The government has so far ignored its own report on administering antiretrovirals Belinda Beresford The government has been sitting on a report it commissioned that vigorously endorses the use of antiretroviral drugs in stopping the transmission of HIV between mothers and children.
The study, commissioned by the Department of Health and delivered four months ago, suggests that using antiretroviral drugs to curtail mother-to-child transmission (MTCT) of the virus could not only save almost 14E000 lives a year, but could also save South Africa as much as R270-million a year. Written by a European Union-sponsored consultant in the directorate for health financing and economics, the report says the estimated costs of a Nevirapine programme work out at approximately R1,99 a person for the whole population. The consultant’s investigation comes amid mounting controversy about the government’s slowness in providing antiretroviral drugs to pregnant women with HIV. An NGO, the Treatment Action Campaign, is poised to take legal action against the government for its failure to do so. The government has justified its hesitation to fund the drugs with a variety of reasons, ranging from possible toxicity to cost. The Department of Health’s Dr Nono Simelela said the department knew the drugs were cost effective but that the government had to consider a whole range of issues in preventing MTCT, such as breast feeding. She said there had not yet been enough information on Nevirapine to carry much weight, but said that policy on MTCT would be a Cabinet decision – and not that of the department alone. The department has also indicated that its decision on such policies is subject to the advice of the Presidential Aids Advisory Panel – a body that includes both orthodox Aids scientists and “dissidents”. The author of the report, Martin Hensher, suggests that substantial HIV/Aids treatment costs could be averted by working to cut MTCT. He writes that the cost-effectiveness model used suggests that “the Nevirapine programme might, at current costs, actually achieve an overall saving of over R270- million – that is, additional savings after paying for its own cost.” While such estimates are complicated by the assumptions being used in the research, Hensher says “crucially though, it is likely that the model’s overall cost and cost-effectiveness results themselves provide a very strong argument for the intervention, regardless of potential savings.” He admits that in practice savings are likely to be less than the theoretical maximum, and that “real financial savings can only be achieved through service restructuring that would require considerable planning”. Hensher does not consider the costs of looking after Aids orphans. But he argues that there is no more reason for doing so than for withholding life support from an orphaned child accident victim. The report, leaked to the Mail & Guardian this week, estimates that “a nationwide Nevirapine MTCT programme could save almost 14E000 babies a year at the cost of R6E284 a life saved”. A similar programme using AZT could save more than 12E000 babies’ lives a year, for just over R10E000 a life. Analysis of the research suggests Nevirapine intervention would be less cost effective than traditional public health measures such as child immunisation, but would be “very substantially more cost effective than many medical and surgical treatments offered as common interventions in the South African public sector”.
The study recommends a rapid planning exercise to provide a clearer estimate of the resources the programme will demand and a realistic timetable to get it running. Hensher also says that costs could be reduced by bringing the private sector into the fray, for example by requiring MTCT intervention as part of the minimum benefits package that medical aids have to provide. Last week Minister of Health Manto Tshabalala-Msimang said it was “imperative to involve the private sector in order to spread the burden of care”. Using the latest data from antenatal clinics of a 22,4% HIV prevalence among pregnant women, the model reckons that total intervention costs would be R87E512E078 for a Nevirapine-based trial –a mere 0,33% of the 2000/01 national and provisional health budget, which was R26,2-billion. The report relies on a cost-effectiveness model, which uses results from a MTCT trial in Uganda using AZT. It has since been updated to incorporate Nevirapine. The model uses prices correct for the time of the report, some of which have already fallen. For example, the report uses an estimate of R40 a course of Nevirapine, whereas the cost is now around R21. It doesn’t take into account more recent offers of price cuts from pharmaceutical companies, including an offer of free Nevirapine for MTCT from Boehringer Ingelheim. The analysis in the Department of Health report relies on a number of assumptions, including an estimated 975E650 live births this year from 1E027E000 pregnancies. It assumes that pre-test counselling is provided by nursing assistants, and that professional nurses are used for post-test counselling to HIV-positive women. Other assumptions include a 69% ultimate uptake of the programme for Nevirapine and 65% for AZT. It does not include data from South African trials, or consider safety issues. The M&G reported last month that a study conducted by a health economist at the University of Cape Town had found that the government could save R800-million a year – and more than 800 childrens’ lives each month – if it made antiretroviral drugs and milk formula available to all HIV-positive women who were pregnant.