Early treatment for infants is cost-effective

Polly Clayden, HIV i-Base

In 2008, the CHER trial demonstrated the effectiveness of universal early antiretroviral treatment for all infants regardless of CD4 or clinical stage.

This in turn influenced paediatric guidance worldwide.

For resource limited countries one of the main obstacles to the implementation of this strategy is cost.

In an oral late breaker, Gesine Meyer-Rath, showed findings from a cost comparison of early (from 6-12 weeks of age) vs deferred (based on CD4 percentage threshold or clinical criteria in accordance with previous WHO guidelines) initiation of antiretrovirals in young infants. The study also included a third arm that used a cost analysis of children in routine care in a standard HIV clinic.

The investigators used data describing outpatient/inpatient resource use during the first 12 months of life from 411 children in the CHER trial randomised to early (n=252) or deferred (n=125) treatment, and 130 infants initiating treatment at the Empilweni Clinic in Johannesburg between 2005 and 2007.

Patient level resource data was accessed from patient files and included information on: antiretroviral drugs, laboratory tests, clinic consultations and inpatient days.

Other costs were obtained from multiple sources: the government drug depot provided drug costs; the National Health Laboratory Service the cost of tests; staff salaries, equipment and overheads were accessed from clinic/hospital accounts and inpatient days calculated on a hospital cost per- patient day equivalent. Cost data was from 2009.

The evaluation revealed that early treatment for children was cost saving.

The cost of early treatment per child for a mean time in care of 10 months was $1349 compared to $2432 for deferred treatment (mean time in care 9 months) and $2908 for routine care (mean time in care 3 months). Dr Meyer-Rath explained that the difference in time in care across the three scenarios was due to higher loss to follow up in the deferred arm and higher loss to follow up and later presentation in the routine care arm.

The differences in cost were largely due to differences in frequency of hospitalistion, which was an average of 2, 7 and 13 days and a maximum of 68, 84 and 121 days per child in the early, deferred and routine care arms respectively.

The proportion of the total cost spent on inpatient care rose from 26% in the early therapy arm to 84% in the routine care arm.

Details of the cost per child are shown in Table one.

Table one: Cost per child (2009 US dollars)

Scenario Early treatment Deferred treatment Routine care
Mean time in care 10 months 9 months 3 months
Cost item Cost $ % Cost $ % Cost $ %
Antiretrovirals 245 18 127 5 35 1
Diagnostics 243 18 341 14 56 2
Staff/overheads 515 38 726 30 266 9
Total out-patient cost 1004 74 1195 49 359 12
Total in-patient cost 346 26 1237 51 2523 84
Total cost 1349 2432 2908
95% CI 1244-1464 1982-2889 2273-3743

The investigators estimated that in South Africa the cost of 90% coverage early treatment for 103,000 infants in 2010/11 would be $67 million, and for 202,000 infants in 2012/13 would be $133 million. This represents 6-7% of the total cost of the national antiretroviral treatment programme and 1% of the public health service budget.

Dr Math-Reyer remarked that the cost of the paediatric programme, “will always be dwarfed by the cost of the adult programme, regardless of eligibility criteria.”

Among the limitations of the analysis she noted that the cost of screening HIV-exposed children was not included and would add about $300 per child.

Reference: Meyer-Rath G et al. The cost of early vs. deferred paediatric antiretroviral treatment in South Africa – a comparative economic analysis of the first year of the CHER trial. 18th IAS Conference, 18–23 July 2010, Vienna. Oral abstract THLBB103.

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