and non-ART costs (human resources, laboratory tests, training, prophylaxis and management of opportunistic infections, hospitalization, operational, and programme management). Data were extracted from procurement records and reports, statements of expenditure at national and state level, records and reports from ART centres, databases of the National AIDS Control Organisation, and reports on use of antiretroviral drugs. The analysis estimates the cost for ART services as US$ 133.89 (?8032) per patient per year, of which 66% (US$ 88.66, ?5320) is for antiretroviral drugs and 34% (US$ 45.23, ?2712) is for non-ART recurrent expenditure, while the cost for pre-ART care is US$ 33.05 (?1983) per patient per year. The low costs incurred for patients in ART and pre-ART care services can be attributed mainly to the low costs of generic drugs. However, further integration with general health systems may facilitate additional cost saving, such as in human resources.
Keywords: antiretroviral therapy, HIV, India, NACP, unit costs
|How to cite this article:|
Agarwal R, Rewari BB, Shastri S, Nagaraja SB, Rathore AS. Delivery of antiretroviral treatment services in India: Estimated costs incurred under the National AIDS Control Programme. WHO South-East Asia J Public Health 2017;6:94-8
|How to cite this URL:|
Agarwal R, Rewari BB, Shastri S, Nagaraja SB, Rathore AS. Delivery of antiretroviral treatment services in India: Estimated costs incurred under the National AIDS Control Programme. WHO South-East Asia J Public Health [serial online] 2017 [cited 2019 Dec 12];6:94-8. Available from: http://www.who-seajph.org/text.asp?2017/6/1/94/206172
| Background|| |
Despite substantial price reduction in recent years, the cost of antiretroviral therapy (ART) typically constitutes a significant component of a country’s overall expenditure on its national HIV/AIDS control programme. Adequate funding for ART programmes is critical to achieving universal access to HIV/AIDS services. With limited financial resources available, programmes must demonstrate cost effectiveness. As with other low- and middle-income countries, competing domestic health priorities and shrinking financial support from external agencies mean that India’s National AIDS Control Programme (NACP) needs sustainable funding mechanisms. Plans to expand the criteria for eligibility for ART in India will have significant financial implications in the near future. There are no cost data on delivery of care for people living with HIV (PLHIV) under the current (i.e. third) phase of the National AIDS Control Programme (NACP III) in India. This study therefore estimates the baseline unit costs for the programme, to inform budget planning, scaling up of services and delivery of the logistics for effective functioning of the programme on an annual basis.
| Context of care for people living with HIV in India|| |
In 2015, the estimated national prevalence of HIV for adults in India was 0.26% (lower and upper uncertainty bounds: 0.22%, 0.32%). The Government of India launched the free ART initiative on 1 April 2004 at eight institutions in six high-prevalence states, under NACP II, and scaled up the services to the entire country in a phased manner. The delivery of care and treatment services for people living with HIV/AIDS under the public sector is provided through ART centres, which are usually established in existing hospital settings like medical colleges and district hospitals. The ART centres provide comprehensive services to all PLHIV enrolled under the programme, which includes those fulfilling national eligibility criteria and receiving ART and those on pre-ART care. A person living with HIV is said to be on active pre-ART care, if he or she is not on ART but has undergone CD4 counts in the last year. The services include initial clinical evaluation, counselling, prophylaxis and management of opportunistic infections, and regular follow-up of patients The ART centres under the programme are financially supported (i) directly by the NACP; and (ii) indirectly by general health systems on a shared costs basis. The NACP supports human resources, including medical doctors, counsellors, nurses, pharmacists, data managers and care coordinators; it also supports capacity-building of the health-care providers in HIV care, infrastructure development, monitoring and evaluation, antiretroviral drugs, testing of CD4 cell count, and co-trimoxazole prophylaxis and treatment of complex opportunistic infections. Support from the general health systems for the ART programme in the country is provided in terms of infrastructure and space for service delivery; consultation services from the specialists of critical departments (medicine, microbiology, obstetrics and gynaecology, paediatrics, dermatology/venereology); provision of laboratory investigations, drugs for the treatment of opportunistic infections, and other essential drugs required for PLHIV; inpatient care for PLHIV; deputation of an institutional staff nurse to support the contractual staff at each ART centre; and maintenance of the centres (housekeeping services, provision of electricity and water supply and management of biomedical waste).
