Cost breakdown perspective Costs are considered from a supplier perspective, with publichealth care facilities involved in HIV/AIDS therapy delivery,including province/city hospitals, H
Trang 1AIDS Acquired immunodeficiency syndrome
ART Antiretroviral therapy
ICER Incremental cost-effectiveness ratio
PEPFAR President’s Emergency Plan for AIDS ReliefQALY Quality adjusted life year
Trang 2In the preparation for resources pooling plans for the HIV/AIDScare and treatment program within the National Strategy forHIV/AIDS control by 2020 and vision to 2030, information onHIV/AIDS treatment costs is a vital input for the estimation offinancial resources needed to make sure that the care and treatmentprogram is well-designed and viable
In ARV therapy, treatment timing may have massive bearing onthe treatment outcomes and access to the program offerings TheWorld Health Organization recommends early treatment forHIV/AIDS patients, at initiation of CD4<350 cells/mm3 Earlyrecognition and treatment however remain a challenge in Vietnam aspatients often seek medical help when their condition has progressed
to a CD4 cell count of less than 100 cells/mm3 In that context,defining the best timing for treatment amid resource constraintsremains a question to be answered by managers of the HIV/AIDStherapy program in Vietnam
The “HIV/AIDS therapy costing and cost-effectiveness by
CD4 cell count in selected provinces” review aims to cover the
* New inputs of the review
- The review provides a comprehensive picture of HIV/AIDStherapy costs in 10 provinces and cities in Vietnam in 2009-2010 Thestudy findings on HIV/AIDS treatment costs are highly representativeand may be used for the HIV/AIDS therapy program in Vietnam Thereview looks at the changes in HIV/AIDS treatment costs depending
on relevant factors and determines the proportions of different costcomponents by treatment stages
- This is the first work on cost-effectiveness in the field of HIV/AIDS treatment The study is a combination of a biological reviewand a health economics review The study finds the relationshipbetween the costs and effectiveness of HIV/AIDS treatment bydifferent CD4 cell counts, where effectiveness is converted andmeasured by the added life years at different CD4 levels
* How the report is structured
Trang 3The study has 130 pages and 4 chapters, including Introduction:
2 pages, Chapter 1 Overview: 32 pages, Chapter 2 Subject andmethodology: 25 pages, Chapter 3 Findings: 43 pages, Chapter 4.Discussion: 25 pages, Conclusion: 2 pages, Recommendations: 1page, 39 tables, 39 charts, 7 figures and 150 references, 22 inVietnamese and 128 in English
Chapter 1 OVERVIEW I.1 HIV/AIDS treatment and HIV/AIDS treatment models in the
world and Vietnam
I.1.1.The HIV/AIDS treatment context and global ARV therapy
needs
By the end of 2011, as many as 8 million people in low andmiddle income countries have had access to antiretroviral drugs,which was a 25 fold increase over 2002 While many HIV-positivepeople have been admitted to the therapy program, as they oftenresorted to medical help at a later stage, their CD4 cell counts wereoften much lower than the level recommended by the World HealthOrganization for ideal therapy commencement
I.1.2.ARV therapy need in Vietnam
As the number of HIV-positive people is increasing, so is theneed for HIV/AIDS treatment and care The need for HIV/AIDStreatment for 2012-2015 is estimated as follows: 2012 – 119,298people; 2013 – 129,379 people; 2014 – 139,646 people; 2015 –150,120 people; 2020 projection – 195,380 people
1.1.3 Existing HIV/AIDS treatment models around the world
1.1.3.1 Centralized treatment at health care facilities
1.1.3.2 Community-based HIV/AIDS treatment
1.1.4 HIV/AIDS treatment models available in Vietnam
1.1.4.1 HIV/AIDS management and treatment within the health system
a) At central level hospitals
b) At province/district general hospitals
c) At province/district health centers
1.1.4.2 HIV/AIDS treatment at institutions outside the health system
a) At penitentiaries and 05/06 centers
b) Treatment at social welfare facilities
c) Piloting models: the treatment initiative 2.0 andcommune/ward-based basic therapeutic service delivery
1.1.5 Cost-effectiveness analysis
Trang 4Cost-effectiveness analyses help estimating costs perincremental effectiveness unit (ICER) These analyses may be used tocompare between national or regional interventions The World HealthOrganization introduces rules on how to determine cost-effectivenessratings:
- ICER < GDP per capita: very cost-effective intervention
- ICER of 1-3 GDP per capita: cost-effective intervention
- ICER > 3 GDP per capita: Cost-ineffective intervention
on first line ART from the second year and those on second-line ART,with periods in treatment meeting the timing requirements for costing
Trang 5An inpatient episode is the entire amount of time following apatient’s admission to discharge for all patients known to be HIV-positive before or during inpatient treatment.
