Workplace provision of ART: potentially cost-saving in high prevalence settings

The impact of company-level ART provision to a mining workforce in South Africa: a cost-benefit analysis.

Meyer-Rath G, Pienaar J, Brink B, van Zyl A, Muirhead D, Grant A, Churchyard G, Watts C, Vickerman P. PLoS Med. 2015 Sep 1;12(9):e1001869. doi: 10.1371/journal.pmed.1001869. eCollection 2015.

Background: HIV impacts heavily on the operating costs of companies in sub-Saharan Africa, with many companies now providing antiretroviral therapy (ART) programmes in the workplace. A full cost-benefit analysis of workplace ART provision has not been conducted using primary data. We developed a dynamic health-state transition model to estimate the economic impact of HIV and the cost-benefit of ART provision in a mining company in South Africa between 2003 and 2022.

Methods and findings: A dynamic health-state transition model, called the Workplace Impact Model (WIM), was parameterised with workplace data on workforce size, composition, turnover, HIV incidence, and CD4 cell count development. Bottom-up cost analyses from the employer perspective supplied data on inpatient and outpatient resource utilisation and the costs of absenteeism and replacement of sick workers. The model was fitted to workforce HIV prevalence and separation data while incorporating parameter uncertainty; univariate sensitivity analyses were used to assess the robustness of the model findings. As ART coverage increases from 10% to 97% of eligible employees, increases in survival and retention of HIV-positive employees and associated reductions in absenteeism and benefit payments lead to cost savings compared to a scenario of no treatment provision, with the annual cost of HIV to the company decreasing by 5% (90% credibility interval [CrI] 2%-8%) and the mean cost per HIV-positive employee decreasing by 14% (90% CrI 7%-19%) by 2022. This translates into an average saving of US$950 215 (90% CrI US$220 879-US$1.6 million) per year; 80% of these cost savings are due to reductions in benefit payments and inpatient care costs. Although findings are sensitive to assumptions regarding incidence and absenteeism, ART is cost-saving under considerable parameter uncertainty and in all tested scenarios, including when prevalence is reduced to 1%-except when no benefits were paid out to employees leaving the workforce and when absenteeism rates were half of what data suggested. Scaling up ART further through a universal test and treat strategy doubles savings; incorporating ART for family members reduces savings but is still marginally cost-saving compared to no treatment. Our analysis was limited to the direct cost of HIV to companies and did not examine the impact of HIV prevention policies on the miners or their families, and a few model inputs were based on limited data, though in sensitivity analysis our results were found to be robust to changes to these inputs along plausible ranges.

Conclusions: Workplace ART provision can be cost-saving for companies in high HIV prevalence settings due to reductions in healthcare costs, absenteeism, and staff turnover. Company-sponsored HIV counselling and voluntary testing with ensuing treatment of all HIV-positive employees and family members should be implemented universally at workplaces in countries with high HIV prevalence.

Abstract [1]  Full-text [free] access [2]

Editor’s notes: HIV-associated diseases generally hit adults at the prime of their working life, which in turn takes a heavy economic toll on private companies. The infection increases rates of absenteeism, labour force turnover and costs of company operations. HIV care has been provided by mining companies in South Africa since 2002 (before the provision of ART in the public sector). Although the cost and cost-effectiveness of public sector HIV provision in South Africa has been estimated, the cost and impact of ART provision at the workplace level has not been establish. This paper explores cost and impact of both HIV and ART in a mining company in South Africa.

A dynamic Markov health-state transition model, the Workplace Impact Model (WIM), was developed to evaluate both the past and future impact and costs of introducing ART into the workforce from the perspective of the employer. Two scenarios are explored: no ART provision, and scale-up of ART provision in the workforce. Costs and impacts are projected over a 20-year period starting in 2003.

The results illustrate that as ART coverage increases, there are increases in survival and employee retention, as well as reductions in absenteeism and benefit payments. These lead to cost savings compared to the no ART provision scenario. Annual cost of HIV to the company dropped by 5% and the mean cost per HIV-positive employee decreased by 14%. The biggest savings are due to reductions in benefit payment for death and ill-health retirement and in the cost of employee healthcare use. Importantly, the finding that ART is cost-saving is robust to the uncertainty around the model parameters as well as to other changes in the assumptions made in the model.

This paper is very strong due to the nuances built into the model, as well as due to the quality and precision of the data used. The model takes into account different factors associated to workforce profile, HIV progression, health effects of ART initiation, age groups, and job grade categories, to mention a few. It also includes CD4 progression data from the specific population for every trimester from 2003-2010. Additionally, it includes company-specific bottom-up cost data on the costs of providing ART (medications, monitoring costs, etc.). The potential policy implications, namely that it is cost-saving for employers to provide HIV care, is a substantial one. Provision of services by private companies may not only make business sense, they may also provide a respite to public sector HIV service provision programmes.

It would be interesting to see how these findings relate to other industries. Different industries have different features. Mining, for example, is a labour-intensive, high profit industry. Others are not. Understanding the costs and effects in other types of companies, and whether ART provision remains cost-saving, would be worthwhile in order to create more specific policy guidelines. 

Africa [8]
South Africa [9]
  • [10]