South African HIV treatment costs, scope of plan, begin to emerge

Following yesterday's announcement of a go-ahead of antiretroviral treatment in South Africa, the government has released preliminary information on the broad shape of antiretroviral treatment programme it wants the Department of Health to get to work on. Even in its most limited form, it would be the largest developing world treatment programme within three to four years, and in its most comprehensive form would treat over one million people by 2008.

A South

African Health and Treasury task force reviewed what would be needed to deliver

antiretroviral therapy and other HIV treatment and care in South Africa. A summary of their report can be downloaded in pdf form here.

The

report’s recommendations were developed with the aid of South African

clinicians and a team from the Clinton Foundation AIDS Initiative.

In

developing their projections, they worked on the assumption that treatment

should be made available to people with a CD4 cell count below 200 cells/mm³, and that clinical condition would also affect whether individuals were recommended for antiretroviral treatment.

Two first

line regimens will be recommended, in line with the WHO guidelines, and

patients will be monitored with both CD4 counts and viral load after three

months on treatment, and then every six months thereafter. Patients should be

reviewed every three months by a doctor, with intervening monthly review by

nurses.

Nutritional

support and prophylaxis against opportunistic infections will also need to be

rolled out, since not everyone will be able to access immediate antiretroviral

therapy. Indeed, one of the decisions still to be made is just how broad and

ambitious antiretroviral treatment will be.

The team

looked at the cost of four options, assuming that antiretroviral therapy would

extend illness-free life by 3.6 to 4.4 years:

• “No ARV”: Providing

  comprehensive access to current standard treatment guidelines for all who

  need it, but with no antiretroviral therapy for people with AIDS

• “20% ARV coverage”:

  Working up via phased implementation to provide ART for 20% of all new

  AIDS cases in 2008, with full access to non-ARV care for all those who need

  it. This option would see 200,000 people on treatment by 2008. Between

  2003 and 2010, the 20% ARV coverage scenario would result in 293,000

  deaths being deferred until after 2010 (deaths of individuals who, without

  ART, would have died prior to 2010).

• “50% ARV coverage”:

  Working up via phased implementation to provide ART for 50% of all new

  AIDS cases in 2008, with full access to non-ARV care for all those who need

  it. This option would see 600,000 people on treatment by 2008. The 50% ARV

  scenario would result in 733,000 deaths being deferred until after 2010.

• “100% ARV coverage”:

  Working up via phased implementation to provide ART for 100% of all new

  AIDS cases in 2008, with full access to non-ARV care for all those who need

  it. This option would see 1.2 million people on treatment by 2008, and

  would defer 1,721,000 deaths by 2010

These

results would be achieved at an incremental cost of between R 23,674 per death deferred (20% scenario) and R 26,238 per death

deferred (100% scenario) beyond 2010. The assumed cost of treatment, including all monitoring and care, would be 8,139 rand in the first year (US$1098), falling to 7,611 rand in each subsequent year of treatment (US$1027). The precise drug costs within these sums are unclear, and as the report notes, there are considerable grounds for assuming that these costs will come down.

Total

AIDS treatment & care costs by scenario (target year 2008

, in billions of rand per year (US $ in brackets

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These

calculations do not include externalities such as orphans averted. Without ART,

it is estimated that 1.8 million children will become orphans between 2003 and

2010. 20% ARV coverage could reduce this total by 140,000 children; 50%

coverage by 350,000; and 100% ARV coverage by as many as 860,000 children.

Under

all scenarios, a comprehensive health sector prevention programme

will be required, which will cost an additional R 550 to 570 million per year for the rest of the decade.

Managing the programme

The

Treasury Team says that any programme (including any ARV programme)must ensure that it meets the needs of those in “desperate need” (i.e. the sickest and the poorest). It lays out a number of equity criteria for the programme:

• Provision for

  the rural poor must not be delayed until after urban areas have been served, but must commence concurrently.

• The South African government must have a clear,

  transparent and reasonable plan, which has the flexibility to address changing circumstances.

• Phased implementation of programmes is acceptable, as long

  as the State is working towards the realisation of a programme to which everyone in need will ultimately have access.

• Rationing on the basis of behaviour (e.g. poor adherence to treatment) is justifiable
• A coordinated

  national is required to ensure equitable

  resource allocation roll-out across provinces

Once a decision to introduce ART has been taken it is the team’s view that six to nine months’ preparatory activities would be required before the first patients would start to receive medication on the

ground.

They recommend that the programme should be managed at a national level, and that Regional Training Centres should be established in order to train the vast numbers of doctors and health care workers who will need to be involved in the

delivery of HIV care. Renewed efforts to

encourage HIV testing will be accompanied by a scaling up of voluntary counseling and testing facilities.

In the first year of

the programme, a minimum of 80 centres divided between larger urban centres and less well resourced rural hospitals would need to join the programme in order to reach the goal of 50% ARV coverage by 2008.