The high cost of non-antiretroviral medicines used by people with AIDS in Côte d’Ivoire

In the Côte d’Ivoire, the cost of non-antiretroviral medicines used to treat illnesses in people with HIV increases dramatically as their CD4 cell count falls, and when CD4 cell counts are below 200, those yearly costs commonly exceed the yearly cost of generic antiretroviral therapy (ART), according to a study published in last month’s JAIDS.

Although this study did not actually look at the cost of medicines in people on ART, the researchers calculated "that successful ART, which would stabilise the CD4 count above 500 cells, could reduce by roughly 5-fold the cost of non-antiretroviral drugs in sub-Saharan African HIV-infected adults."

In addition to more widespread use of ART, the authors believe that greater efforts are needed to reduce the costs of non-antiretroviral drugs, in particular, the costs of antibiotics and antifungals.

Drug costs in Africa

While treatment advocacy and competition among brand and generic drug manufacturers has dramatically lowered the price of ART for the most resource-poor countries, relatively little attention has been paid to the costs of other medications commonly used in the care of people with HIV.

But in sub-Saharan Africa, people with HIV are at an increased risk to a wide range of bacterial or endemic infections, such as tuberculosis, malaria, various tropical diseases and severe bacterial infections that may cut their lives short long before they qualify for antiretroviral treatment. The survival of people with HIV often depends on access to medicines that are not considered as classic 'HIV drugs'.

The study

So researchers in the Côte d’Ivoire conducted a study to better identify how much various nonantiretroviral drugs contribute to the overall cost of care, by estimating the consumption and cost of nonantiretroviral drugs in a cohort of HIV-infected adults followed at different stages of immunosuppression in Côte d’Ivoire between 1996 and 2001.

The study cohort was drawn from two ANRS studies conducted in Abidjan, a trial of cotrimoxazole and a maternal HIV transmission study. Any medication that study doctors prescribed for participants in those studies was dispensed by the study centre pharmacy and each dispensation was recorded in the cohort database. The costs 'per person per year' (CPPY) were calculated and analysed by drug characteristics, and by patients’ baseline CD4 cell count.

Results

A cohort of 592 HIV-infected adults were followed for 1292 person-years. Over 58,000 drug dispensations occurred over the course of the study and were included in the study. The pharmacy purchased these medicines from a variety of sources, including non-governmental organisations, the public sector (which procured drugs from the national drug supplier or generic sources) and private sector (which obtained medications from local wholesalers and pharmacies). Although only 17% of the drugs were purchased from the private sector, these purchased accounted for about 42% of the overall cost.

The breakdown of costs in US dollars, overall and by baseline CD4 cell count were as follows:

• The mean CPPY (MCPPY) was $198 overall
• $83 for CD4 counts ≥500 cells
• $101 for 350 to 499 CD4 cells
• $186 for 200 to 349 CD4 cells
• $233 for 100 to 199 CD4 cells and
• $459 in patients with CD4 cell counts

Treatments for infectious disease accounted for almost one third of the prescriptions, but two thirds of the overall cost. These medicines were chiefly antifungals (32.7% of the total costs) and antibiotics (26.4% of the total costs). The most frequently prescribed class of drugs (analgesics and anti-inflammatories) accounted for only 4.9% of the overall cost.

However, the relative frequency of drug use varied by baseline CD4 cell counts. In patients with CD4 cell counts over 500, the most costly classes of drugs were antibiotics (MCPPY $30), antifungals ($16), and analgesics ($6), compared to antifungals ($208), antibiotics ($49), and antiparasitics ($31) in patients with CD4 cell counts

Study limitations and discussion

These data were drawn from only one setting, and drug prices differ from country to country. Also, the prices in this study are a little dated. Researchers also had no way of recording the cost drugs that patients could have bought in other settings.

However, most of the patients’ medicines were probably obtained through the clinical trial pharmacy, since the drugs were dispensed free of charge. Yet, for this reason alone, these data are not completely representative of the situation of all HIV-infected patients and all HIV centre in sub-Saharan Africa.

"These conditions differ substantially from those faced by most patients in rural and urban populations in sub-Saharan African countries," the study author's note. "Such a favorable context could have increased the demand for health care and the number of prescriptions, leading to an overestimation of the costs and pharmaceutic utilisation. Conversely, the early treatment of diseases could have avoided later complications that would have required more costly treatments."

Nevertheless, the study highlights some important issues. For example, in people with the most advanced disease, antiretroviral therapy becomes cost-effective, simply by obviating the need for expensive antifungal medications.

However, because people with higher CD4 cell counts still require frequent treatment for bacterial infections, the authors conclude that "in settings where ART is largely available, reducing the cost of nonantiretroviral drugs would thus require lowering the price of the most costly drugs in patients with a high CD4 cell count, starting with antibacterial drugs.. In the HAART era, antibacterial drugs could become the second group of drugs for which it is most worth fighting for price reductions."