Outpatient costs are estimated based on the cost per patient per year
Outpatient costs include counseling, testing, medication,opportunist infection treatment, human resources, overheads andfacility/equipment depreciation divided by the following periods:
- Pre-ART treatment (cost/person/year)
- First line ART Year 1 (cost/person/year)
- First line ART From Year 2 (cost/person/year)
- Second line ART (cost/person/year)
Outpatient treatment is identified based on the HIV/AIDStreatment protocol using antiretroviral drugs (ARV) issued as part of
Decision 3003/2006/QĐ-BYT of June 9, 2009, of the Ministry of
Health, providing guidelines on HIV/AIDS diagnostics and treatment
2.1.2.2 Cost breakdown perspective
Costs are considered from a supplier perspective, with publichealth care facilities involved in HIV/AIDS therapy delivery,including province/city hospitals, HIV/AIDS centers and districthealth centers
2.1.2.3 Costing methodology
Costing methodology is hybrid of top-down cost analysis (stepdown) for labor, operating costs, depreciation, and a bottom-upapproach, which involves detailed breakdown for medication,supplies, diagnostic imaging and testing The method allowsestimation of average treatment costs by different stages
2.1.2.4 Sample size
20 adult medical records with different treatment stages areselected From 16 outpatient clinics, the total number of outpatientnon-second-line regimen medical records selected is 960 From 5second-line regimen clinics, a sample of 150 adult patients on asecond-line regimen is selected
For inpatients, 40 adult medical records are collected from everyprovincial and central level health care facilities There are no patients
of this kind at the district level From the 8 inpatient clinics in thesample, a total of 320 inpatient medical records are selected
The gross number of medical records collected for costing is
1430 Of these, 1401 inpatient and outpatient HIV/AIDS medicalrecords have been processed
2.1.3 Study parameters
Trang 6- Participant background indicators in the study includedemography, median CD4, percentages of patients by different CD4counts and distribution of patients by levels of care and types ofclinics.
- Indicators for HIV/AIDS inpatient and outpatient costs andchanges of therapeutic expenses depending on relevant determinantsand the proportions of cost components include 27 items
2.1.4 Toolkit and materials
The data collecting toolkit consists of: (i) a form to collectproviders’ outputs; (ii) a form to collect staffing cost data; (iii) a form
to collect overheads data; (iv) a form to collect depreciation cost data;(v) a form to collect inpatient care cost data; and (v) a form to collectoutpatient care cost data
2.2 Cost-effectiveness analysis by different CD4 basiline
2.2.1 Sites, subjects, locations and timing
To estimate effectiveness as gained life years for patients withdifferent CD4 initiation, secondary data review is conducted usingclinical and immunological response studies for adult patients on ART
in Vietnam to understand the changes in the patients’ survival bydifferent CD4 baseline
Clinical and immunological response studies on adult patients onART in Vietnam are conducted on 7758 adult HIV/AIDS patients.The studies take place at 30 clinics randomly selected from 120facilities nationwide having 50 or more patients on ART These 30clinics are located in 16 provinces/cities: Hanoi, Hung Yen, ThaiNguyen, Bac Giang, Vinh Phuc, Bac Can, Lang Son, Dien Bien,Quang Ninh, Haiphong, Thanh Hoa, Nghe An, Thai Binh, BinhDuong, Long An and Ho Chi Minh City
The study completed in 2010 was designed as a cohort study,collecting retrospective data from medical records selected at theclinics
2.2.2 Methodology
2.2.2.1 Study design
HIV/AIDS treatment efficacy by CD4 baseline is measured bythe ratio of cost to treatment efficacy Cost parameters are extractedfrom the results of component 1 and the treatment efficacy ismeasured by the life years gained by different CD4 baseline calculatedbased on the patient’s survival chance by CD4 counts
Survival chance by CD4 levels: The Kaplan Meier survival
estimator is used to calculate the survival chance of patients in early
