The Epidemic In HIV For South Africa Social Policy Essay

The epidemic of HIV is still a heavy load on South Africa. The prevalence rate among grownups ( 15-49 ) has bit by bit risen from an norm of 16.9 % in 2001 to 18.1 % in 2007, with an mean figure of deceases due to AIDS estimated at 350,000 for both grownups and kids in 20071.

Management of HIV septic persons with Highly Active Anti Retroviral Treatment ( HAART ) involves the usage of a combination of three drugs as follows ; a peptidase inhibitor ( PI ) combined with two nucleoside contrary RNA polymerase inhibitors ( NRTIs ) or a PI, a Non Nucleoside Reverse RNA polymerase Inhibitor ( NNRTI ) and an NNRTI 2.The three drugs are administered together day-to-day on a uninterrupted footing. Since the beginning of the usage of HAART in 1996, there has been a rapid and important decrease in HIV related morbidity and mortality rates in states where HAART was made readily available and accessible. HAART is effectual in cut downing the rate of viral reproduction, the rate of patterned advance of the disease to AIDS and subsequent decease 2.

Economic rating refers to “the comparative analysis of alternate classs of action in footings of both their costs and consequences”3. Health attention resources are scarce and markets are an inefficient agencies of apportioning resources for health/health attention. Decisions ( particularly over alternate picks ) have to be made desperately despite unsure fortunes. Economic rating can supply the footing for budgeting and equal scene of precedences, therefore bettering the efficiency of resource allotment. Economic analysis can be done either along-side randomized clinical tests ( RCTs ) , or utilizing determination analytical modeling. Economic ratings done along-side RCTs are unequal because the clip skyline for the analysis is inappropriate, non all available options are compared, assorted positions can non be assessed ( societal/health service ) and the consequences are non generalisable to other scenes. The usage of determination analytical modeling addresses the jobs mentioned supra, every bit good as leting for synthesis of grounds across a figure of tests, doing the consequences more generalisable. It is besides able to capture costs and benefits that occur in the hereafter long after clinical tests have ended, and therefore enabling determination devising when there is deficiency of lucidity from bing informations 4.The purpose of this survey was to compare the use and cost of HIV related wellness attention between cohorts of patients having HAART compared to those non having HAART, to measure if the usage of HAART is cost-efficient. A wellness service position was taken.



A Markov theoretical account dwelling of 60 rhythms of one twelvemonth periods each was used to imitate the patterned advance of a conjectural cohort of 1000 South African HIV positive persons and to gauge the cost, effects and cost-effectiveness of the two viing intervention options 5. The theoretical account consisted of four distinct and reciprocally sole wellness provinces which were based on CD4 counts ( fig-1 ) .

All the participants enter the theoretical account in phase 1 ( 200 & lt ; =CD4 & lt ; 350 cells/micro-litre ) with the decease province being the all absorbing province. Each twelvemonth the patients have a certain chance of either staying in the same wellness province or traveling to a poorer wellness province ( Fig.1 ) . Therefore, it was assumed that there could be no reversal to a better wellness province. The CD4 cells/µL count, which is a step of the degree of an person ‘s immune position, was used as an index for HIV related wellness provinces and as the CD4 count beads, the degree of wellness of an septic single diminutions. At the terminal of each twelvemonth the cohort was so redistributed to one of the 4 wellness provinces, depending on the events of the old twelvemonth. The chances associated with decease represent mean all-cause mortality across age and gender groups relevant to the determination context ( Fig-1 ) .

Treatment Premises

Due to the fact that no Randomized control tests ( RCTs ) comparing intervention of HIV positive patients with HAART to no intervention in South Africa, the comparative hazard of disease patterned advance with HAART was derived by indirect comparing of RCTs that compare several drug regimens. In this instance, the comparative hazard decrease was assumed to stand for the decrease in passage chances between wellness provinces ; Stage 1 to Stage 2, Stage 2 to Aids and from Aids to Death. The same comparative hazard decrease applied to each of these passages. It was besides assumed that the passage from Phase 1 to Death and Stage 2 to Death were non associated with HAART intervention. The continuance of intervention consequence was merely observed for 10 old ages following the beginning of HAART, and the nature of the long term consequence beyond that is mostly unknown.

