Early treatment initiation reduces costs in Indonesia

Costs of HIV/AIDS treatment in Indonesia by time of treatment and stage of disease.

Siregar AY, Tromp N, Komarudin D, Wisaksana R, van Crevel R, van der Ven A, Baltussen R. BMC Health Serv Res. 2015 Sep 30;15(1):440. doi: 10.1186/s12913-015-1098-3.

Background: We report an economic analysis of Human Immunodeficiency Virus (HIV) care and treatment in Indonesia to assess the options and limitations of costs reduction, improving access, and scaling up services.

Methods: We calculated the cost of providing HIV care and treatment in a main referral hospital in West Java, Indonesia from 2008 to 2010, differentiated by initiation of treatment at different CD4 cell count levels (0-50, 50-100, 100-150, 150-200, and >200 cells/mm3); time of treatment; HIV care and opportunistic infections cost components; and the costs of patients for seeking and undergoing care.

Discussion: Before antiretroviral treatment (ART) initiation, costs were dominated by laboratory tests (>65 %), and after initiation, by antiretroviral drugs (≥60 %). Average treatment costs per patient decreased with time on treatment (e.g. from US$580 per patient in the first 6 month to US$473 per patient in months 19-24 for those with CD4 cell counts under 50 cells/mm3). Higher CD4 cell counts at initiation resulted in lower laboratory and opportunistic infection treatment costs. Transportation cost dominated the costs of patients for seeking and undergoing care (>40 %).

Conclusions: Costs of providing ART are highest during the early phase of treatment. Costs reductions can potentially be realized by early treatment initiation and applying alternative laboratory tests with caution. Scaling up ART at the community level in certain high prevalence settings may improve early uptake, adherence, and reduce transportation costs.

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

Editor’s notes: There is a growing evidence base on the costs of HIV treatment and care, however much of the evidence to date is from sub-Saharan African settings. A review conducted by Siapka et al. in 2014 [3] found 31 studies reporting unit costs for antiretroviral therapy, only 10 of which were outside of Africa and only four of which were set in Asia and the Pacific. This study provides necessary evidence on ART costs in Indonesia. This will be important for Indonesian policy makers as they seek to scale up HIV treatment - especially in the context of recent guideline reforms for ART provision.

Findings from this study largely confirm what has been found elsewhere. Antiretroviral drug costs are primary cost drivers, followed closely by treatment of opportunistic infections. Costs of ART provision are therefore highest during the treatment initiation phase, and drop off as people are established on care. For the same reason, this study also found that costs for treating people with a CD4 count > 200 were significantly lower than costs for treating people with a CD4 count < 200. 

Unit costs per person per year range from $1699 to $2346. This is higher than previously published costs from studies in Thailand, Viet Nam and India, as reported by Siapka et al. It is difficult to tell whether it is representative of ART costs generally in Indonesia as this is the first study reporting costs from this country. 

The authors note that delivering HIV treatment at the community level may reduce costs. It is difficult to tell from the results of this study whether this is indeed the case, as costs are estimated for only one health facility (the largest public referral hospital in West Java province). However, it poses an interesting question for further research. Further evidence on costs for provision of HIV treatment and care across a variety of settings in Indonesia would improve policy relevance and help decision-makers identify potential avenues for improving efficiency.

Asia [8]
Indonesia [9]
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