Trang 7treatment (CD4 >=100 cells/mm3) and patients in late treatment (CD4
<100 cells/mm3)
Mortality risk of participants in the sample: The Cox
multiparameter regression model is used to compare mortality-relateddeterminants
The cost-effectiveness of interventions is measured by the
incremental cost-effectiveness ratio (ICER) by different CD4 levels
Chapter III FINDINGS 3.1 Situational analysis of HIV/AIDS therapy costs in selected provinces in Vietnam for 2009-2010
3.1.1 Participant background
In total, there are 1401 participants, including inpatients andoutpatients Of these, 319 people are inpatients and 1082 areoutpatients (305 pre-ART patients, 332 first year first line ARVpatients, 323 first line ARV patients from the second year and 122second line ARV patients)
Male participants account for 64% of the total, with the other36% being women Mean ages of participants was 33.6 year (SE + 0.2year)
3.1.2 HIV/AIDS inpatient costs
3.1.2.1 HIV/AIDS inpatient costs and changes in treatment costs
by relevant determinants
The HIV/AIDS inpatient cost is VND 4,341,253 per session (SE+ VND 299,367)
a) HIV/AIDS inpatient cost and average length of stay at clinics
The average treatment cost/length of stay in national andmunicipal level hospitals are higher than those of lower level hospitals(Figure 3.3)
Trang 8Figure 3.3 HIV/AIDS inpatient cost and average LOSat clinics
b) Percentage of opportunistic infections and respective treatment costs
Respiratory tract infection is the most prevalent opportunisticinfection in the sample, followed by tuberculosis, diarrhea, pathogenicfungi and some other symptoms The most expensive treatment cost ismore than VND 10 million for such opportunist infections astoxoplasmosis, though this disease is not as prevalent as the mostcommon conditions of respiratory infections and tuberculosis, whichboth cost approximately VND 3.7 million for a treatment session
c) Changes in treatment costs by gender and age group
Table 3.6 &3.7 HIV/AIDS inpatient cost by gender, age group
Description N % AverageLOS
(days)
Meancost/episode(VND)
Meancost/day(VND)
Cost
Cost (VND)
National Tropical Diseases Hospital
HCMC Tropical Diseases Hospital
Dong Da Hospital
Czech Hospital
Vietnam-Ninh Binh General Hospital
Hai Duong AIDS Center
Dong Thap General Hospital
Can Tho General Hospital
Diherria P
Maneifei
Unidentifed group Tuberculo
sis
Trang 9d) Changes in treatment cost by conditions
42% of the patients in the sample are in seriousimmunodeficiency conditions with CD4 count of less than 50cells/mm3 The treatment cost for these patients is twice that ofpatients with improved immunological conditions
Table 3.8 HIV/AIDS inpatient costs by different CD4 levels
CD4
levels at
AverageLOS(days)
Meancost/episode(VND)
Meancost/day(VND)
101 cells/mm3 and those with CD4 of 101-200 cells/mm3
e) Changes in treatment cost by levels of care
Table 3.9 HIV/AIDS inpatient costs by levels of care
Patient
distribution by N %
AverageLOS(days)
Meancost/episode(VND)
Mean cost/day(VND)
Provincial level 195 61.1 11 3,225,616 293,238Provincial AIDS
The mean cost at national level inpatient clinics is 2.5 timeshigher than that of provincial level clinics The mean inpatient cost atprovincial AIDS centers is higher than that of other provincial levelclinics
f) Changes in treatment cost by regions
Trang 10Table 3.10 HIV/AIDS inpatient costs by regions
(days)
Meancost/episode(VND)
Meancost/day(VND)
The HIV/AIDS treatment cost in the North is VND4,576,128/patient/treatment session, which is higher than the VND3,930,222/patient/session in the South
g) Changes in treatment costs by ART status
Table 3.11 HIV/AIDS inpatient costs by ART status
ART status N % AverageLOS
(days)
Meancost/episode(VND)
Meancost/day(VND)
Only 33.5% of inpatients in the sample are on ART, and theaverage treatment costs for patients on ART are higher (66.5%) Theaverage treatment cost for patients on ART is higher than that of thosenot on ART
h) Changes in treatment cost by treatment outcomes
Table 3.12 HIV/AIDS inpatient costs by treatment outcomes
Treatment
AverageLOS(days)
Meancost/episode(VND)
Mean cost/day(VND)
Trang 119,264,868/patient/stay, which is nearly twice that of cured cases andnearly 2.5 times higher than improved cases.
