The overall mean monthly cost of care per-person in our cohort of 966 HIV-infected adults was $98.1, of which antiretroviral drugs and personnel each accounted for one-third, and the remainder was evenly split between laboratory and radiological studies and capital costs. Of those on ART, costs were lowest for those entering the study on therapy and were highest in the patients initiating therapy, driven primarily by the laboratory costs prior to and during ARV initiation.
Patients entering this study were typical of patients in HIV treatment cohorts in sub-Saharan Africa, including a higher proportion of women and low baseline CD4 cell count.8
However, this study is one of few available cost studies from the region and is consistent with and extends the work of costing studies reported from public clinics in South Africa.9,10,11
A study of a public ART facility in Gugulethu reported an average cost of $1,186 per outpatient year for HIV care including ART, similar to our monthly average cost of $98.1 ($1,177 extrapolated to one year), and $119.0 for patients stable on ART ($1,428 for one year).9
Investigators in KwaZulu-Natal reported similar costs of ART for HIV-infected healthcare workers in two state-subsidised hospitals from about ZAR5,697 to ZAR8,762 (about $950-$1348).10
Lastly, a study of public clinics serving patients from Khayaletsha that used a less expensive source of antiretroviral drugs, reported lower yearly costs from $853 to $897 depending on baseline CD4 cell count and excluding inpatient care.11
Controlling costs will be critical as South Africa plans further expansion of ART to greater numbers of those not currently covered. We anticipate that personnel costs per patient will decline over time as provider expertise grows and task shifting to less expensive cadres of health care personnel occurs. Likewise, clinic and capital costs that are fixed despite increasing numbers of patients along with further integration of HIV services into primary healthcare settings will further reduce per-patient costs. Laboratory costs will likely remain elevated until greater numbers of competing CD4 and viral load technologies become available. In the meantime, further work needs be done to determine efficient, yet safe and effective monitoring algorithms for those on ART in limited-resource countries.
This study has several limitations. First, limited study budget led to the use of a relatively small sample on which to base individual patient utilisation in each group, although this sample had the benefit of being randomly selected. Additionally, the PHRU is a research site and may have higher health worker per-patient ratios and perform more investigations than public sector sites but the PHRU lends itself to a study of this nature as virtually all costs are borne by the institution and are therefore easily quantifiable. However, the FTE of 405% medical officers and primary health care nurses for nearly 1,000 patients is similar to staffing levels reported from public, private and non-governmental sectors.12
Also, the sponsor requires that generic antiretroviral drugs be approved or tentatively approved by the US Food and Drug Administration (FDA) and at the time of the study few FDA-approved generic formulations were available so the high antiretroviral prices used in this analysis reflect the purchase of brand-name drugs (including taxes and dispensing and packaging fees). The costs of first-line ARVs available in PEPFAR-funded programs have declined since this analysis was conducted as more generic antiretrovirals are approved by the FDA. The proportion of overall costs attributable to ART has also likely fallen, although may rise over time as patients transition to more expensive second-line regimens.
In conclusion, this study provides the actual costs of providing comprehensive HIV care and treatment for patients in Soweto, South Africa and demonstrated the high costs of human resources, ART, and laboratories (the latter costs are high at ART initiation) as a proportion of overall care costs. Along with further reductions in ART prices, we posit that integration of HIV care into primary healthcare services combined with task-shifting from doctors could optimise the limited human resources available and possibly assist in improving access to ART in South Africa.