Abstract
IntroductionSouth Africa’s National Department of Health launched the National Adherence Guidelines for Chronic Diseases in 2015. These guidelines include adherence clubs (AC) and decentralized medication delivery (DMD) as two differentiated models of care for stable HIV patients on antiretroviral therapy. While the adherence guidelines do not suggest that provider costs (costs to the healthcare system for medications, laboratory tests and visits to clinics or alternative locations) for stable patients in these differentiated models of care will be lower than conventional, clinic‐based care, recent modelling exercises suggest that such differentiated models could substantially reduce provider costs. In the context of continued implementation of the guidelines, we discuss the conditions under which provider costs of care for stable HIV patients could fall, or rise, with AC and DMD models of care in South Africa.DiscussionIn prior studies of HIV care and treatment costs, three main cost categories are antiretroviral medications, laboratory tests and general interaction costs based on encounters with health workers. Stable patients are likely to be on the national first‐line regimen (Tenofovir/Entricitabine/Efavarinz (TDF/FTC/EFV)), so no difference in the costs of medications is expected. Laboratory testing guidelines for stable patients are the same regardless of the model of care, so no difference in laboratory costs is expected as well. Based on existing information regarding the costs of clinic visits, AC visits and DMD drug pickups, we expect that for some clinics, visit costs for DMD or AC models of care could be less, but modestly so, than for conventional, clinic‐based care. For other clinics, however, DMD or AC models could have higher visit costs (see Table 2).ConclusionsThe standard of care for stable patients has already been “differentiated” for years in South Africa, prior to the roll out of the new adherence guidelines. AC and DMD models of care, when implemented as envisioned in the guidelines, are unlikely to generate substantive reductions or increases in provider costs of care.
Highlights
South Africa’s National Department of Health launched the National Adherence Guidelines for Chronic Diseases in 2015
The questions are as follows: What is a stable antiretroviral therapy (ART) patient? 2 What is the conventional model of care used as a comparison? 3 What are the adherence clubs (AC) and decentralized medication delivery (DMD) models of care? 4 Did implementation of these models affect patient outcomes? 5 What do the guidelines say about costs?
The AC and DMD models were limited to stable patients, medications and laboratory tests followed national ART guidelines regardless of the service delivery model, and retention in care was similar between standard of care (SOC) and the new models [27]
Summary
Global goals for treatment of HIV include reaching 90% of diagnosed HIV-positive individuals with antiretroviral therapy (ART) by 2020 and 95% by 2030 [1,2]. The focus of this discussion is on DSD models for patients who are already stable on ART (already virally suppressed). Whether costs to health systems will go up or down in response to the widespread advent of DSD models for stable ART patients will largely depend on how differentiated models differ from conventional care, in terms of such characteristics as visit frequency, medication refill mechanism and provider cadre In this discussion, we use an evaluation of South Africa’s National Adherence Guidelines for Chronic Diseases (HIV, TB and NCDs) [26], referred to here as the AGL evaluation [10,27], to examine how adherence clubs (AC) and decentralized medication delivery (DMD) for stable patients can affect provider costs. Details of the overall evaluation of the National Adherence Guidelines have previously been presented [10,27]
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