i) Changes in treatment cost by financial protection levels
Table 3.14 HIV/AIDS inpatient costs by insurance status
Description N % AverageLOS
(days)
Meancost/episode(VND)
Meancost/day(VND)
Without insurance 287 91.7 16 4,430,215 276,888Only 8.3% of the patients in the sample have a health insurancecard, and the average treatment cost for this group is lower than that ofthose without a health insurance card, who account for 91.7% of thetotal
3.1.2.2 Percentages of cost components in HIV/AIDS inpatient cost
Figure 3.5 Components of HIV/AIDS inpatient cost
In the structure of HIV/AIDS inpatient cost, medicines, supplies,subclinical services and labor are the key items that constitute the totalcost, accounting for about 70-85% of the grand total The proportions
of medicines, supplies and subclinical services in the cost structuredecline as the immunological status is improved
National Tropical Diseases Hospital
HCMC Tropical Diseases Hospital
Dong Da Hospital Vietnam-Czech
Hospital
Ninh Binh General Hospital
Hai Duong AIDS Center
Dong Thap General Hospital
Can Tho General Hospital
Overhead s
Depreciation Labor Paraclinical Medicines and supplies
Trang 12Figure 3.6 Percentages of cost items by CD4 levels
3.1.3 HIV/AIDS outpatient cost
3.1.3.1 HIV/AIDS outpatient cost and changes in treatment cost
by determinants
The HIV/AIDS outpatient costs per patient a year are VND2,138,931 (SE = + VND 1,548,073) for pre-ART patients; VND6,421,893 (SE = + VND 420,366) for first year first line ARVpatients, and VND 6,005,153 (SE = + VND 209.296) for first lineARV patients from the second year onward Second line ART costsVND 28,236,312 (SE= + VND 1,207.563)
a) Treatment cost by gender and age group
The mean costs for the pre-ART group are VND2,189,339/patient/year for men and VND 2,087,011/patient/year forwomen The mean cost for first line ART in year 1 are VND6,391,088/patient/year for men and VND 6,490,059/patient/year forwomen The mean costs for the first line ART from year 2 are VND6,105,861/patient/year for men and VND 5,814,251/patient/year forwomen The mean cost for the second line ART are VND 28,259,482/patient/year for men and VND 28,125,829/patient/year forwomen.The highest mean cost in PRE-ART is at 41-45 (VND3.647.230/person/year) and the lowest cost is at 36-40 (VND1.552.160/person/year) The highest mean cost in first line ART year
1 is at 31-35(VND 6.903.630/person/year) and the lowest cost is at41-45 (VND 5.433.696/persone/year) The highest mean cost in firstline ART from year 2 is at over 46 (VND 7.012.858 per person/year)
và the lowest cost is at 41-45 (VND 5.202.876/person/year) Thehighest mean cost in second line ART is at below 25 (VND31.452.388/person/year) and the lowest cost is at 41-45 (VND25.517.383 /person/year)
b) Treatment cost by CD4 levels
Overheads Labor Medicines, supplies
Depreciation Paraclinical