The short-term effects of the implementation of the "Treat All" guidelines on ART service delivery costs in Namibia

The introduction of “Treat All” (TA) has been promoted to increase the effectiveness of HIV/AIDS treatment by having patients initiate antiretroviral therapy at an earlier stage of their illness. The impact of introducing TA on the unit cost of treatment has been less clear. The following study evaluated how costs changed after Namibia’s introduction of TA in April 2017. A two-year analysis assessed the costs of antiretroviral therapy (ART) during the 12 months before TA (Phase I–April 1, 2016 to March 31, 2017) and the 12 months following (Phase II–April 1, 2017 to March 31, 2018). The analysis involved interviewing staff at ten facilities throughout Namibia, collecting data on resources utilized in the treatment of ART patients and analyzing how costs changed before and after the introduction of TA. An analysis of treatment costs indicated that the unit cost of treatment declined from USD360 per patient per year in Phase I to USD301 per patient per year in Phase II, a reduction of 16%. This decline in unit costs was driven by 3 factors: 1) shifts in antiretroviral (ARV) regimens that resulted in lower costs for drugs and consumables, 2) negotiated reductions in the cost of viral load tests and 3) declines in personnel costs. It is unlikely that the first two of these factors were significantly influenced by the introduction of TA. It is unclear if TA might have had an influence on personnel costs. The reduction in personnel costs may have either represented a positive development (fewer personnel costs associated with increased numbers of healthier patients and fewer visits required) or alternatively may reflect constraints in Namibia’s staffing. Prior to this study, it was expected that the introduction of TA would lead to a significant increase in the number of ART patients. However, there was less than a 4% increase in the number of adult patients at the 10 studied facilities. From a financial point of view, TA did not significantly increase the resources required in the ten sampled facilities, either by raising unit costs or significantly increasing the number of ART patients.

“全员治疗（Treat All，TA）”方案的推行初衷，是通过让患者在疾病更早阶段启动抗逆转录病毒疗法（antiretroviral therapy，ART），提升艾滋病（HIV/AIDS）的诊疗效能。但TA方案推行对治疗单位成本的影响尚不明确。本项研究评估了2017年4月纳米比亚推行TA方案后的成本变化情况。本次为期两年的分析，评估了TA方案推行前12个月（第一阶段：2016年4月1日至2017年3月31日）与推行后12个月（第二阶段：2017年4月1日至2018年3月31日）的抗逆转录病毒疗法（ART）成本。分析过程中，研究团队访谈了纳米比亚境内10家医疗机构的工作人员，收集了ART患者诊疗所用资源的相关数据，并对比分析了TA方案推行前后的成本变化。诊疗成本分析结果显示，治疗单位成本从第一阶段的每名患者每年360美元，降至第二阶段的301美元，降幅达16%。上述单位成本下降主要受三大因素驱动：1）抗逆转录病毒（antiretroviral，ARV）治疗方案的调整，使药物及耗材成本降低；2）病毒载量检测费用通过谈判达成下调；3）人力成本有所缩减。前述前两项因素的变动，不太可能受TA方案推行的显著影响。目前尚无法确定TA方案是否对人力成本产生了影响。人力成本的缩减，既可能源于患者中健康状况更佳者占比提升、所需随访次数减少，进而降低了人力成本，属于积极向好的态势；也有可能反映出纳米比亚医护人员编制紧张的现状。在本研究开展前，学界普遍预计TA方案的推行将使ART患者数量大幅增长。但在本次研究涉及的10家医疗机构中，成年ART患者数量的增幅仅不足4%。从财务视角来看，TA方案并未使本次抽样的10家医疗机构所需资源出现显著增长——既未推高单位成本，也未造成ART患者数量的大幅增加。