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The President announced in December 2009 that the criteria for initiating ART in the South African public sector would be increased from 200 cells/µl to 350 cells/µl which means that more HIV-infected people will be able to get treatment.

For those who have to plan and budget resources, it is important to find out as much as possible about the costs of providing HIV health care and how these change over time. However, few studies have investigated these costs, particularly those incurred before an individual starts taking ART.

Recent research has analysed the direct costs of treating more than 100,000 HIV-infected adults enrolled in a private HIV care programme in South Africa from 3 years before they started ART until up to 5 years after ART initiation. Within this programme, individuals began to receive ART when their CD4 cell count fell below 350 cells/ml. The ART initiation criteria used in the private sector study setting is thus the same as the recently adjusted criterion in the public sector.

Findings from the study have policy implications:

To reduce early costs of ART:

Start ART at higher CD4 cell counts.

Results suggest that starting ART once the patient is severely immune compromised (e.g. at CD4<50 cells/µl) is bad for the patient and bad for the budget. Recent policy announcements about when to start ART implies that more patients in South Africa will get treatment, and there could be a reduction in the early costs of ART programmes. However, starting ART earlier is likely to lead to overall cost increases in the long run as patients could live for longer.

Identify HIV infection at an earlier stage.

To reduce later costs of ART:

Invest in systems to monitor ART adherence and implement effective interventions if patients do not take their drugs regularly.

This blog is based on a journal article  titled “Early and Late Direct Costs in a Southern African Antiretroviral Treatment Programme: A Retrospective Cohort Analysis”  published in PLoS Medicine 6(12) in 2009 and is freely available online at: www.plosmedicine.org.

Alternatively, download the policy brief based on this article.