The cost of providing hospital-based (early) antiretroviral treatment in Indonesia: what has changed in almost a decade?

17% of all people living with HIV in Indonesia who are in need of antiretroviral treatment (ART) actually receive the treatment. The cost of ART based on three CD4 cell count groups (e.g., 0-200, 201-350, >350 cells/mm3) in a main referral hospital in West Java, Indonesia, in 2011-2016 was compared to the results from a decade earlier in the same setting. Costs were estimated including resources used for opportunistic infection treatment, laboratory tests, and antiretroviral (ARV) drugs. For each group, we divided the costs into several periods: pre-ART, and every 6 months up to 24 months after onset of treatment. Before ART, costs were dominated by laboratory tests (>80%); ARV drugs were the main cost after treatment onset (>92%). Average cost of treatment per year was US$600 across all groups. Moreover, the patient cost to access ART (n = 49 patients) did not exceed 10% of their household monthly expenditures (i.e., 4%). The unit cost of providing ART per patient/year is half the cost under the previous treatment initiation guidelines. A lower ARV drug cost, more patients in higher CD4 cell-count groups, and lower viral load test cost characterize the current cost profile.

Costs of HIV/AIDS treatment in Indonesia by time of treatment and stage of disease.

BACKGROUND: We report an economic analysis of Human Immunodeficiency Virus (HIV) care and treatment in Indonesia to assess the options and limitations of costs reduction, improving access, and scaling up services. METHODS: We calculated the cost of providing HIV care and treatment in a main referral hospital in West Java, Indonesia from 2008 to 2010, differentiated by initiation of treatment at different CD4 cell count levels (0-50, 50-100, 100-150, 150-200, and >200 cells/mm(3)); time of treatment; HIV care and opportunistic infections cost components; and the costs of patients for seeking and undergoing care. DISCUSSION: Before antiretroviral treatment (ART) initiation, costs were dominated by laboratory tests (>65 %), and after initiation, by antiretroviral drugs (≥60 %). Average treatment costs per patient decreased with time on treatment (e.g. from US$580 per patient in the first 6 month to US$473 per patient in months 19-24 for those with CD4 cell counts under 50 cells/mm(3)). Higher CD4 cell counts at initiation resulted in lower laboratory and opportunistic infection treatment costs. Transportation cost dominated the costs of patients for seeking and undergoing care (>40 %). CONCLUSIONS: Costs of providing ART are highest during the early phase of treatment. Costs reductions can potentially be realized by early treatment initiation and applying alternative laboratory tests with caution. Scaling up ART at the community level in certain high prevalence settings may improve early uptake, adherence, and reduce transportation costs.

Cost-effectiveness of scaling up voluntary counselling and testing in West-Java, Indonesia.

AIM: to evaluate the costs-effectiveness of scaling up community-based VCT in West-Java. METHODS: the Asian epidemic model (AEM) and resource needs model (RNM) were used to calculate incremental costs per HIV infection averted and per disability-adjusted life years saved (DALYs). Locally monitored demographic, epidemiological behavior and cost data were used as model input. RESULTS: scaling up community-based VCT in West-Java will reduce the overall population prevalence by 36% in 2030 and costs US$248 per HIV infection averted and US$9.17 per DALY saved. Cost-effectiveness estimation were most sensitive to the impact of VCT on condom use and to the population size of clients of female sex workers (FSWs), but were overall robust. The total costs for scaling up community-based VCT range between US$1.3 and 3.8 million per year and require the number of VCT integrated clinics at public community health centers to increase from 73 in 2010 to 594 in 2030. CONCLUSION: scaling up community-based VCT seems both an effective and cost-effective intervention. However, in order to prioritize VCT in HIV/AIDS control in West-Java, issues of budget availability and organizational capacity should be addressed.

Costs and outcomes of VCT delivery models in the context of scaling up services in Indonesia.

OBJECTIVE: To evaluate costs and outcomes of voluntary counselling and testing (VCT) service delivery models in urban Indonesia. METHODS: We collected primary data on utilization, costs and outcomes of VCT services in a hospital clinic (568 clients), HIV community clinic (28 clients), sexually transmitted infection (STI) community clinic (784 clients) and prison clinic (574 clients) in Bandung, Indonesia, in the period January 2008-April 2009. RESULTS: The hospital clinic diagnosed the highest proportion and absolute number of HIV infections, but with the lowest average CD4 cell count and with the highest associated travelling and waiting time. The prison clinic detected fewer cases, but at an earlier stage, and all enrolled in HIV care. The community clinics detected the smallest number of cases, and only 0-8% enrolled in HIV care. The unit cost per VCT was highest in the hospital clinic (US$74), followed by the STI community clinic (US$65), the HIV community clinic (US$39) and the prison (US$23). CONCLUSION: We propose a reorientation of the delivery models for VCT and related HIV/AIDS treatment in this setting. We call for the scaling up of community clinics for VCT to improve access, promote earlier detection and to perform (early) treatment activities. This would reduce the burden of the hospital clinic to orient itself towards the treatment of AIDS patients. This is one of very few studies addressing this issue in Asia and the first of its kind in Indonesia, which has a rapidly growing HIV epidemic. The conceptual framework and overall conclusions may be relevant to other low-income settings.

Economic aspect of HIV/AIDS control and injecting drug use in Indonesia.

The HIV epidemic in Indonesia is among the fastest growing in Asia, and limited funding is available for HIV/AIDS control. This raises a number of important policy questions, about the adequacy of the level of available funding, the appropriateness of its use, and its financial sustainability. This paper puts these questions in context of the present Indonesian health system. The Indonesian health policy response to HIV/AIDS faces a number of challenges. The nature of the Indonesian HIV epidemic (increasing overall prevalence, with different epidemic profiles); the characteristics of the Indonesian health system (decentralized policy making, low and inequitable funding), and the low and highly internationalized funding of HIV/AIDS control (resulting in low service coverage and questions of sustainability) draw out a very specific health environment of HIV/AIDS. Economic analyses in health are instrumental to guide policy makers on the best use of scarce resources, and holds as such also large potential in this context. However, very little information on the costs and effects of HIV/AIDS control in Indonesia is available, and we call for a broader application.