Out-of-pocket costs of AIDS care in China: are free antiretroviral drugs enough?

Abstract

Financial access to HIV care and treatment can be difficult for many people in China, where the government provides free antiretroviral drugs but does not cover the cost of other medically necessary components, such as lab tests and drugs for opportunistic infections. This article estimates out-of-pocket costs for treatment and care that a person living with HIV/AIDS in China might face over the course of one year. Data comes from two treatment projects run by Médecins Sans Frontières in Nanning, Guangxi Province and Xiangfan, Hubei Province. Based on the national treatment guidelines, we estimated costs for seven different patient profiles ranging from WHO Clinical Stages I through IV. We found that patients face significant financial barriers to even qualify for the free ARV program. For those who do, HIV care and treatment can be a catastrophic health expenditure, with cumulative patient contributions ranging from approximately US$200–3939/year in Nanning and US$13–1179/year in Xiangfan, depending on the patient's clinical stage of HIV infection. In Nanning, these expenses translate as up to 340% of an urban resident's annual income or 1200% for rural residents; in Xiangfan, expenses rise to 116% of annual income for city dwellers and 295% in rural areas. While providing ARV drugs free of charge is an important step, the costs of other components of care constitute important financial barriers that may exclude patients from accessing appropriate care. Such barriers can also lead to undesirable outcomes in the future, such as impoverishment of AIDS-affected households, higher ARV drug-resistance rates and greater need for complex, expensive second-line antiretroviral drugs.

Keywords:

• cost of AIDS care
• access to treatment
• China
• MSF
• out-of-pocket costs
• AIDS

Acknowledgements

We wish to thank two anonymous referees for their helpful comments and suggestions, the staff and PLWHA of the Xiangfan and Nanning projects and other PLWHA who have brought these issues to our attention. All errors remain our own.

Notes

1. The Four Frees, One Care policy also stipulates “…(b) free voluntary counselling and testing (VCT); (c) free drugs to HIV-infected pregnant women to prevent mother-to-child transmission, and HIV testing of newborn babies; free schooling for children orphaned by AIDS; and (d) care and economic assistance to the households of people living with HIV/AIDS.”

2. Delivery by Caesarean section is standard practice in China for PMTCT. However, abortion is sometimes recommended as the first option, before PMTCT. For example, Article 21 of the Hubei province policy states, “If either the husband or the wife, or both of the couple, is HIV-positive, the pregnancy should be terminated; if they don't want to terminate the pregnancy, they must adopt measures to prevent mother-to-child-transmission of HIV.” (Hubei Province, 2004). We do not include price information on abortion for lack of data.

3. Median amount per round-trip that MSF reimbursed to patients, extrapolated to estimate annual transport costs. Médecins Sans Frontières reimburses transport costs to selected patients based on needs assessments made by counselors; transport costs also vary widely depending not only on where patients live, but also on the type of transport, catchment area of the program, availability of services, geographical factors and other issues. Thus, transport figures are not representative and should only be used as a point of reference.

4. Patients frequently mention lodging as an additional cost. However, MSF does not provide financial support for lodging as another NGO has established free shelters in both locations where patients coming to the clinics can stay. Thus, lodging costs are excluded from this calculation for lack of data.

5. As of 2004, national policy states that TB drugs should be free for patients who are sputum positive or negative (with clinical diagnosis). Many TB/HIV-co-infected patients are sputum negative (including 100% of TB-diagnosed patients in the Xiangfan project as of May 2006); yet, the majority of patients seen in the Xiangfan clinic did not receive free drugs for various reasons, indicating that the new policy was not yet implemented everywhere.

6. Penicilliosis is one of the most common OIs seen in Nanning (17%) and is also prevalent in other southern provinces such as Yunnan, Guizhou and Guangdong. However, it is not seen in central China and, therefore, the cost of treatment is not included in the Xiangfan calculation.

7. After a number of patients requested financial assistance, MSF began paying the Western blot fee for all patients in June 2005 in the Nanning project.

8. The government price for a generic ARV triple-combination of stavudine or zidovudine, didanosine and nevirapine is about 438 US$ per year (Bureau of Economic Operations, 2005). There is no publicly available information regarding the government price paid for a 3TC-based combination, although this is the recommended first-line regimen, as the terms of supply from GlaxoSmithKline for 3TC are kept confidential.

9. See Free by 5: Economists’, Public Health Experts’ & Policy Makers’ Declaration on Free Treatment for HIV/AIDS, (2005).