Other Model Premises

It was assumed that the patients within groups 1 and 2 in both cohorts had the same chance of deceasing from all other Non-HIV related cause irrespective of their age and sex. The theoretical account besides assumed that the mean passage chance from one province to another of an person remained the same irrespective of the province that the person might hold experienced in the old rhythm 6. A life clip skyline was adopted for the analysis and the comparative hazard of intervention was assumed to stay the same over clip i.e. “continuous effect”3.


Cost item/Health State

Average cost

Assurance Time interval

HAART Treatment



Phase 1



Phase 2



Phase 3



Phase 4

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Merely costs associating to intervention of timeserving infections, proviso of HAART and other relevant wellness attention costs were included in the theoretical account. These were mean costs and their 95 % assurance intervals ( CIs ) . Productiveness costs due to work loss, costs of ballad attention and costs of travel were non included. Costss were reported in 2008 US Dollars ( table 2 ) .

Economic Analysis and Discounting

Effectss were measured in life old ages and Quality adjusted life old ages ( QALYs ) gained. QALYs were calculated utilizing public-service corporation values matching to the assorted wellness provinces obtained from a study of South African patients who at assorted disease phases filled a Euroqol ( EQ-5D ) questionnaire. The public-service corporation weights were derived from a United Kingdom population. Both future costs and result were discounted at a rate of 3 % per year7-9. The incremental cost-effectiveness ratio ( ICER ) was calculated after running the theoretical account for 60 rhythms.

Sensitivity Analysis

Uni-variate deterministic sensitiveness analysis were conducted on the cost of HAART, the comparative hazard decrease from intervention with HAART, the public-service corporation values for each Health province and the price reduction rate. A probabilistic sensitiveness analysis was carried out to measure “uncertainty around the values of parameters”4 at the same time. Parameters include ; cost of HAART, costs associated with being in each wellness province, quality of life weights ( public-service corporations ) and passage chances. Costss followed a Gamma distribution ; passage chances followed a normal distribution, while public-service corporations and comparative hazard of disease patterned advance with drug followed a Log-normal distribution4. The scopes of values used are listed in table 3. New values from within each of the chance distributions were indiscriminately selected during each of the 1000 palingenesiss of the simulation. This was to measure how the determination to O.K. an intercession would change as the fiscal worth of wellness addition alterations, and accordingly the grade of uncertainness that can be linked to the values of the parametrs4.


LIFE Old ages



( $ )

Incremental cost/Life Year ( $ )

Incremental Cost/Qaly ( $ )

Treatment Group




No Treatment Group











In the base line analysis, ( Table_1 ) an ICER of $ 9511 per life-year gained was estimated. Modifying the life anticipation for alterations in wellness related quality of life generated an ICER of $ 10532 per QALY gained.

Sensitivity Analysis ( table 2 )

3 % Discount rate

Deterministic values

Scope used in a sensitiveness analysis

ICER range US $ /QALYs

% alteration


Min CI

Max CI

Cost ( US $ )

