medicines — made by Mylan and other companies — were incorporated into treatment regimens, America could save between $3 billion and $5 billion, with about $1 billion of that savings accruing to Medicare and Medicaid. But even we have limits to what we can do — because of spending on drugs.”. See S3 Table for the detailed cost results by paper. Just under half of all people living with H.I.V. But it’s hard for them to refuse to cover a recommended drug, and they can pass their costs along in the form of higher premiums. We reviewed available cost data as part of the South African HIV Investment Case, a modelling exercise to inform the optimal use of financial resources for the country’s HIV programme. In most people using antiretroviral drugs, the virus is under control within 6 months. medicines affordable in poor countries. For this, we first conducted a systematic review of available published data on the costs of the selected interventions, based on primary cost analyses published between 2000 and 2016 that described a mode of delivery of the intervention that was relevant to South Africa, with or without a comparator population or intervention, and as part of any type of economic analysis, including cost and cost-effectiveness or cost-utility analyses. What does it cost to make each year’s supply of that $39,000 therapy? During 1999–2008, South African government leadership had a both a president and a minister of health who doubted openly that HIV caused AIDS or that antiretroviral drugs were needed. What do we get from spending so much? Ingredient-based costing is used to cost interventions for which there is no data from economic study. We reviewed the available literature on primary cost data for HIV services in South Africa. Table 2 gives an overview of the methods used in arriving at the unit cost of each intervention and TE factor included in the South African HIV Investment Case, the sources of all data, and the resulting unit cost. For more information about PLOS Subject Areas, click Of the estimated 36.7 million individuals living with HIV worldwide in 2015, approximately 70% resided in sub-Saharan Africa (SSA) . Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa, For those estimates that did not include enough details regarding ingredients and quantities, we forward-adjusted the estimate for inflation to 2016 costs as above. drugs. In the United States, pharmaceutical companies have built a system which supports high costs for H.I.V. For those without private insurance, Medicare or Medicaid, the Ryan White AIDS Drug Assistance Program steps in. (They differ in one piece of their triple therapy, but the World Health Organization and the United States government consider those drugs to be interchangeable.). In line with the impact ART has on the total cost of the HIV programme in South Africa, more than two thirds of the identified 42 papers detailed the cost of ART. Competing interests: SANAC provided support in the form of salary support for SC, but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. Along with the inconvenience of multiple-pill regimens, this is a big reason generics aren’t much used. Yes A useful benefit of building unit costs in this manner is that one is able to view the proportional contribution of each ingredient to the total unit cost. Next year for the first time, Express Scripts, which is one of the country’s largest pharmacy benefits managers, with coverage of 25 million people, is kicking an H.I.V. Mylan also makes three-drug combos, Symfi (equivalent to Atripla, which costs $32,000) and lower-dose Symfi Lo. H.I.V. The need to reduce drug costs is especially acute in South Africa. The results of both the literature review and the cost calculation exercise are presented in both ZAR and US dollars (USD), using the 2017/18 period average exchange rate of 1 USD = 13.32 South African Rand. However, only 62% of papers reported some estimate of uncertainty, increasing the risk of potential reporting bias. The contents are the responsibility of the authors and do not necessarily reflect the views of USAID or the United States Government. Yes A young woman who is taking H.I.V. The United States is infamous for its high cost of health care — and H.I.V. In the United States, many people with H.I.V. Plenty of drugs carry outrageous prices: EpiPens, insulin, cancer treatments, even some antibiotics. This year the company brought out three new H.I.V. Yes It is similar to bottom-up costing but estimates resource use during the intervention based on assumptions, expert opinion, or other literature, rather than on a sample of service recipients, and applies costs taken from literature or other sources to reach a unit cost. The Investment Case used a novel optimisation methodology to inform local programme planners and both local and international funders about the most cost effective mix of interventions against both HIV and TB in South Africa over the next twenty years, using as the main outcome measure cost per life-year gained. The same is true for Mylan’s three-drug combos. South Africa has begun rolling out a state-of-the-art antiretroviral drug in a “game-changing” bid to drastically reduce the number of people living with HIV. Our analysis yielded some insight into those interventions that need further cost analysis. We want to make sure everybody continues to have access to prescription drugs and services.”. medicine, Atripla, off its list of covered drugs. Where no data was found in the literature, we constructed unit costs either based on available information regarding ingredients and relevant public-sector prices, or based on expenditure records. drugs. S4 Table furthermore gives details on the type, cost and quantities of ingredients included in each unit cost where applicable. Super-organized, savvy patient groups all over the world banded together to make H.I.V. But in the United States, virtually no one on antiretrovirals has to pay for them. Other specified cost items not attributable to these categories comprised nutritional support or supplements [35,36], communication costs [37], the costs of end of life care [34], field materials [38] and start-up costs [39], bank and interest charges [40] and insurance costs [41]. Instead, a large number of modelled economic analyses of HIV interventions in South Africa which made reference to the same, often outdated, cost analyses, with no reference to any additional review of other literature. