Tseng Ashley S, Barnabas Ruanne V, van Heerden Alastair, Ntinga Xolani, Sahu Maitreyi
Department of Epidemiology, University of Washington, Seattle, Washington, United States of America.
Department of Global Health, University of Washington, Seattle, Washington, United States of America.
PLOS Glob Public Health. 2024 Dec 30;4(12):e0003368. doi: 10.1371/journal.pgph.0003368. eCollection 2024.
Antiretroviral therapy (ART) is needed across the lifetime to maintain viral suppression for people living with HIV. In South Africa, obstacles to reliable access to ART persist and are magnified in rural areas, where HIV services are also typically costlier to deliver. A recent pilot randomized study (the Deliver Health Study) found that home-delivered ART refills, provided at a low user fee, effectively overcame logistical barriers to access and improved clinical outcomes in rural South Africa. In the present costing study using the provider perspective, we conducted retrospective activity-based micro-costing of home-delivered ART within the Deliver Health Study and when provided at-scale (in a rural setting), and compared to facility-based costs using provincial expenditure data (covering both rural and urban settings). Within the context of the pilot Deliver Health Study which had an average of three deliveries per day for three days a week, home-delivered ART cost (in 2022 USD) $794 in the first year and $714 for subsequent years per client after subtracting client fees, compared with $167 per client in provincial clinic-based care. We estimated that home-delivered ART can reasonably be scaled up to 12 home deliveries per day for five days per week in the rural setting. When delivered at-scale, home-delivered ART cost $267 in the first year and $183 for subsequent years per client. Average costs of home delivery further decreased when increasing the duration of refills from three-months to six- and 12-month scripts (from $183 to $177 and $135 per client, respectively). Personnel costs were the largest cost for home-delivered refills while ART drug costs were the largest cost of clinic-based refills. When provided at-scale, home-delivered ART in a rural setting not only offers clinical benefits for a hard-to-reach population but is also comparable in cost to the provincial standard of care.
抗逆转录病毒疗法（ART）对于艾滋病毒感染者来说，需要终身使用以维持病毒抑制。在南非，可靠获取抗逆转录病毒疗法存在障碍，且在农村地区更为严重，因为在农村地区提供艾滋病毒服务的成本通常也更高。最近一项试点随机研究（“提供健康研究”）发现，以较低的用户费用提供的家庭送药式抗逆转录病毒疗法药物补充，有效克服了获取药物的后勤障碍，并改善了南非农村地区的临床治疗效果。在本项从提供者角度进行成本核算的研究中，我们在“提供健康研究”范围内以及大规模提供（在农村环境中）时，对家庭送药式抗逆转录病毒疗法进行了基于活动的回顾性微观成本核算，并使用省级支出数据（涵盖农村和城市地区）与基于医疗机构的成本进行比较。在“提供健康研究”试点项目中，平均每周三天，每天有三次送药服务，扣除客户费用后，家庭送药式抗逆转录病毒疗法在第一年的成本（以2022年美元计算）为每位客户794美元，后续年份为714美元，而省级诊所护理每位客户的成本为167美元。我们估计，在农村环境中，家庭送药式抗逆转录病毒疗法可以合理地扩大到每周五天、每天12次家庭送药服务。大规模提供时，家庭送药式抗逆转录病毒疗法在第一年的成本为每位客户267美元，后续年份为183美元。当将药物补充的时长从三个月延长至六个月和十二个月的处方时，家庭送药的平均成本进一步降低（分别从每位客户183美元降至177美元和135美元）。人员成本是家庭送药式药物补充的最大成本，而抗逆转录病毒疗法药物成本是基于诊所的药物补充的最大成本。在农村环境中大规模提供时，家庭送药式抗逆转录病毒疗法不仅为难以接触到的人群带来临床益处，而且在成本上与省级护理标准相当。
