1. Antiretroviral Treatment Costs in Mexico WHO/UNAIDS Workshop on Strategic Information for Anti-Retroviral Therapy Programmes 30 June to 2 July, 2003 Assessment of programme outcomes (economic) Sergio Bautista, Tania Dmytraczenko, Gilbert Kombe and Stefano Bertozzi

2. Presentation prepared by INSP, 30 June 2003 Purpose of the Study l To document—using a consistent methodology—the Mexican experience in HIV/AIDS treatment in 3 health subsystems –Ministry of Health (SSA) –Mexican Social Security Institutes (IMSS/ISSSTE) –National Institutes of Health (INS)

3. Presentation prepared by INSP, 30 June 2003 Specific Objectives of the Study l Identify patterns of HIV/AIDS care and treatment and related costs by type of therapy received –ARV triple therapy or not l To estimate the annual care costs per patient by Subsystems SSA, IMSS/ISSSTE, INS Care setting Inpatient, outpatient Level of care Specialized clinics, secondary and tertiary hospitals Disease stage CDC classification CD4

4. Presentation prepared by INSP, 30 June 2003 Background of HIV/AIDS in Mexico l Health spending is 5.3% of GDP –48% public / 52% private l Mexico ranks 13th globally and 3rd in the Americas in total reported HIV cases l Government estimates 64,000 AIDS cases and 177,000 HIV+ (2000) l Estimated Adult HIV prevalence 0.29% (1999)

5. Presentation prepared by INSP, 30 June 2003 Antiretroviral Treatment Issues l Mexico started providing ARVs in 1997 l By 1999, 55% of PLWA had regular access to ARVs l Access to ARV treatment and care varies considerably across socioeconomic groups l Current SSA services do not include ARVs although federal, states, local provide some coverage l Official norms state that all patients have the right to prescribed treatment at any facility and in any subsystem

6. Presentation prepared by INSP, 30 June 2003 Study Approach: Site selection l 11 health facilities were selected –SSA sites (5) –IMSS/ISSSTE sites (4) –INS sites (2) l Geographic Location –Mexico City (6) –Guadalajara (2) –Cuernavaca (2) l Level of Care –Highly specialized tertiary care facilities (3) –Secondary care facilities (7) –Specialized HIV clinic (1)

7. Presentation prepared by INSP, 30 June 2003 Study Approach: Sample size and eligibility l Convenience sample to reflect clinical and treatment criteria of interest: –ARV recipients (75%) –Not on ARVs (15%) –Deceased (10%) –1062 patients randomly selected, with sample stratification l Patients eligibility criteria –18 years or older at first consultation –Diagnosed with HIV and confirmed by Western, Elisa or laboratory culture, or symptomatic AIDS –Documented visit at a study site between 1/1/2000- 12/31/2001

8. Presentation prepared by INSP, 30 June 2003 Data Collection Instruments l Utilization (patient chart review) –Socio-demographic characteristics –Clinical events including outpatient, inpatient, labs, drugs, surgical procedures and interventions l Unit costs (facility questionnaire) –Existing unit cost data Facility- or subsystem-specific –Micro-costing of AIDS-specific diagnostic tests and drugs –Recurrent costs (except for AIDS-specific tests)

9. Presentation prepared by INSP, 30 June 2003 Data Collection Process l 5 trained teams, each composed of an economist and a MD/nurse l Data were captured retrospectively for a period of 3 years from the date of last consultation in the study period l Accuracy and reliability of data collection was strengthened with real-time data entry in the field and error checking interface

10. Presentation prepared by INSP, 30 June 2003 Characteristics of the Sample (n=1062)

11. Presentation prepared by INSP, 30 June 2003 Key Finding #1: There has been a progressive and rapid uptake of HAART Distribution of Patients by Type of Therapy

12. Presentation prepared by INSP, 30 June 2003 Key finding #2: Patients start treatment in advanced stages, improvement is gradual.003.002.001 0 2000150010005000 year –1 (n = 319) year 1 (n = 712) year 3 (n = 140) Distribution of CD4 Count

13. Presentation prepared by INSP, 30 June 2003 Key Finding #3: Total costs are substantially higher under HAART Average Annual per Patient Cost of Treatment

14. Presentation prepared by INSP, 30 June 2003 Key Finding #4: Lab tests and Outpatient visits are the largest contributors to treatment costs, excluding ARVs Average Annual per Patient Cost of Treatment, Excl. ARVs

15. Presentation prepared by INSP, 30 June 2003 Key Finding #5: Treatment costs are higher for patients in advanced stages of illness CD4 Range Outpatient visits Hospital days Lab tests OI drugs+ procedures Total 0-199 (n = 1016) 190104759911144 200-349 (n = 484) 2053660330874 350-499 (n = 270) 2792356621888 >500 (n = 306) 271849661836 Avg Annual per Patient Cost of Treatment Excl. ARVs, by CD4 count

16. Presentation prepared by INSP, 30 June 2003 Key Finding #6: Treatment costs are higher for patients in their last year of life Year Outpatient visits Hospital days Lab tests OI drugs+ procedures Total -1 (n = 23) 1529174911081668 1 (n = 51) 1897326992731893 2 (n = 30) 20410026432442092 3 (n = 13) 29679511112512452 Average Annual per Patient Cost of Treatment Excl. ARVs, During Last Year of Life

17. Presentation prepared by INSP, 30 June 2003 Limitations of the study l Used existing cost data, no micro-costing l Did not capture patients entire lifecycle

18. Presentation prepared by INSP, 30 June 2003 For future research l Costing patient’s life cycle –Update clinical data l Tracking patients –Movement across subsystems –Out-of-pocket expenditures l Care provider and facility characteristics l Effectiveness

19. Presentation prepared by INSP, 30 June 2003 Summary l Our findings are consistent with studies done in other countries –ARV comprises >75% of total treatment costs –Outpatient and monitoring costs increase as patients start triple therapy l Unlike Sub-Saharan African countries, hospitalization is not a big factor in Mexico l Costs associated with late initiation of treatment and during last year of life

20. Presentation prepared by INSP, 30 June 2003 Policy Recommendations I l Governments should be realistic about resource requirements of starting and scaling-up ARV treatment –Lab capacity –Human resource training l Countries should be prepared for the shift in care and treatment patterns of patients on HAART especially from inpatient to outpatient l Clinicians should clearly understand when to initiate and how to monitor patients on therapy

21. Presentation prepared by INSP, 30 June 2003 Policy Recommendations II l Estimating total cost of ARV treatment can significantly help countries plan for scaling-up –Negotiating drug prices l Medium to long-term prospective is needed for a full evaluation of program costs

22. Presentation prepared by INSP, 30 June 2003