Retention in care and outpatient costs for children receiving antiretroviral therapy in Zambia: a retrospective cohort analysis
Callie A Scott, Hari Iyer, Deophine Lembela Bwalya, Kelly McCoy, Gesine Meyer-Rath, Crispin Moyo, Carolyn Bolton-Moore, Bruce Larson, Sydney Rosen, Callie A Scott, Hari Iyer, Deophine Lembela Bwalya, Kelly McCoy, Gesine Meyer-Rath, Crispin Moyo, Carolyn Bolton-Moore, Bruce Larson, Sydney Rosen
Abstract
Background: There are few published estimates of the cost of pediatric antiretroviral therapy (ART) in Africa. Our objective was to estimate the outpatient cost of providing ART to children remaining in care at six public sector clinics in Zambia during the first three years after ART initiation, stratified by service delivery site and time on treatment.
Methods: Data on resource utilization (drugs, diagnostics, outpatient visits, fixed costs) and treatment outcomes (in care, died, lost to follow up) were extracted from medical records for 1,334 children at six sites who initiated ART at <15 years of age between 2006 and 2011. Fixed and variable unit costs (reported in 2011 USD) were estimated from the provider's perspective using site level data.
Results: Median age at ART initiation was 4.0 years; median CD4 percentage was 14%. One year after ART initiation, 73% of patients remained in care, ranging from 60% to 91% depending on site. The average annual outpatient cost per patient remaining in care was $209 (95% CI, $199-$219), ranging from $116 (95% CI, $107-$126) to $516 (95% CI, $499-$533) depending on site. Average annual costs decreased as time on treatment increased. Antiretroviral drugs were the largest component of all outpatient costs (>50%) at four sites. At the two remaining sites, outpatient visits and fixed costs together accounted for >50% of outpatient costs. The distribution of costs is slightly skewed, with median costs 3% to 13% lower than average costs during the first year after ART initiation depending on site.
Conclusions: Outpatient costs for children initiating ART in Zambia are low and comparable to reported outpatient costs for adults. Outpatient costs and retention in care vary widely by site, suggesting opportunities for efficiency gains. Taking advantage of such opportunities will help ensure that targets for pediatric treatment coverage can be met.
Conflict of interest statement
Competing Interests: The authors have declared that no competing interests exist.
References
- World Health Organization (2011) Global HIV/AIDS response: epidemic update and health sector progress towards universal access: progress report 2011. Available at: . Accessed: 3 September 2012.
- Ciaranello AL, Chang Y, Margulis AV, Bernstein A, Bassett IV, et al. (2009) Effectiveness of pediatric antiretroviral therapy in resource-limited settings: a systematic review and meta-analysis. Clin Infect Dis 49: 1915–1927.
- Bolton-Moore C, Mubiana-Mbewe M, Cantrell RA, Chintu N, Stringer EM, et al. (2007) Clinical outcomes and CD4 cell response in children receiving antiretroviral therapy at primary health care facilities in Zambia. JAMA 298: 1888–1899.
- van Dijk JH, Sutcliffe CG, Munsanje B, Sinywimaanzi P, Hamangaba F, et al. (2011) HIV-infected children in rural Zambia achieve good immunologic and virologic outcomes two years after initiating antiretroviral therapy. PLoS One 6: e19006.
- Galarraga O, Wirtz VJ, Figueroa-Lara A, Santa-Ana-Tellez Y, Coulibaly I, et al. (2011) Unit costs for delivery of antiretroviral treatment and prevention of mother-to-child transmission of HIV: a systematic review for low- and middle-income countries. Pharmacoeconomics 29: 579–599.
- Menzies NA, Berruti AA, Berzon R, Filler S, Ferris R, et al. (2011) The cost of providing comprehensive HIV treatment in PEPFAR-supported programs. AIDS 25: 1753–1760.
- Marques HH, Couttolenc BF, Latorre Mdo R, Aquino MZ, Aveiro MI, et al. (2007) Costs of care provided in a university hospital for children exposed to or infected with the HIV/AIDS. Cad Saude Publica 23 Suppl 3S402–413.
- Meyer-Rath G, Brennan A, Long L, Ndibongo B, Technau K, et al. (2013) Cost and outcomes of paediatric antiretroviral treatment in South Africa. AIDS 27: 243–250.
- Rosen S, Long L, Sanne I (2008) The outcomes and outpatient costs of different models of antiretroviral treatment delivery in South Africa. Trop Med Int Health 13: 1005–1015.
- Long L, Fox M, Sanne I, Rosen S (2010) The high cost of second-line antiretroviral therapy for HIV/AIDS in South Africa. AIDS 24: 915–919.
- Government of the Republic of Zambia, Ministry of Health (2007) Zambian guidelines for antiretroviral therapy of HIV infection in infants and children: towards universal access, 2007. Available: . Accessed 3 September 2012.
- International Monetary Fund (2012) World Economic Outlook Database, April 2012. Available: . Accessed 3 September 2012.
- Oanda Corporation (2012) Historical exchange rates: daily midpoint rates: January 1, 2011 to December 31, 2011. Available: . Accessed 2 March 2012.
- Weinstein MC, Siegel JE, Gold MR, Kamlet MS, Russell LB (1996) Recommendations of the Panel on Cost-effectiveness in Health and Medicine. JAMA 276: 1253–1258.
- World Health Organization (2011) Global price reporting mechanism. Available: . Accessed 22 March 2012.
- Government of the Republic of Zambia, Ministry of Health. Medical Stores Limited: 2010 catalogue. Lusaka, Zambia: Government of the Republic of Zambia, Ministry of Health; 2010.
- Bratt JH, Torpey K, Kabaso M, Gondwe Y (2011) Costs of HIV/AIDS outpatient services delivered through Zambian public health facilities. Trop Med Int Health 16: 110–118.
- Tagar E, Sundaram M, Condliffe K, Over M, Assefa Y, et al. The cost of scaling-up antiretroviral treatment: a costing study in 161 representative facilities in Ethiopia, Malawi, Rwanda and Zambia [abstract THPE738]; XIX International AIDS Conference, 22–27 July 2012; Washington, DC, USA.
- Marseille E, Giganti MJ, Mwango A, Chisembele-Taylor A, Mulenga L, et al. (2012) Taking ART to scale: determinants of the cost and cost-effectiveness of antiretroviral therapy in 45 clinical sites in Zambia. PLoS One 7: e51993.
Source: PubMed