Delivery of antiretroviral treatment services in India: estimated costs incurred under the National AIDS Control Programme

Competing domestic health priorities and shrinking financial support from external agencies necessitatesthat India’s National AIDS Control Programme (NACP) brings in cost efficiencies to sustain theprogramme. In addition, current plans to expand the criteria for eligibility for antiretroviral therapy(ART) in India will have significant financial implications in the near future. ART centres in India providecomprehensive services to people living with HIV (PLHIV): those fulfilling national eligibility criteriaand receiving ART and those on pre-ART care, i.e. not on ART. ART centres are financially supported(i) directly by the NACP; and (ii) indirectly by general health systems. This study was conducted todetermine (i) the cost incurred per patient per year of pre-ART and ART services at ART centres; and(ii) the proportion of this cost incurred by the NACP and by general health systems. The study usednational data from April 2013 to March 2014, on ART costs and non-ART costs (human resources,laboratory tests, training, prophylaxis and management of opportunistic infections, hospitalization,operational, and programme management). Data were extracted from procurement records andreports, statements of expenditure at national and state level, records and reports from ART centres,databases of the National AIDS Control Organisation, and reports on use of antiretroviral drugs. Theanalysis estimates the cost for ART services as US$ 133.89 (`8032) per patient per year, of which 66%(US$ 88.66, `5320) is for antiretroviral drugs and 34% (US$ 45.23, `2712) is for non-ART recurrentexpenditure, while the cost for pre-ART care is US$ 33.05 (`1983) per patient per year. The low costsincurred for patients in ART and pre-ART care services can be attributed mainly to the low costs ofgeneric drugs. However, further integration with general health systems may facilitate additional costsaving, such as in human resources.

Adoption of the 2015 World Health Organization guidelines on antiretroviral therapy: programmatic implications for India

The therapeutic and preventive benefits of early initiation of antiretroviral therapy (ART) for HIV arenow well established. Reflecting new research evidence, in 2015 the World Health Organization (WHO)recommended initiation of ART for all people living with HIV (PLHIV), irrespective of their clinical stagingand CD4 cell count. The National AIDS Control Programme (NACP) in India is currently following the 2010WHO ART guidelines for adults and the 2013 guidelines for pregnant women and children. This desk studyassessed the number of people living with HIV who will additionally be eligible for ART on adoption of the2015 WHO recommendations on ART. Data routinely recorded for all PLHIV registered under the NACP upto 31 December 2015 were analysed. Of the 250 865 individuals recorded in pre-ART care, an estimated135 593 would be eligible under the WHO 2013 guidelines. A further 100 221 would be eligible under theWHO 2015 guidelines. Initiating treatment for all PLHIV in pre-ART care would raise the number on ART from0.92 million to 1.17 million. In addition, nearly 0.07 million newly registered PLHIV will become eligible everyyear if the WHO 2015 guidelines are adopted, of which 0.028 million would be attributable to implementationof the WHO 2013 guidelines alone. In addition to drugs, there will be a need for additional CD4 tests andtests of viral load, as the numbers on ART will increase significantly. The outlay should be seen in the contextof potential health-care savings due to early initiation of ART, in terms of the effect on disease progression,complications, deaths and new infections. While desirable, adoption of the new guidance will have significantprogrammatic and resource implications for India. The programme needs to plan and strengthen the servicedelivery mechanism, with emphasis on newer and innovative approaches before implementation of theseguidelines.