The Economic Burden to Families of HIV and HIV/Tuberculosis Coinfection in a Subsidized HIV Treatment Program Wilson E. Sadoh, MD and Osa Oviawe, MD
Introduction: The high cost of antiretroviral (ARV) drugs has led to the initiation of subsidized HIV treatment programs in developing countries. The care of tuberculosis (TB), a common opportunistic infection, is not built into the subsidized program. The current study was done to evaluate the cost burden of HIV/AIDS, TB, and TB and HIV/AIDS coinfections to the family. Subjects and Methods: The study was carried out in the consultant outpatient department of the University of Benin Teaching Hospital in Nigeria. Consecutive families with >1 family member managed for HIV and or TB were recruited into three cohorts of HIV only, TB only and HIV/TB cohorts. The average monthly costs of treatment, transportation family income and percentage of income spent on care were computed for-each family. The average monthly man-hours per family spent on clinic visitation were determined. Results: A total of 61 families consisting of 128 family members met the study criteria. The mean cost of treatment per month was significantly higher in families in the HIV/TB cohort than in other cohorts, P=0.0001. The mean percentage of income spent on treatment was significantly higher in the HIV/TB cohort compared to other cohorts, P=0.0001.
Conclusion: The cost of managing TB/HIV coinfection significantly increased the costs to the families in the subsidized HIV treatment program. It is recommended that a comprehensive package of subsidized HIV care that is inclusive of TB treatment and care for other comorbidities be initiated in developing countries. Key words: HIV/AIDS U tuberculosis * coinfection © 2007. From the Department of Child Health (Sadoh) and Institute of Child Health (Oviawe), University of Benin/University of Benin Teaching Hospital, Benin City, Edo State, Nigeria. Send correspondence and reprint requests for J Natl Med Assoc. 2007;99:627-631 to: Dr. Wilson E. Sadoh, Department of Child Health, University of Benin/University of Benin Teaching Hospital, PMB 1 154, Benin City, Edo State, Nigeria; phone: +234 802 880 9710; e-mail:
[email protected]
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INTRODUCTION T he burden of HIV and AIDS pandemic in subSaharan Africa can be ameliorated by an effective prevention campaign and the judicious use of antiretroviral drugs (ARVs) to treat the large number of persons living with HIV and AIDS (PLWHA).'-4 The cost of treatment, however, is beyond the reach of the majority of PLWHA in the subregion.5 Affected children are worse off as they rely on their parents with limited resources to provide care for them. This has prompted a global effort through nongovernmental organizations-such as Global HIV/AIDS Initiative in Nigeria; the Centers for Disease Control and Prevention in the United States; and President Bush's programme for AIDS relief, Presidential Emergency Plan for AIDS Relief-to provide HIV care in resource-poor countries. In Nigeria, the Government of Nigeria, in response to the rising prevalence of HIV and the prohibitive cost of ARVs, initiated a subsidized treatment program in some health centers across the country from July 2001. HIV infection is often associated with opportunistic infections. A major coinfection is tuberculosis (TB). Its prevalence has been on the rise since the advent of HIV and AIDS and has thus further increased the economic burden to the family.6'7 Additional cost of treating TB and other opportunistic infections is not built into the subsidized HIV program. The extra burden of care to the family may, therefore, significantly alter the quality of life of affected families, as scarce resources meant for other purposes will be spent on treatment. In families with multiple affected members, the socioeconomic outlook is envisaged to be grimmer because of the accompanying decline in family income. This becomes more pertinent in Nigeria, where an estimated 70.2% of the people are living on less than a dollar a day.8 With an HIV prevalence of 4.4% and a population of 134 million people,9 Nigeria has 2.86 million PLWHA. In addition, the prevalence of TB in Nigeria is 531.3/100,000-being one of the largest TB burdens in Africa and fourth largest in the world.10 It is against this background that we decided to evaluate the cost burden to the family of HIV/AIDS, TB and AIDS/TB coinfections. V
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SUBJECTS AND METHODS
Selting This study was carried out in the consultant outpatient department of the University of Benin Teaching Hospital (UBTH), Benin, Nigeria, between February 2005 and March 2006. UBTH is one of the health centers under the HIV-subsidized treatment program in which the subsidized monthly course of HAART as well as cost of laboratory tests is N1000:00 (U.S. $7.87). The HIV-infected children were seen in the pediatric outpatient clinic, while their infected parents attended the adult outpatient clinic.
