Nevertheless, in contrast to most countries in Eastern and Southern Africa, Western African countries are generally facing relatively low HIV prevalence levels. Most important are the distorted incentives for patients. Data entries from one researcher were checked by another researcher working independently, and discrepancies resolved by reference to the original paper. Our review has a number of other limitations. What’s new about Mylan’s Cimduo is that it combines two medicines available in generic form: tenofovir and lamivudine. Oh, and the price — together the two generics add up to $1,635 per year. https://doi.org/10.1371/journal.pone.0210497, Editor: Nicky McCreesh, London School of Hygiene and Tropical Medicine, UNITED KINGDOM, Received: August 10, 2018; Accepted: December 23, 2018; Published: February 26, 2019. This puts ARV treatment within reach of many more people. HIV treatment is made up of three or more antiretroviral drugs normally combined into one pill. Strategic Development Consultants, Pietermaritzburg, South Africa. While the importance of the paper as one of very few sources of ART cost data in the early years of the public-sector ART programme cannot be overstated, it was still used as a cost source for papers published as recently as 2016 [47–49]- at which stage the data used in the models was over 10 years old. According to the article, Cipla was offering to sell the AIDS cocktail for $350 a year per patient, or roughly $1 a day, as compared to Western prices of between $10,000 and $15,000 a … This paper reviews available information on the costs for two types of services: a) Interventions: These were all biomedical or behavioural interventions for which available evidence showed a direct impact on HIV risk, transmission, morbidity and mortality; b) Technical efficiency (TE) factors: These were defined as activities that improve the technical efficiency of existing programmes, often by increasing their quality, uptake or coverage, but only affect a single intervention- in contrast to the enablers and synergies that have the potential to affect a number of interventions, possibly across different programme areas. Sub-Saharan Africa is bound to become the biggest user of antiretroviral drugs in the world, so it has to start preparing to use them now, a conference of AIDS experts was told last week. For the results of our own ingredient cost analysis, however, we added the details of the exact ingredients, quantities and unit prices included for each intervention and technical efficiency factor in S4 Table in order to allow other analysts to easily update our estimates to their settings and future prices. Table 19b. here. We systematically reviewed publication databases for published cost data covering a large range of HIV interventions and summarised relevant unit costs (cost per person receiving a service) for each. No, PLOS is a nonprofit 501(c)(3) corporation, #C2354500, based in San Francisco, California, US, https://doi.org/10.1371/journal.pone.0210497, https://ghcosting.org/pages/data/ucsr/app/index, http://dx.doi.org/10.1371/journal.pone.0168118, http://dx.doi.org/10.1371/journal.pone.0148546, http://www.statssa.gov.za/?page_id=1854&PPN=P0141, http://dx.doi.org/10.1371/journal.pone.0135048. These medicines are by far the largest item in Medicaid’s drug budget, the third largest for the insurance exchanges and the fifth largest for commercial insurers. Of these 1,054 papers, 219 (21%) were duplicates, and 18 (2%) could not be found, leaving us with 817 papers for full-text screening (see Fig 1 for PRISMA diagram). But that may be starting to change. Ingredient-based costing is used to cost interventions for which there is no data from economic study. For most of these estimates we updated input costs to more recent prices, using the same input costs as for those interventions costed based on ingredients. Steve Cohen’s time on this study was funded by the South African National AIDS Council (SANAC). Validation, https://doi.org/10.1371/journal.pone.0210497.t002. Click through the PLOS taxonomy to find articles in your field. However, only 62% of papers reported some estimate of uncertainty, increasing the risk of potential reporting bias. Data curation, The specific roles of this author is articulated in the ‘author contributions’ section. If Medicare could get the same prices that, say, the Department of Veterans Affairs gets, it would save nearly $3 billion a year on just the 20 most-prescribed drugs, according to a study by Senate Democrats. It is estimated that the first‐line regimen of antiretroviral treatment for adults and children costs about US$368 per person per year (about 1US$ per day). “Whenever I hear that, I pretty much have a seizure,” said Dr. Daskalakis. For those without private insurance, Medicare or Medicaid, the Ryan White AIDS Drug Assistance Program steps in. Data curation, Plenty of drugs carry outrageous prices: EpiPens, insulin, cancer treatments, even some antibiotics. S2 Table summarises the definition of each parameter collected from the included papers. The results of both the literature review and the cost calculation exercise are presented in both ZAR and US dollars (USD), using the 2017/18 period average exchange rate of 1 USD = 13.32 South African Rand. But in the United States, virtually no one on antiretrovirals has to pay for them. “There are new options in the market,” according to Lida Etemad, who is vice president for pharmacy management services at UnitedHealthcare. So logic says it must cost less than $75. Cost items included in papers that only reported the provider perspective were staff costs (in 81% of these papers), consumables (69%), ARVs (in 61% of papers), non-ARV drugs (69%), laboratory tests (58%), equipment (58%), radiology (36%), inpatient cost (19%), transport costs (17%). Of the 42 papers identified through the literature review (5% of all papers included in full-text review), 30 (71%) reported on the cost of antiretroviral treatment in different models of care, 4 (10%) reported on HIV counselling and testing (HCT), 3 (7%) each on medical male circumcision and inpatient care, and 1 each (2%) on palliative care and pre-ART care (cotrimoxazole preventive therapy only) (Table 2). Supervision, Writing – review & editing, Affiliation (They differ in one piece of their triple therapy, but the World Health Organization and the United States government consider those drugs to be interchangeable.). This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Table 2 gives an overview of the methods used in arriving at the unit cost of each intervention and TE factor included in the South African HIV Investment Case, the sources of all data, and the resulting unit cost. S2 Table summarises the definition of each parameter collected from the included papers. The results informed unit costs for 5 of 11 intervention categories included in the Investment Case, with the remainder costed based on ingredients (35%) and expenditure data (10%). Mr. Horn believes things are changing. “But the first-line regimens recommended still favor the absolute best — and often most expensive — drugs available. Super-organized, savvy patient groups all over the world banded together to make H.I.V. “We should be planning in a smart way to make these switches when they become possible,” said Mark Harrington, executive director of the Treatment Action Group, which works globally to help people get medicines for H.I.V., tuberculosis and hepatitis C. “If this were a rational world, this would set in play a dynamic series of negotiations between buyers and manufacturers, trying to bid around for the lowest price,” he said. Estimates that were made available to us ahead of being published are denoted as “personal communication”, or “PC”, in Table 2. Finally, we collected which cost categories had been reported as having been included in the cost analysis (costs of antiretroviral and any other drugs; laboratory, radiology, staff, consumable, overhead, capital, and transportation costs). The agreement‚ negotiated with international organisations and agencies‚ meant the fixed-dose combination treatment will cost about $75 (about R991) per person a year. Despite HIV interventions making up a large proportion of the health interventions in South Africa for which cost estimates are available , and despite a large number of reviews showing that South Africa is home to more cost estimates for HIV interventions than any other low- and middle-income country [43–46], our search yielded limited results. e0210497. These resource costs are then summed to calculate the unit cost of the intervention. take an almost identical therapy. Price secrecy elsewhere along the chain of purchases — from manufacturer to insurers and ultimately to patients — leaves doctors totally in the dark about the cost of what they prescribe, and patients as well. The fact that antiretroviral medicines were priced beyond the reach of most people who needed them in Africa had long been an international concern: at the International AIDS Conference in Stockholm in 1988 there was debate about how to ensure people in the developing world could access the treatment of that time - zidovudine monotherapy - which was marketed at a price of US$8000 per year . Secondly, our search strategy might have not retrieved all relevant papers, especially those reporting on results from smaller settings or using smaller sample sizes. The Investment Case framework includes biomedical interventions most often implemented by the healthcare sector alongside structural enablers (activities that have the potential to improve the efficiency of more than one intervention) and development synergies (investments into sectors other than health that have a positive effect on HIV outcomes amongst a broader range of impacts across different health and other development sectors). She’s talking about new drugs from Mylan — the generic manufacturer that achieved infamy for the $600 EpiPen in 2016. Similarly, drug costs, also a significant contributor to total costs, do not increase each year with inflation as the costs are negotiated through a tender process and may be fixed for a number of years, and in the past the prices tended to decrease as a result of tender negotiations. Just under half of all people living with H.I.V. The majority of the reviewed publications included all cost categories relevant to the intervention under study, and more than half had collected data through bottom-up resource use analyses, often using large patient samples. The timing of when to start therapy has continued to be a core controversy within the medical community, though recent studies have led to more clarity. Papers found spanned the 12 years between 2005 and 2016, with slightly more papers (60%) published in the second six years than in the first. For more information about PLOS Subject Areas, click That’s not only way below countries like Britain and France; it’s worse than Zimbabwe, Kenya and Malawi. In the United States, many people with H.I.V. More than 25 million people in the region are HIV positive, out of a total of 36 million worldwide, yet only a few thousand are being treated with antiretroviral drugs. To receive email alerts for Fixes columns, sign up here. Next year for the first time, Express Scripts, which is one of the country’s largest pharmacy benefits managers, with coverage of 25 million people, is kicking an H.I.V. Interventions for which the unit cost came directly from