HIV This Week

Rosen S, Feeley F, Connelly P, Simon J. The private sector and HIV/AIDS in Africa: taking stock of 6 years of applied research. AIDS 2007;21 Suppl 3:S41-51.

Until recently, little was known about the costs of the HIV epidemic to businesses in Africa or about business responses to the epidemic.  This paper synthesizes the results of a set of studies conducted between 1999 and 2006. Data for the studies included were drawn from human resource, financial, and medical records of 16 large companies and from 7 surveys of small, medium-sized, and large companies in South Africa, Uganda, Kenya, Zambia, Ethiopia, and Rwanda. The estimated workforce HIV prevalence ranged from 5 to 37%. The average cost per employee lost to AIDS varied from 0.5 to 5.6 times the average annual compensation of the employee affected. Labour cost increases were estimated at 0.6-10.8% but exceeded 3% at only two of 14 companies. Antiretroviral treatment at a cost of US$360/patient per year was found to have positive financial returns for most but not all companies. Managers of small and medium-sized enterprises (SME) reported low HIV-related employee attrition, little concern about the impacts of HIV, and relatively little interest in taking action. HIV was estimated to increase the average operating costs of small and medium-sized enterprises by less than 1%. In conclusion, for most companies, HIV is causing a moderate increase in labour costs, with costs determined mainly by HIV prevalence, employee skill level, and employment policies. Treatment of HIV-positive employees is a good investment for many large companies. Small companies have less capacity to respond to workforce illness and little concern about it. Research on the effectiveness of workplace interventions is needed.

Editors’ note: This synthesis suggests that well-designed interventions can achieve the double benefit of reducing costs to employers while improving the welfare of individual employees. Small and medium-sized companies face business challenges such as power failures, unpredictable taxes, and political instability, and are unable to benefit from economies of scale. Their HIV workplace programmes require support from business associations or external funders for HIV prevention activities and must rely on governments and non-governmental organizations for healthcare provision.

Koenig SP, Riviere C, Leger P, Severe P, Atwood S, Fitzgerald D, Pape JW, Schackman BR. The cost of antiretroviral therapy in Haiti. Cost Eff Resour Alloc. 2008; 14;6(1):3.

Koenig and colleagues determined direct medical costs, overhead costs, societal costs, and personnel requirements for the provision of antiretroviral therapy (ART) to patients with AIDS in Haiti. The authors examined data from 218 treatment-naive adults who were consecutively initiated on ART at the GHESKIO Center in Port-au-Prince, Haiti between December 23, 2003 and May 20, 2004 and calculated costs and personnel requirements for the first year of ART. The mean total cost of treatment per patient was $US 982 including $US 846 in direct costs, $US 114 for overhead, and $US 22 for societal costs. The direct cost per patient included generic ART medications $US 355, lab tests $US 130, nutrition $US 117, hospitalizations $US 62, pre-ART evaluation $US 58, labour $US 51, non-ART medications $US 39, outside referrals $US 31, and telephone cards for patient retention $US 3. Higher treatment costs were associated with hospitalization, change in ART regimen, TB treatment, and survival for one year.  The authors estimate that 1.5 doctors and 2.5 nurses are required to treat 1000 patients in the first year after initiating ART. Initial ART treatment in Haiti costs approximately $US 1,000 per patient per year. With generic first-line antiretroviral drugs, only 36% of the cost is for medications. Patients who change regimens are significantly more expensive to treat, highlighting the need for less-expensive second-line drugs. There may be sufficient health care personnel to treat all HIV-infected patients in urban areas of Haiti, but not in rural areas. New models of HIV care are needed for rural areas using assistant medical officers and community health workers.

Editors’ note: Costing studies such as this one provide key information for programme management and budgeting, as well as hard data to feed into national, regional, and global cost estimates. Equity in treatment scale-up in Haiti and elsewhere will depend on keeping costs for first-and-second-line antiretroviral drugs low and developing innovative task-shifting scenarios for rural areas.