Swaziland has one of the highest adult HIV prevalence rates worldwide, 27%; with approximately 200,000 people 15 years and older living with HIV. Swaziland and many other countries in sub-Saharan Africa have adopted universal test-and-treat (UTT) policies. As the number of people needing and receiving ART in Swaziland is rapidly increasing, it is critical to understand the cost of UTT scale-up and its implications for the health system. The study presented here is the first empirical longitudinal costing study of annual ART patient costs under a public-sector UTT policy with routine viral load monitoring.
We collected comprehensive monthly facility-level data on ART patient costs from 14 facilities implementing UTT as part of a large-scale randomized stepped-wedge health systems trial (September 2014-December 2016). In addition to a comprehensive time-and-motion study, we used extracted cost data from facility budgets, expenditure reports, and patient records. Items included in this 'bottom-up costing' included direct personnel, medications, laboratory services including viral load, and treatment for opportunistic infections (OI). We express all costs per patient per year (PPPY). Costs were converted from local currency to U.S. Dollars using annualized exchange rates.
Total ART costs PPPY were $214 (95% CI: 201-226). ARVs costs accounted for the largest proportion at $102 (95% CI: 101-103), followed by personnel $77 (95% CI: 67-88), laboratory services (including viral load) $31 (95% CI: 27-35) and OI costs $4 (95% CI: 3-4). In the descriptive data (Figure 1) and in multilevel regression analysis controlling for time fixed effects and facility random effects, we identified strong economies of scale in the relationship between costs PPPY and facility size (measured in the number of visits per month). As facility size increases, costs initially decrease rapidly (from about $800 PPPY) and then plateau (below $200 PPPY) approximately at 250 patient visits.
Swaziland's public-sector ART program displays strong economies of scale under UTT, with far less efficiency achieved in clinics reaching less than 250 patient visits per month. In the context of scaling up UTT, increases in patient volumes are efficient trajectories but where not feasible (such as rural and remote populations), alternative delivery models could provide efficiency gains; including community health worker delivered ART.