| Methodology|| |
This study was conducted to determine (i) the cost incurred per patient per year of pre-ART and ART services at ART centres; and (ii) the proportion of this cost incurred by the NACP and by the general health systems. The study used national data from April 2013 to March 2014. As of March 2014, nearly 1.1 million PLHIV were enrolled in active care, of whom nearly 0.77 million were receiving ART from 432 ART centres across the country. Nearly 10 000 PLHIV were receiving second-line ART at 10 centres of excellence and selected ART-plus centres.
Permission to conduct the study was obtained from the implementing authorities of the National AIDS Control Organisation (NACO), New Delhi, India.
| Cost components|| |
Different functional components of the ART programme were identified as cost categories: (i) laboratory tests; (ii) human resources; (iii) training for capacity-building; (iv) prophylaxis and treatment for opportunistic infections; (v) hospitalization; (vi) operational; and (vii) programme management. The costs of antiretroviral drugs were estimated separately. All the costs are expressed per patient per year. These costs were calculated for pre-ART and ART care services. For most cost categories, a top-down approach was used in calculation.
A key component of this costing exercise involved estimating shared costs, which includes the costs of inputs that are not exclusive to the ART programme, but are necessary for the programme to function. Therefore, further disaggregation was done into (i) direct costs; and (ii) shared costs, to understand the costs borne by the programme and by general health systems respectively. Direct costs are defined for operational reasons as the costs incurred directly by the programme to implement pre-ART/ART services. Shared costs, for operational reasons, are defined as the costs incurred by the general health system for the resources that are utilized by the programme. The costs for subsidiary items such as space, infrastructure and maintenance were not calculated because insufficient data were available to calculate meaningful national data, owing to variability in these factors among centres.
Sources of data and analysis
Programme costs were estimated from data for the financial year 2013–2014 (1 April 2013 to 31 March 2014). The data for calculation were obtained from procurement records and reports, statements of expenditure from national and statelevel data, records and reports from ART centres, databases of the NACO central procurement and financial management software and strategic information management system software, and reports on use of antiretroviral drugs. Since the data on hospitalization were not uniformly maintained across all the ART centres under programmatic settings, information gathered from selected ART centres was extrapolated and an average cost was calculated.
The details of the cost categories, expenditure items and types, rationale for inclusion, sources of data, and other considerations are summarized in [Table 1]. The data were analysed using Microsoft Excel and the World Health Organization (WHO) Guidance for completing the financial indicators for ART programmes in the universal access questionnaire, which was adapted to include other cost categories in the context of the NACP.
|Table 1: Details of the cost categories, expenditure types and items, rationale for inclusion, sources of data and other considerations|
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The various headings under which costing was calculated are shown in [Table 2]. The cost for the ART component and the rationale for inclusion are explained in the table.
|Table 2: Categories and costs considered for calculating the cost for patients on antiretroviral therapy (2013–2014)|
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Patients in ART care
The estimated cost for ART services is US$ 133.89 (₹5320) per patient per year, of which 66% (US$ 88.66, ?8032) is for antiretroviral drugs and 34% (US$ 45.23, ?2712) is for non-ART recurrent expenditures. Of the total non-ART expenditure of US$ 45.23 (₹2712) per person per year, US$ 32.51 (₹1949, 72%) is borne by the NACP and the remaining US$ 12.72 (₹763, 28%) is borne by health systems (see [Table 2]).