Methodology The subjects were consecutive (newly diagnosed) children managed for HIV, TB or HIV/TB coinfection and their affected parents. The number of families and affected members in a family for each of the conditions was computed. The child was the focal point for tracing other affected family members. The family was the unit of analysis in this study because decisions about treatment are made within the family. Since the cost of illness is met from the family budget, cost of illness is therefore incurred by the entire family.""2 The patients live within Benin and neighboring towns. The family units were recruited into three cohorts of HIV only, TB only and HIV/TB coinfection. The HIVonly cohort comprised families with .1 family member seropositive for HIV infection, attending the consultant outpatient department of UBTH. The TB cohort comprised families with .1 family member diagnosed with TB and managed at the consultant outpatient department. The HIV/TB cohort consisted of families with .1 family member with HIV and TB coinfections and attending the consultant outpatient department. The diagnosis of HIV was made when a patient was positive to two HIV antibody tests and confirmed by ELISA. The diagnosis of TB was based on isolation of Mycobacterium TB or on clinical criteria of history of exposure to a person with active TB, cough of >3 weeks, fever, unexplained weight loss, a positive tuberculin skin sensitivity test and typical radiological findings on chest radiograph. Gastric aspirate or sputum was taken for
acid- and alcohol-fast bacilli examination in young children and older children/adults, respectively. At recruitment, the purpose and requirements of the study were explained to participants. Verbal consent was obtained from the parents who were told to note the various costs relevant to treatment of their condition and present them at subsequent visits. For each cohort, the family name, the addresses and the number of affected family members were obtained from the patients' records. Anti-TB therapy consisted of isoniazid, rifampicin, pyrazinamide and streptomycin. All four were administered initially for the first two months; streptomycin and pyrizinamide were then dropped, while isoniazid and rifampicin were continued for the next four months. The patients were entirely responsible for their anti-TB treatment and investigations. The total amount spent monthly on transportation for clinic visits by the affected families was obtained from the parents on subsequent clinic visit. Follow-up clinic visits for all patients were on a monthly basis. Duration of the study was six months for each patient. The duration of treatment for patients with TB was for 6-9 months, and the follow-up period thereafter was one year, while those with HIV/AIDS are still on treatment. The socioeconomic classes of the families were determined using the methods described by Olusanya et al.3
Determination of Cost of Treatment and Transportation The cost of treatment in the study consisted of the subsidized HIV treatment cost (of drugs, including consumables and cost of laboratory tests). Charges for the consultation were added to cost of treatment. On each monthly visit, the cost of purchasing anti-TB drugs, syringes and needles (where applicable) in the preceding month for each affected member of the family was provided by the parents. Where the program ran out of ARV stock and the patients had to buy at unsubsidized rates, the cost was added on to the cost of drugs for the month. The hospital charges for consultations were also included. The total cost of drugs to the family was then summed up for the month. The cost of routine laboratory tests such as CD4 count and viral load determination were built into the monthly subsidized HIV treatment
Table 1. Characteristics of the study population
Cohorts
Number of Families
HIV only HIV/TB TB only Total
N 41 14 6 61
Children Males Females N (%) N (%) 21 (21.9) 28 (29.2) 10 (41.7) 4 (17.7) 4 (50.0) 3 (37.5) 35 35
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Mother
Father
Total Family Members
N(%) 37 (38.5) 8 (33.3) 1 (12.5) 46
N(%) 10 (10.4) 2 (8.2) 0 (0.0) 12
96(100.0) 24 (100.0)
N(%) 8 (100.0) 128
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cost (N1000:00 per person). The cost of investigations for TB, which included chest radiograph, Mantoux tests, full blood count, erythrocyte sedimentation rate, etc., were computed and added to the cost of treatment. The costs of both illnesses were added together in the HIV/ TB cohort. Where any affected family member was hospitalized, the cost of routine HIV and TB drugs and investigations (where applicable) were included in the monthly cost computation. The cost of treating other illnesses other than HIV and TB during admission was excluded. The mean monthly cost to the family was calculated based on the reported cost for six months. The average monthly cost of transportation was determined by computing the amount spent by affected family members and caregivers on clinic visits (to and from the hospital) each month.
Calculation of Man-Hours During the study period, the average number of working adults per family visiting the clinic monthly, the average number of clinic visits per family per month and the time spent on clinic visits monthly by each family were determined. The man-hours spent by each family monthly were calculated as the product of the number of working adults per family attending clinic and the time in hours spent on clinic visits each month. A working day consists of eight hours (Federal Government of Nigeria regulation).
Determination of Family Income The average monthly income of each family was determined from the monthly income of both parents (including monies from other sources such as petty trading,
animal farming, etc.) for six months. The percentage of income spent on managing the disease monthly was then calculated. Families whose total income was 1 times a month, were excluded.
Statistical Analysis Analysis of data was done using the SPSS' for Windows' 10.0 (SPSS Inc., Chicago, IL). Simple proportions were represented in percentages. One-way ANOVA was used to test for significant difference in the means of the parametric variables in the three cohorts. While TukeyKramer multiple comparison test was used to determine which cohort was significantly different from the others, P values