One rhythm in 200 & lt ; =CD4 & lt ; 350





-2.43- -2.44

One rhythm in 50 & lt ; CD4 & lt ; 200






One rhythm in AIDS






Cost of HAART




7027-14038 #

-33.28- -33.29


200 & lt ; =CD4 & lt ; 350






50 & lt ; CD4 & lt ; 200





-0.30- -0.30

Acquired immune deficiency syndrome





-0.70- -0.712

Drug effectivity





-14.99- -22.20


The theoretical account was run for 60 rhythms even though 99.9 % of the patients had died after 20 old ages in the “No intervention group” and 35 old ages in the “treatment group” in order to to the full capture alterations in cost and effects of intervention of HAART, given the grade of uncertainness around the comparative intervention consequence of HAART beyond 10 old ages. Sensitivity analysis showed that the ICER was non sensitive to the clip frame beyond 8 old ages. The ICER was $ 10608/QALY at 20 old ages, $ 10,534/QALY at 35years and $ 10,534/QALY at 65 old ages ( Fig 2 ) . Uni-variate sensitiveness analysis turn toing uncertainness around the cost of HAART, public-service corporation values for wellness provinces, comparative hazard of intervention consequence and the price reduction rates, were conducted for the undermentioned grounds ; There was considerable uncertainness sing the cost of HAART, as it is likely to alter with clip, and surveies have shown that the cost is likely to be lower in the close hereafter in South Africa as International pharmaceutical companies have been late granted contracts by the South African section of wellness to provide drugs for HAART to the public wellness sector at an estimated cost of $ 181 per patient-year ( PPY ) 10. There is besides considerable uncertainness environing the public-service corporation values which were used to cipher QALYs because the public-service corporation tonss were derived from a UK population and these tonss may be different from the existent tonss for South Africa. The WHO every bit good as other surveies, have recommended that a average rate of 3 % should be used to dismiss hereafter costs and benefits7-9, but in a state like South Africa, with a high mortality rate and low life anticipation ( 52years ) 11, the present value of future benefits ( old ages of life/QALYs gained ) and costs saved would conceivably be less than that of parts with higher life anticipation and lower mortality rates12. Previous surveies on cost effectivity of HAART in South Africa have used price reduction rates of 8 % 10. A plausible option would be to utilize the price reduction rate set by the South African National exchequer for wellness undertakings was 9 % for 2007 13, ( The price reduction rate for 2008 was non available ) . The comparative hazard of intervention consequence has merely been observed for 10 old ages and its long term consequence beyond 10 old ages is unsure, therefore the demand for sensitiveness analysis utilizing upper and lower bounds of 95 % assurance intervals ( CI ) for the values, while maintaining other parametric quantities unchanged.

The ICER was sensitive to the cost of HAART. It showed that a unit alteration in cost of HAART resulted in a disproportionate alteration in ICER ( 35 % alteration in cost of HAART resulted in 33 % alteration in ICER, snap of 0.96 ) . The ICER was found to be even more sensitive to the comparative hazard of intervention consequence as a 10 % addition in the comparative hazard resulted in a more than 22 % addition in the ICER. Multi-variate sensitiveness analysis was done to turn to uncertainness around the public-service corporation values, by changing the upper and lower bounds of 95 % CIs for all public-service corporation values, while maintaining other parametric quantities changeless. The ICER was merely marginally sensitive to public-service corporation values. Using lower bounds of the CIs resulted in a lessening in ICER by approximately 5 % and an addition in ICER by 6 % when upper bound values were used. Further analysis turn toing methodological uncertainness showed that ICER was highly sensitive to the price reduction rate. At a price reduction rate of 8 % ( a 5 % addition ) the ICER rose by 12.3 % and at a rate of 9 % ( a 6 % addition ) the ICER rose by 14.7 % .

The ensuing ICER braces from Probabilistic sensitiveness analysis were plotted on a cost-effectiveness plane and it showed that the drug was more dearly-won and more effectual than “no treatment” in all cases. A cost-effectiveness acceptableness curve ( CEAC ) was constructed demoing the chance that the intercession is cost-efficient for each cost effectivity threshold ( CET ) , given the base line ICER ( fig 3 ) . The CEAC showed that the intercession had a 100 % chance of being cost-efficient at a CET of $ 20,000 per QALY gained and a 0 % chance of being cost-efficient at a CET of $ 6,000 per QALY gained. The base line ICER read off the CEAC had a 50 % chance.


In this analysis, cost-effectiveness of HAART was evaluated utilizing analytical modeling techniques which incorporated information on cost of intervention with HAART, comparative effectivity of the drug and disease patterned advance. Base line ICERs of $ 9511 per life twelvemonth and $ 10532 per QALY were obtained. The theoretical account assumed that persons could non change by reversal to a better wellness province, therefore consequence of intervention may hold been under estimated.