our literature review are denoted with the reference to the paper from which the cost was sourced in Table 2. Across all types of unit cost, we used the same public-sector input costs to establish a common frame of reference. Taxpayers should care about price; after all, health care represents 18 percent of the national economy. We reviewed available cost data as part of the South African HIV Investment Case, a modelling exercise to inform the optimal use of financial resources for the country’s HIV programme. UnitedHealthcare, one of the biggest insurance companies in America, is experimenting with a different way to control costs. Data curation, Conceptualization, While planned simplification of HIV service delivery promises to reduce expenditure, the drug cost of ART provision consumes the bulk of most HIV programme Since we do not attempt to synthesize the evidence further, for example by creating a mean cost and cost range of a single intervention from several such reported estimates, we do not think that our analysis is subject to reporting bias. Patients with suppressed H.I.V. The quality of some of the results of this analysis is therefore limited; however, in each of these cases an estimate based on inferior methodology was deemed better than no estimate at all. Third, where no unit cost could be found in the literature, cost was established using ingredient costing based on published data on the type and number of resources used in the intervention, and input costs from government commodity tenders, public servant remuneration documents, retail advertisements, government programme costings and budgets from South Africa’s current and past portfolio of grants with the Global Fund to Fight Aids, Tuberculosis and Malaria (GFATM). And it neutralizes a powerful potential adversary of the drug companies. “Cost considerations are becoming considerable factors in H.I.V. This arbitrage is very profitable. therapy aims to suppress the virus to the point where it is undetectable in a patient’s blood. We identified 1,047 papers through the search and another 7 references either mentioned in these papers or suggested by experts (Table 1). medicines are a big part of that. Follow The New York Times Opinion section on Facebook and Twitter (@NYTopinion), and sign up for the Opinion Today newsletter. Our analysis yielded some insight into those interventions that need further cost analysis. Pharmaceutical companies have built a system in which no one in a position to limit costs wants to do so. Bottom-up costing starts by identifying actual resource use (number of staff minutes, drugs etc. Other papers detailed the costs of HCT, MMC, palliative and inpatient care; no papers were found on the costs of PrEP, social and behaviour change communication, and PMTCT. Conceptualization, Along with the inconvenience of multiple-pill regimens, this is a big reason generics aren’t much used. For more information about PLOS Subject Areas, click For these reasons we would advise caution in applying straight-line inflation adjustments to the costs of health interventions in South Africa over a number of years. No, Is the Subject Area "Antiretroviral therapy" applicable to this article? Few analyses however use locally relevant cost data. A new gold-standard triple therapy for H.I.V. Marvin Joseph/The Washington Post, via Getty Images, is kicking an H.I.V. https://doi.org/10.1371/journal.pone.0210497.s001, https://doi.org/10.1371/journal.pone.0210497.s002, https://doi.org/10.1371/journal.pone.0210497.s003, https://doi.org/10.1371/journal.pone.0210497.s004, https://doi.org/10.1371/journal.pone.0210497.s005. “Lower cost” is relative — obviously, these prices are pretty far from $75. But in the meanwhile, people in the U.S. have problems staying on medicines because of our crazy system.”. Center for Global Health and Development, Boston University, Boston, Massachusetts, United States of America, Roles It should be borne in mind that the purpose of this paper is to summrise potential sources of cost data rather than every sub-aspect of our own or other analysts’ cost analyses. Of the 11 models reporting incremental costs, 7 found DART to be cost saving. The median incremental saving per patient per year among cost -saving models was $67. The remaining interventions had to be costed using an ingredients-based approach, which is more prone to over- or underestimation than the detailed analysis of actual resources used in a bottom-up cost analysis. It’s ‘if this were my dad, what would I want him to have?’” she said. But what an irrational world it is! “There’s a complex patchwork in place. 55% of papers used a bottom-up approach to analysing resource use, 43% an ingredients or top-down approach, and one paper (2%) used both . Well, the generic manufacturers Aurobindo and Mylan, which supply the drug in Africa, make a profit when they sell it to the United States’ President’s Emergency Plan for AIDS Relief and to the Global Fund to Fight AIDS, Tuberculosis and Malaria — two organizations that buy drugs for low-income countries. “That we are going to be able to scale up all over the world is amazing. The United States spends about $20 billion a year on H.I.V. All cost data taken from published estimates was updated to 2016 South African Rand (ZAR) using the South African consumer-price index published by StatsSA  and relevant exchange rates if the estimate was not given in ZAR. In its My ScriptRewards program, patients who choose the cheaper H.I.V. The principal summary measures that we collected were the mean or median cost estimate with ranges, cost year, currency, and where relevant, exchange rate between the reported currency and USD in the cost year. 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