Patients in pre-ART care
The estimated cost for pre-ART care is US$ 33.05 (₹1983) per patient per year, of which, US$ 19.29 (₹1158, 58%) is borne by the NACP and US$ 13.76 (₹825, 42%) is borne by the health systems (see [Table 3]).
|Table 3: Categories and costs considered for calculating the cost per patient per year for patients on pre-ART care (2013–2014)|
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| Discussion|| |
To the best of authors’ knowledge, this is the first national study conducted in India to estimate the cost of delivery of care for PLHIV under the current (i.e. third) phase of the NACP (NACP III) in India, which started in 2007. The study found that the costs incurred for patients in ART and pre-ART care services are low. An earlier study carried out by Gupta et al. was based on data collected between 2004 and 2006 from seven selected ART centres in India. The programme components costed in that study included antiretroviral drugs, treatments for opportunistic infections, diagnostic tests and human resources but the health-systems costs were not included. The authors in that study extrapolated their estimates to project an average unit cost per patient per year of about US$ 350. The present study has used costs for 2013–2014 and drug costs had reduced significantly from the 2006 costs used in the study by Gupta et al.
Agarwal et al.: Cost to treat ART patients under the National AIDS Control Programme, India The United States President’s Emergency Plan for AIDS Relief (PEPFAR) is supporting ART treatment in many countries across the globe; their estimated costs per patient per year for 2006–2009 were US$ 436; the cost components included were similar to those in the present study. A report from Zambia suggests that the cost for a first-line HAART (highly active antiretroviral therapy) regimen is US$ 488 per patient per year, which also includes diagnostics. A systematic review conducted in 2011 on unit costs for delivery of ART and prevention of mother-to-child transmission of HIV estimated that the median cost of ART per patient per year was US$ 792 for lower-middle-income countries and US$ 1454 for upper-middle-income countries; about 47% of the costs were spent on antiretroviral drugs alone. The Multi-country Analysis of Treatment Costs for HIV/AIDS (MATCH) in 2010–2011, which included all the components of service delivery, revealed that the costs ranged from US$ 208 to US$ 682 per person per year across the countries studied (Ethiopia, Malawi, Rwanda, South Africa and Zambia).
In India, the cost per person per year is comparatively less when compared to PEPFAR-supported treatment sites across 12 countries. The use of generic drugs, bulk procurement of drugs and reagents at a national level, and reduction in drug costs over the years has contributed to a low cost for commodities. The lower cost in India may also be attributed to efficient use of general health systems. Also, India has the capacity to scale up its ART services, using the country-owned domestic drug manufacturing base. The low non-ART costs identified in this study may be attributed to expanded eligibility criteria for initiation of ART and improvement in the median CD4 count of PLHIV at the time of reporting, with a consequent reduction in the need for management of opportunistic infections, hospitalization and visits to ART centres.
The training cost incurred is low at below 1% of the total costs, which is due to the strategy adopted for strengthening and capacity-building of general health staff, through establishment of centres of excellence. However, aside from the costs for diagnostics and antiretroviral drugs, the costs of human resources contribute significantly to the programme. Therefore, the programme may still need to consider innovative approaches for delivery and monitoring of individual patients’ treatment, thereby saving the time and resources of general health staff while maintaining quality service delivery. This, and other areas for additional cost saving, may involve further integration between ART centres and general health systems.
The study has some limitations. It has focused on direct costs for providing services to PLHIV under pre-ART and ART care, through the perspective of the programme. However, indirect costs and capital costs (cost of space, infrastructure costs, laboratory establishment costs, depreciation rates of centres) were not included. The study has also not included the cost incurred for the functioning of ART care and support centres.
Acknowledgement: The authors acknowledge the support of all the programme officers and regional coordinators of the Care, Support and Treatment (CST) division working with the National AIDS Control Programme, CST officials at the state AIDS prevention and control societies, nodal officers and staff of ART centres.
Source of support: Nil.
Conflict of interest: None declared.
Authorship: The idea was conceived by RA, RBB, SS, SBN and RAS. All authors contributed to writing and approving the final manuscript.
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[Table 1], [Table 2], [Table 3]