Multi-Country Analysis of Treatment Costs for HIV/AIDS (MATCH): Unit costing at 161 Representative Facilities in Ethiopia, Malawi, Rwanda, South Africa and Zambia

Background Today’s uncertain funding landscape threatens to halt progress towards global HIV/AIDS treatment and prevention goals. Improving the efficiency of HIV/AIDS spending is essential to effectively allocate existing funds and promote additional investment. Prior research focused on efficiency opportunities in ART, however recent and representative data on ART costs were limited. Methods and Findings Comprehensive data on twelve months of ART costs w ere collected at 161 representative facilities across five countries. Sites were selected using stratified random sampling. Patient characteristics and treatment outcomes were measured by reviewing 100 randomly-selected charts per facility. ART costs were significantly lower than expected, averaging $200 per patient-year in low- and lower-middle income countries. Costs in South Africa were higher at $682 per patient-year. Main cost components were ARVs and personnel, together comprising more than 70% of costs. Facilities demonstrated the ability to keep patients alive and on treatment at these cost levels, with relatively low average annual attrition rates for established patients, ranging from 2 - 8%. Retention rates for new patients were highly variable and strongly correlated with CD4 count at initiation. Conclusions This study provides new evidence that aggressive scale-up of high-quality treatment in developing countries is possible and sustainable. The low cost of ART should allay concerns about incurring a prohibitively expensive “treatment mortgage” through aggressive scale-up. Additionally, there has been a significant global focus on driving savings by optimizing service delivery design and it appears as though significant savings are unlikely in facility-level A RT costs. Optimization efforts should instead focus on treatment costs outside the facility and program costs unrelated to treatment. In South Africa, and likely other upper-middle income countries, optimizing ART service delivery will generate savings and should be pursued. Finally, across countries, there are clear opportunities to improve patient outcomes without substantially increasing cost, the most prominent of which is better using the money already being spent on pre-ART to more effectively drive earlier initiation of treatment. Funding The Bill and Melinda Gates Foundation