ASSESSING THE PERFORMANCE OF ART DELIVERY: A COSTS EFFICIENCY ANALYSIS OF THE MEXICAN HIV PROGRAM
In Mexico, around 60,000 individuals currently benefit from universal, free-of-charge antiretroviral treatment (ART) through MoH facilities. The financial constraints of a publicly funded system threaten the short-term sustainability of the HIV national program. Thus, facility-level performance data is required to increase value-for-money in HIV spending. Indicators of the treatment cascade provide relevant insight of quality-adjusted outcomes and its associated costs, which could have a managerial role in assisting decision-making.
Administrative databases of the Mexican MoH were analyzed to assemble a dashboard showing the distribution of three key indicators of facility-level performance. We calculated the proportion of people who initiated ART with CD4>200 cel/mm3 - a proxy for early initiation -, the proportion of those who were not lost to follow-up, and those who ever achieved viral suppression (viral load<50 copies/mm3) during treatment. We calculated total annual costs of antiretroviral drugs per patient, for they comprise nearly 80% of the total cost of treatment. We then compared costs per treated person along the steps of the service cascade and assessed inter-facility variation as a measure of performance.
In 2012, 55% of all new patients initiated ART with CD4>200 cel/mm3(IQR: 48.9;63.6). 91% were retained for at least 12 months (IQR: 84.6;96.9), 16 pp more than in 2008. 57% were below the undetectable viral load threshold (IQR: 48.4;66.7). Average annual cost per patient treated was 3,595 USD (IC95%: 4,155-3,035), and this figure increased steadily along the treatment cascade: 6,484 per early initiated patient , 7,163 per retained patient and 12,608 per virally suppressed patient. The difference in costs between the least and the most expensive facility was 3.4 times the cost per retained patient, and 94.8 times per virally suppressed patient. The gains in retention yielded a decrease of 20% in costs between 2008 and 2012.
We found considerable room to improve early initiation and retention of HIV patients receiving ART. Breakdown of clinical information into useful metrics is imperative for managers and policy-makers. Late initiation and treatment withdrawal do matter on account of their impact on costs, and because they portray themselves a considerable effect on mortality. Our results encourage prompt and continuous surveillance of the treatment cascade indicators in Mexico and other settings, where administrative data is available.