HIVAN/ECI May 2005 HIV/AIDS Public Health Journal Club

Costing was the topic under discussion at the HIV/AIDS Journal Club hosted by HIVAN/ECI KZN PLUS on 6 May 2005. Christopher Browne talked about ?“The Costs of AIDS: How much do we know??”, and Nicola Deghaye followed this with a presentation titled ?“Cost and cost-effectiveness of treating multidrug-resistant tuberculosis?”.

Browne opened the discussion by explaining the need for economic costing studies related to HIV/AIDS. Economic costs take into account opportunity costs, allowing us to determine more exactly the additional cost of ?“doing something?” as opposed to ?“doing nothing?”. Existing literature on the substantive costs of HIV/AIDS Africa is thin, in particular that of highly active antiretroviral therapy (HAART). One study based on information provided by AID for AIDS showed that before treatment, it cost R750/month to treat someone who had AIDS, and that once ART was introduced the cost rose sharply to R1400/month. This was a direct result of starting antiretroviral (ARV) medication.

Estimates of the future cost of HAART were given, for example: ABT/loveLife (2000) estimated the cost of HAART at R70 billion per annum by 2010. The TAC (2002) estimated that the cost of an adult HAART programme would peak at R18 billion per annum to treat 2.3 million adults, in 2015. Geffen (2003) looked at the spending for concurrent prevention efforts and treatment for opportunistic infection, as well as HAART, and found an estimated cost of R20.3 billion in 2015. Geffen stated that the net costs to government would be ?“significantly lower than the direct costs of providing HAART?”.

Apart from other things, the cost of HAART depends to a great extent on when it is started, when CD4 count is below 200 (according to national government guidelines), or earlier. One difficult question remains: how would one measure the true no-HAART opportunity costs, for comparison against like quality of care?

(Browne had to end his presentation at this point due to lack of time, but please see the righthand side of this page to access his PowerPoint presentation).

?“What is the cost and the cost-effectiveness of treating multidrug resistant TB (MDRTB)??” was the question then asked by Nicola Deghaye. With the highest rates of MDRTB in the world seen in South Africa and Khazakstan, this was a pertinent question for the Journal Club. Unfortunately, there is a dearth of literature on costing MDRTB, especially in Southern Africa. Deghaye reviewed the results of an online literature search, and found four studies that investigated the cost of MDRTB in South Africa, and only one of those looked at the cost-effectiveness of treatment.

Hensher (1999) and Rockcliffe (2002) gave figures in the region of R26 000 (R26 000 and R25 947 respectively) for treating one MDRTB patient for one year, while the Department of Health gave R30 000 as an equivalent figure for standardised treatment. This is about twenty times the cost of treating normal TB in a patient for one year (Weyer and Stander, 1996). Even so, these seem to be gross underestimates, especially when the cost of hospitalisation is taken into account.

Deghaye quoted calculations which showed that the total cost of a 24-month course of standardised medication (kanamycin, ethionamide, ciprofloxacin, pyrazinamide and cycloserine), given seven times per week, is R45 381. (R9 147 in the intensive phase (4months, 5 drugs) and R36 234 in the continuation phase (20 m, 3 drugs).) This excludes the cost syringes and needles used to administer Kanamycin and excludes staff time in administering all drugs. Using ethambutol instead of cycloserine brought the total cost down to R5 709. The conclusion to note from this simple calculation is that the cost of cycloserine (for ethambutol-resistant patients) drives the drug cost up drastically. According to Rockcliffe (2002), individualised treatment for MDRTB costs around R19 400 per year, the lower cost being accounted for by lower drug costs. However, ?“when ethambutol resistance is less than 20%, standardised treatment becomes the cheaper option,?” says Deghaye.

In conclusion, Deghaye suggested that to better estimate cost we need empirical evidence of resource utilisation in treating this disease. Too few studies worldwide have looked specifically at costs such as the human resource component and other recurrent expenditure. In addition, based on retrospective evaluation of MODS (microscopic observation broth-drug susceptibility assay) in Peru which showed significantly shorter time to culture positivity and good concordance with existing MDR TB tests, there is a need to evaluate the cost-effectiveness of using new rapid diagnosis tests versus existing tests.

References:

References for ?“The Cost of AIDS: How much do we know??” (Christopher Browne): Various references. Please see the PowerPoint presentation available on this webpage for a complete reference list.

References for ?“Cost and cost-effectiveness of treating multidrug-resistant tuberculosis?” (Nicola Deghaye):

• Various references, including those stated below. Please see the PowerPoint presentation available on this webpage for a complete reference list.
• SA National Department of Health (1999). The management of Multidrug resistant tuberculosis in South Africa, South African National Department of Health.
• Hensher, M. (1999). Budget Planning Assistance for North West Province TB and HIV/AIDS/STD Programmes. Pretoria, Health Financing & Economics Directorate Department of Health.
• Rockcliffe, N. (2002). Investigation of the comparative cost-effectiveness of different strategies for the management of multidrug-resistane tuberculosis. Faculty of Pharmacy. Grahamstown, Rhodes University: 162.
• Weyer, K. and M. F. Stander (1996). "Multidrug-resistant tuberculosis in South Africa." The Lancet (Letter to the Editor) 348: 1658.


Biosketches:

Mr Christopher Browne: Christopher Browne is a member of the School of Economics and Finance, where he has been working since 1998, lecturing undergraduates in Economics. Recently he started teaching Health Economics, and has a special interest in the economics of HIV/AIDS. Browne and his wife, Angela, have a ministry teaching basic skills to women involved in community projects.

Ms Nicola Deghaye: Nicola Deghaye works as a Health Economics Researcher at Enhancing Care Initiative KZN PLUS at the Nelson R. Mandela School of Medicine. Deghaye?’s background is in economics. She completed her BCom and BCom Honours in Economics at the University of KwaZulu-Natal, and her MSC in Health Economics at the University of York, England in 2003. Deghaye has worked in market research and as an industry analyst in the banking sector. Her research interests include the economic evaluation of HIV/AIDS treatment strategies.