Woman holds AIDS ribbon. Picture: Supplied

With almost four million patients, the South African national public-sector antiretroviral treatment programme is the largest in the world.

And increases in antiretroviral treatment costs for HIV/AIDS patients in the country have been offset by the introduction of cost-saving measures and universal treatment, according to a study led by a researcher from the Health Economics and Epidemiology Research Office (HE2RO), a collaboration between Wits’ School of Medicine and Boston University’s School of Public Health.
 
The study, published this month in PLoS­ ONE, an internationally regarded science and medical journal, analysed the cost of the national South African HIV treatment programme and estimated the expected cost and impact of treatment guidelines issued by the World Health Organization (WHO) between 2009 and 2016. Those guidelines aimed to increase eligibility for antiretroviral treatment (ART) whilst providing better drugs for patients.
 
The local ARV programme is also one of the few in Africa funded mostly from domestic resources, rather than by international donors. The cost of this programme remains one of the major challenges confronting the South African government. Over the last eight years, the National Department of Health faced the double challenge of expanding eligibility for and coverage of the HIV treatment programme while simultaneously reducing the per-person cost of treatment.
 
Results
 
The researchers worked with the South African government to analyse the costs and impacts of the HIV programme since 2009. They constructed the National ART Cost Model (NACM), a budget impact model, to capture guideline changes suggested by the World Health Organization and to calculate how to offset the additional costs of the changing guidelines through implementing procurement, health systems and technical improvements.
 
The researchers found that certain cost-saving measures, such as introducing task-shifting from doctors to nurses and opening the drug tenders for international competition, more than offset the increases in treatment costs due to the guidelines suggested by WHO in 2010. In addition, the introduction of adherence clubs for stable patients on ART could offset some of the costs of universal treatment, introduced in September 2016. The researchers predicted a reduction in the annual costs of by 2024 as the programme reaches universal coverage and successful, large-scale treatment reduces new HIV infections.
 
“Annual budgets for ART will continue to increase in South Africa until universal treatment is taken to full scale,” the authors wrote. “Model results were instrumental in changing South African ART guidelines, more than tripling the population on treatment between 2009 and 2017, and reducing the per-patient cost of treatment by 64%.”
 
Good maths; good policy

 
“We discovered that good maths leads to good policy,” explains lead author Gesine Meyer-Rath, research assistant professor of global health at Boston University who is based in South Africa. “The paper summarises our close collaboration with the South African Department of Health and Treasury over the last eight years which resulted in us helping to change public policy - an unusual situation for an academic,” she says. “Many factors have contributed to the remarkable expansion of HIV treatment in South Africa over the last decade, with the political will demonstrated by the current Minister of Health being the most important. Our model supported the process by allowing the Department of Health to submit budget bids to Treasury that were based on precise estimates of patients in need of treatment and overall costs.”
 
“Since 2009 HE2RO has supported the Department with calculating the required budget for various HIV interventions, in particular ART,” says Nthabiseng Khoza, Director: HIV/AIDS Conditional Grant at the National Department of Health. “Resource mobilisation was not an easy process without knowing how much was required. HE2RO designed and introduced the NACM. This was a major step in helping the department to answer key questions that were asked by all funders, including National Treasury. Audit outcomes for the department have improved as a result of this partnership.”
 
The researchers found that overall, the annual cost for ART would continue to increase until universal treatment is implemented and reaches full coverage around 2024. Universal HIV treatment became policy in South Africa in September 2016, in part based on the model findings.
 
Co-authors include:
Leigh F. Johnson, senior researcher at the University of Cape Town;
Yogan Pillay, deputy director general for special programmes at the South African National Department of Health;
Mark Blecher, chief director for health and social development at the South African National Treasury;
Alana Brennan, global health instructor at Boston University;
Lawrence Long, research assistant professor at Boston University;
Matthew P. Fox, professor of epidemiology at Boston University;
Sydney Rosen, research professor of global health at Boston University;
Harry Moultrie, senior researcher at the University of the Witwatersrand; and
Ian Sanne, associate professor of internal medicine and infectious diseases at the University of the Witwatersrand. 

(Adapted from a press release)