Health Economics and Epidemiology Research Office (HE²RO), Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.
Department of Global Health, Boston University School of Public Health, Boston, United States.
BMC Health Serv Res. 2023 Mar 11;23(1):240. doi: 10.1186/s12913-023-09147-7.
While South Africa's national HIV program is the largest in the world, it has yet to reach the UNAIDS 95-95-95 targets. To reach these targets, the expansion of the HIV treatment program may be accelerated through the use private sector delivery models. This study identified three innovative non-governmental primary health care models (private sector) providing HIV treatment, as well as two government primary health clinics (public sector) that served similar populations. We estimated the resources used, and costs and outcomes of HIV treatment across these models to provide inputs to inform decisions around how these services might best be provided through National Health Insurance (NHI).
A review of potential private sector models for HIV treatment in a primary health care setting was conducted. Models actively offering HIV treatment (i.e. in 2019) were considered for inclusion in the evaluation, subject to data availability and location. These models were augmented by government primary health clinics offering HIV services in similar locations. We conducted a cost-outcomes analysis by collecting patient-level resource usage and treatment outcomes through retrospective medical record reviews and a bottom-up micro-costing from the provider perspective (public or private payer). Patient outcomes were based on whether the patient was still in care at the end of the follow up period and viral load (VL) status, to create the following outcome categories: in care and responding (VL suppressed), in care and not responding (VL unsuppressed), in care (VL unknown) and not in care (LTFU or deceased). Data collection was conducted in 2019 and reflects services provided during the 4 years prior to that (2016-2019).
Three hundred seventy-six patients were included across the five HIV treatment models. Across the three private sector models there were differences in the costs and outcomes of HIV treatment delivery, two of the models had results similar to the public sector primary health clinics. The nurse-led model appears to have a cost-outcome profile distinct from the others.
The results show that across the private sector models studied the costs and outcomes of HIV treatment delivery vary, yet there were models that provided costs and outcomes similar to those found with public sector delivery. Offering HIV treatment under NHI through private delivery models could therefore be an option to increase access beyond the current public sector capacity.
尽管南非的国家艾滋病规划是世界上最大的，但它尚未达到联合国艾滋病规划署 95-95-95 目标。为了实现这些目标，可能需要通过使用私营部门提供模式来加速扩大艾滋病毒治疗规划。本研究确定了三种提供艾滋病毒治疗的创新型非政府初级保健模式（私营部门），以及两个为类似人群提供服务的政府初级保健诊所（公共部门）。我们估算了这些模式下艾滋病毒治疗的资源利用情况、成本和结果，为国家健康保险（NHI）下如何提供这些服务提供决策依据。
对初级保健环境中艾滋病毒治疗的潜在私营部门模式进行了审查。符合纳入评估条件的模式是指那些积极提供艾滋病毒治疗的模式（即 2019 年），前提是数据可用且地点合适。这些模式由在类似地点提供艾滋病毒服务的政府初级保健诊所补充。我们通过回顾性病历审查和从提供者角度进行的自下而上的微观成本核算（公共或私人支付者）收集患者层面的资源使用和治疗结果，进行成本-效果分析。根据患者在随访期末是否仍在接受治疗以及病毒载量（VL）状况，患者结局分为以下几类：在治疗中且有反应（VL 抑制）、在治疗中但无反应（VL 未抑制）、在治疗中（VL 未知）和不在治疗中（失访或死亡）。数据收集于 2019 年进行，反映了在此之前的 4 年（2016-2019 年）提供的服务。
五个艾滋病毒治疗模式共纳入 376 名患者。在三个私营部门模式中，艾滋病毒治疗提供的成本和结果存在差异，其中两个模式的结果与公共部门初级保健诊所相似。护士主导的模式似乎具有与其他模式不同的成本-效果特征。
研究结果表明，在所研究的私营部门模式中，艾滋病毒治疗提供的成本和结果存在差异，但也有一些模式提供的成本和结果与公共部门提供的相似。因此，通过私营部门提供模式在 NHI 下提供艾滋病毒治疗可能是一种增加现有公共部门能力之外的获取途径的选择。
