Starting ART earlier may not only improve health outcomes, but perhaps save money too?

Time and money: the true costs of health care utilization for patients receiving 'free' HIV/TB care and treatment in rural KwaZulu-Natal.

Chimbindi N, Bor J, Newell ML, Tanser F, Baltusen R, Hontelez J, de Vlas S, Lurie M, Pillay D, Bärnighausen T. J Acquir Immune Defic Syndr. 2015 Jun 18. [Epub ahead of print]

Background: HIV and TB services are provided free-of-charge in many sub-Saharan African countries, but patients still incur costs.

Methods: Patient-exit interviews were conducted with a representative sample of 200 HIV-infected patients not yet on ART (pre-ART), 300 ART patients, and 300 TB patients receiving public sector care in rural South Africa. For each group, we calculated health expenditures across different spending categories, time spent traveling to and utilizing services, and how patients financed their spending. Associations between patient group and costs were assessed in multivariate regression models.

Results: Total monthly health expenditures (7.3 South African Rand: 1 USD) were: 171 (95%CI 134-207) for pre-ART, 164 (95%CI 141-187) for ART, and 122 (95%CI 105-140) for TB patients. Total monthly time costs (in hours) were: 3.4 (95%CI 3.3-3.5) for pre-ART, 5.0 (95%CI 4.7-5.3) for ART and 3.2 (95%CI 2.9-3.4) for TB patients. Though costs were similar across groups, pre-ART patients spent significantly more on traditional healers, chemists, and private doctors, while ART and TB patients spent more on transport to clinic visits. 31% of pre-ART, 39% of ART and 41% of TB patients borrowed money or sold assets to finance health costs.

Conclusions: Patients receiving nominally free care for HIV/TB face large private costs. Subsidized transport, fewer clinic visits, and drug pick-up points closer to home could reduce costs for ART patients, potentially improving adherence and retention. Large expenditure on alternative care among pre-ART patients suggests that transitioning patients to ART earlier, as under TASP, may not impose substantial costs on patients.

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Editor’s notes: At the time of this study, in 2010 in South Africa, people living with HIV and on antiretroviral therapy (ART) made monthly visits to the clinic to collect their medication and for clinic observation in their first year on ART. They visited every other month in subsequent years. People receiving TB treatment also attended the clinic once a month. People living with HIV who had not yet started ART visited the clinic every six or 12 months, depending on the CD4 cell count. The authors were surprised to find that for the third group, people who they term ‘pre-ART’, the costs of health care utilisation were roughly equivalent to the costs for people receiving monthly or bi-monthly ART and/or TB treatment.  The difference is attributed in this paper to the time and money spent by people living with HIV yet to commence ART on traditional healers and self-medication. Hence, the conclusion that the earlier initiation of ART is unlikely to increase health utilisation costs. Indeed, alternative treatment schedules, with people on ART visiting health facilities less frequently as their years on treatment progress, can reduce costs further for people on ART. The assumption made in the paper is that pre-ART people starting treatment cease to access alternative care. Given the context of this study, where the authors claim that the use of alternative therapies for people on ART is not common, this may be correct. The possibility exists that given that data were collected through patient-exit interviews, people taking ART or TB medication may have been cautious about disclosing their use of alternative therapies. Concerns over sharing such information with interviewers attached to a medical research organisation, are not uncommon. This is an area in need of further, mixed methods, research to investigate the ‘true costs of health care utilisation’. This current paper takes us a step towards that goal. 

South Africa
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