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Finally, for selected interventions for which no published data on either unit cost or ingredients was available, we used information from budgets or expenditure records. The crazy system exists because until very recently, there has been virtually no price competition in H.I.V. doi: 10.1093/infdis/jit110. “There’s a complex patchwork in place. We also found that the actual age of the input costs used in models was often lost through chains of referencing, where a modelled analysis used input costs that were the outputs of an older modelled analysis based on an even older primary analysis. epidemic. Formal analysis, H.I.V. Across all types of unit cost, we used the same public-sector input costs to establish a common frame of reference. AIDS triple-combination therapy, which costs US$ 10 000 per patient per year in industrialized countries, can now be obtained from Indian generic drugs company, Cipla, for less than US$ 200 per year. There are several different types and they work in different ways. Finally, we collected which cost categories had been reported as having been included in the cost analysis (costs of antiretroviral and any other drugs; laboratory, radiology, staff, consumable, overhead, capital, and transportation costs). Beginning this fall, it will encourage patients it covers to choose a less expensive H.I.V. The principal summary measures that we collected were the mean or median cost estimate with ranges, cost year, currency, and where relevant, exchange rate between the reported currency and USD in the cost year. The majority of papers (62%) reported results as a point estimate only, without giving a range. “They really do help to subsidize a lot of H.I.V. Validation, Cost categories included varied between intervention areas and perspectives. Discover a faster, simpler path to publishing in a high-quality journal. Writing – review & editing, Roles Alternatively, we suggest searching the unit cost study repository of the Global Health Cost Consortium (https://ghcosting.org/pages/data/ucsr/app/index) which, at the time of writing, contained data from four of the papers included in our review). Writing – original draft, Two papers (4%) reported on both provider and patient perspectives [30,31]. “We should be planning in a smart way to make these switches when they become possible,” said Mark Harrington, executive director of the Treatment Action Group, which works globally to help people get medicines for H.I.V., tuberculosis and hepatitis C. “If this were a rational world, this would set in play a dynamic series of negotiations between buyers and manufacturers, trying to bid around for the lowest price,” he said. But we are seeing the first attempts to control the galloping cost of treating H.I.V. take an almost identical therapy. Conceptualization, This arbitrage is very profitable. Why now? PLOS ONE promises fair, rigorous peer review, Copyright: © 2019 Meyer-Rath et al. “Cost considerations are becoming considerable factors in H.I.V. We searched Pubmed for publications on the cost of each of the interventions, using a combination of MeSH and manually set search terms describing the intervention as well combinations of “economics”, “cost”, “cost analysis”, “costing”, “financial”, “budget” or “resource use”, at the level of title or abstract, as well as “South Africa” at the level of the text. Cimduo is two pills (taken together) instead of one. But that may be starting to change. https://doi.org/10.1371/journal.pone.0210497.g001, https://doi.org/10.1371/journal.pone.0210497.t001. Writing – review & editing, Affiliation However, in our review we were able to find publications on the costs of a number of other interventions such as HCT, MMC, palliative and inpatient care. For more information, we suggest to contact either the authors of the papers we reference or, if more information on the ingredients cost summarised in S4 Table is required, the corresponding author of this paper. Data curation, Secondly, our search strategy might have not retrieved all relevant papers, especially those reporting on results from smaller settings or using smaller sample sizes. For example, clinics that serve H.I.V. UnitedHealthcare, one of the biggest insurance companies in America, is experimenting with a different way to control costs. Few analyses however use locally relevant cost data. Is the Subject Area "Economic analysis" applicable to this article? If patients develop complications or resistance to first line therapy drugs, they may need to proceed to second-line or third-line therapy to successfully limit the HIV infection. For the purposes of this paper we define a unit cost as the cost per unit of output delivered by an intervention or technical efficiency factor (summarised as “services” in the following). For these reasons we would advise caution in applying straight-line inflation adjustments to the costs of health interventions in South Africa over a number of years. No, Is the Subject Area "Systematic reviews" applicable to this article? Marvin Joseph/The Washington Post, via Getty Images, is kicking an H.I.V. There are lots of antiretroviral drugs, and they can be combined in different ways. Thirty-two papers (76%) reported financial costs only, 5 papers (12%) economic costs, and another 5 papers (12%) both financial and economic costs. The quality of some of the results of this analysis is therefore limited; however, in each of these cases an estimate based on inferior methodology was deemed better than no estimate at all. “Lower cost” is relative — obviously, these prices are pretty far from $75. Yes But no class of medicines is more scandalously expensive than for H.I.V. , people in the U.S. have problems staying on medicines because of spending on drugs... 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