The cost of early vs. deferred paediatric antiretroviral treatment in South Africa - a comparative economic analysis of the first year of the CHER trial
G. Meyer-Rath1,2,3, A. Violari4, M. Cotton5, B. Ndibongo2, A. Brennan1,2,3, L. Long2,3, R. Panchia4, A. Coovadia6, D.M. Gibb7, S. Rosen1,2
1Boston University School of Public Health, Center for Global Health and Development, Boston, United States, 2Health Economics and Epidemiology Research Office, Johannesburg, South Africa, 3University of the Witswatersrand, Faculty of Health Sciences, Johannesburg, South Africa, 4University of the Witwatersrand, Perinatal HIV Research Unit, Johannesburg, South Africa, 5Stellenbosch University, Children's Infectious Diseases Clinical Research Unit, Stellenbosch, South Africa, 6University of the Witswatersrand, Department of Paediatrics, Johannesburg, South Africa, 7Medical Research Council, Clinical Trials Unit, London, United Kingdom
Background: In 2007, the CHER trial showed the effectiveness of early (at 6-12 weeks of age) antiretroviral treatment (ART) in asymptomatic HIV-infected infants with CD4 percentage >25%. We compared the cost of this strategy with ART initiation based on CD4% threshold or clinical criteria according to old WHO guidelines.
Methods: We collected data on outpatient/inpatient resource use during the first 12 months of life in 411 children randomised to early (arms 2/3 combined, n=252) or deferred (arm 1 n=125) ART in the CHER trial and 130 infants initiating ART at a clinic in Johannesburg between 2005 and 2007. Patient-level resource use data included the number of clinic consultations and of antiretroviral drugs (ARVs) dispensed, laboratory tests and inpatient days. Clinic and hospital accounts provided the cost of staff (including benefits), equipment, supplies, and overheads. Unit cost data for drugs and laboratory tests was obtained from the government medical depot and government laboratory service respectively. All cost data was from 2009.
Results: The mean cost per child of deferred ART was USD 1,794 (95% CI 1,475 - 2,113); 33% ARV, 27% inpatient care, 23% staff/overheads, and 17% laboratory costs. The mean cost per child of early ART was USD 1,322 (95% CI 1,145 - 1,499); 20% ARV, 31% inpatient care, 31% staff/overheads and 18% laboratory costs. The per-patient cost of inpatient care was lower in the early (USD 406) than the deferred (USD 590) arms. Among infants initiating ART in routine care, costs were USD 1,281 (95% CI 1,179 - 1,383): 87% inpatient, 9% staff/overheads, 3% ARV, and 2% laboratory costs.
Conclusions: In HIV-infected infants, initiating early ART at a median age of 7 weeks is cost-saving compared with deferring ART until median age 29 weeks. In routine care, 3-fold lower outpatient costs are overwhelmed by high inpatient costs before ART initiation.
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