The Cost effectivity threshold ( CET ) is the maximal sum that determination shapers will be willing to pay for a unit of wellness addition and is of import in Cost effectual analysis ( CEA ) , as it is the comparative value against which acceptableness is denoted 14. In this analysis, the CET was estimated utilizing a human capital attack, in which the CET is defined by standardised agencies and therefore puting the value of life in footings of what an single contributes to society E.g. money, and would normally be expressed in footings of Gross National Income ( GNI ) or Gross Domestic Product ( GDP ) 14. In my analysis, the CET was defined as an ICER less than 2 times the nominal GNI per Capita 15-16. The GNI per capita for South Africa for 2008 was $ 5820 11 and therefore the CET was set at $ 11,640 per QALY/life twelvemonth gained. The base instance consequence of $ 10,532 per QALY ( excepting indirect costs ) was less than 2 times the GNI per Capita for South Africa, therefore considered cost-efficient. Previous surveies conducted by Badri et al measuring cost-effectiveness of HAART in South Africa showed lower ICER estimations, though the costs were estimated based on 2004 rates 17. Deterministic sensitiveness analysis turn toing uncertainness around parametric quantities showed that the ICER was really sensitive to the monetary value of HAART with the comparative effectivity of HAART. This was found to be important as Upper bounds of the assurance intervals of both variables yielded ICERs of $ 12,870 and $ 14,038 severally, both of which were greater than the CET. This has an of import bearing on policy as it is imaginable that the intercession will be more cost economy if determination shapers implement policies that will guarantee proviso of HAART at a lower cost as was mentioned antecedently. Further research will be required to measure accurately the long term effects of HAART beyond 10 old ages every bit good as the side effects given the grade of uncertainness around the base instance values and the sensitiveness of the ICER to the comparative effectivity of HAART. It is besides imaginable that in world there may be opposition to HAART and accordingly the demand to follow a 2nd line intervention. Multi manner analysis turn toing uncertainness around public-service corporation values showed that the ICER was merely marginally sensitive to public-service corporation values. This nevertheless was non important, as none of the bounds of the assurance interval pushed the ICER beyond the threshold. The ICER was besides significantly sensitive to dismiss rate as the ICER was pushed beyond the CET when the price reduction rate was raised to 8 % and 9 % .

The CEAC obtained the from probabilistic sensitiveness analysis showed that at a CET of $ 11,640 per QALY, intervention with HAART had 64 % chance of being cost effectual, given the base line ICER of $ 10532 per QALY.

There were several restrictions in this survey.

The usage of Markov ‘s theoretical account was justified in position of the chronic nature of HIV/AIDS, but it has some intrinsic lacks. It assumes that the chance of passage of a patient remains the same irrespective of their old province i.e. it is memory less 3. One manner of turn toing this is by attaching clip dependent passage chances. The theoretical account besides assumes that patients remain changeless throughout a rhythm and that the passage takes topographic point merely at the terminal of the rhythm. The effects may hold been over estimated as accommodations were non made for inauspicious effects of the drug. The survey besides assumed that the all cause mortality rates remained the same irrespective of the age of the patient. Another possible beginning of prejudice is the premise that the cost of intervention of timeserving infections was the same for those without HAART as for those with HAART. This conversely may hold led to under appraisal of the effects of HAART as surveies suggest that intervention with HAART reduces the rate of timeserving infections in HIV patients 18.

Evocation of the CET for in-between and low income states utilizing the human capital attack has a figure of restrictions which include ; unfairness and high cost. An alternate agencies of arousing CETs would be by utilizing preference-elicitation methods, but this may ensue in even higher cost estimations. CETs can besides be estimated utilizing the conference table attack i.e. in maintaining with a preset estimation. This has been suggested to be most appropriate for authoritiess in low and in-between income states given a specific budget 14.

Assuming a wellness service position may hold yielded a conservative ICER as it is conceivable that the analysis would be more cost-efficient if it had incorporated indirect costs saved, every bit good as productiveness gained i.e. taking a social position.


The consequences of this analysis suggest that intervention of HIV patients with HAART is a cost effectual intercession compared to merely handling timeserving infections in South Africa. Broadening the analysis to a social position may increase the cost-effectiveness. The analysis besides suggests that cut downing the cost of HAART could significantly increase cost effectivity. It is therefore justifiable for policy shapers in South Africa to supply free entree to HAART for HIV patients in South Africa. It is imaginable that there will be social additions even if the determination is entirely based on economic rating.


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