cost analysis of hivaids treatment and cost effective analysis of different cd4 baseline in selected provinces, municipalities

1
ACRONYMS
AIDS Acquired immunodeficiency syndrome
ART Antiretroviral therapy
ARV Antiretroviral drug
CD4 Cluster of differentiation 4
VC Voluntary care
DI Diagnostic imaging
DALY Disability adjusted life year
DFID
LOS
Department for International Development
Length of Stay
PMTCP Prevention of mother-to-child transmission
HIV Human immuficiency virus
ICER Incremental cost-effectiveness ratio
IDU Injecting drug user
MSM Men who have sex with men
OI Opportunist infection
OPC Outpatient clinic
PEPFAR President’s Emergency Plan for AIDS Relief
QALY Quality adjusted life year
GF Global Fund
STI Sexually transmitted infection
HC Health center
UNAIDS Joint United Nations Programme on HIV/AIDS
UNICEF United Nations Children's Fund
VCT Voluntary counseling and testing
WB World Bank
WHO World Health Organization
2

INTRODUCTION
In the preparation for resources pooling plans for the HIV/AIDS
care and treatment program within the National Strategy for
HIV/AIDS control by 2020 and vision to 2030, information on
HIV/AIDS treatment costs is a vital input for the estimation of
financial resources needed to make sure that the care and treatment
program is well-designed and viable.
In ARV therapy, treatment timing may have massive bearing on
the treatment outcomes and access to the program offerings. The
World Health Organization recommends early treatment for
HIV/AIDS patients, at initiation of CD4<350 cells/mm
3
. Early
recognition and treatment however remain a challenge in Vietnam as
patients often seek medical help when their condition has progressed
to a CD4 cell count of less than 100 cells/mm
3
. In that context,
defining the best timing for treatment amid resource constraints
remains a question to be answered by managers of the HIV/AIDS
therapy program in Vietnam.
The “HIV/AIDS therapy costing and cost-effectiveness by
CD4 cell count in selected provinces” review aims to cover the
following mandates:
1. Situational analysis of HIV/AIDS therapy costs in selected
provinces in Vietnam for 2009-2010;
2. Treatment cost-effectiveness analysis by CD4 cell count at
different study points.
* New inputs of the review
- The review provides a comprehensive picture of HIV/AIDS

therapy costs in 10 provinces and cities in Vietnam in 2009-2010. The
study findings on HIV/AIDS treatment costs are highly representative
and may be used for the HIV/AIDS therapy program in Vietnam. The
review looks at the changes in HIV/AIDS treatment costs depending
on relevant factors and determines the proportions of different cost
components by treatment stages.
- This is the first work on cost-effectiveness in the field of
HIV/AIDS treatment. The study is a combination of a biological
review and a health economics review. The study finds the
relationship between the costs and effectiveness of HIV/AIDS
treatment by different CD4 cell counts, where effectiveness is
converted and measured by the added life years at different CD4
levels.
* How the report is structured
3
The study has 130 pages and 4 chapters, including Introduction:
2 pages, Chapter 1. Overview: 32 pages, Chapter 2. Subject and
methodology: 25 pages, Chapter 3. Findings: 43 pages, Chapter 4.
Discussion: 25 pages, Conclusion: 2 pages, Recommendations: 1
page, 39 tables, 39 charts, 7 figures and 150 references, 22 in
Vietnamese and 128 in English.
Chapter 1. OVERVIEW
I.1. HIV/AIDS treatment and HIV/AIDS treatment models in the
world and Vietnam
I.1.1.The HIV/AIDS treatment context and global ARV therapy
needs
By the end of 2011, as many as 8 million people in low and
middle income countries have had access to antiretroviral drugs,
which was a 25 fold increase over 2002. While many HIV-positive
people have been admitted to the therapy program, as they often

resorted to medical help at a later stage, their CD4 cell counts were
often much lower than the level recommended by the World Health
Organization for ideal therapy commencement.
I.1.2.ARV therapy need in Vietnam
As the number of HIV-positive people is increasing, so is the
need for HIV/AIDS treatment and care. The need for HIV/AIDS
treatment for 2012-2015 is estimated as follows: 2012 – 119,298
people; 2013 – 129,379 people; 2014 – 139,646 people; 2015 –
150,120 people; 2020 projection – 195,380 people.
1.1.3. Existing HIV/AIDS treatment models around the world
1.1.3.1. Centralized treatment at health care facilities
1.1.3.2. Community-based HIV/AIDS treatment
1.1.4. HIV/AIDS treatment models available in Vietnam
1.1.4.1. HIV/AIDS management and treatment within the
health system
a) At central level hospitals
b) At province/district general hospitals
c) At province/district health centers
1.1.4.2. HIV/AIDS treatment at institutions outside the
health system
a) At penitentiaries and 05/06 centers
b) Treatment at social welfare facilities
c) Piloting models: the treatment initiative 2.0 and
commune/ward-based basic therapeutic service delivery.
1.1.5. Cost-effectiveness analysis
4
Cost-effectiveness analyses help estimating costs per
incremental effectiveness unit (ICER). These analyses may be used to
compare between national or regional interventions. The World
Health Organization introduces rules on how to determine cost-

effectiveness ratings:
- ICER < GDP per capita: very cost-effective intervention
- ICER of 1-3 GDP per capita: cost-effective intervention
- ICER > 3 GDP per capita: Cost-ineffective intervention.
Chapter 2. METHODOLOGY
The study has two key components: 1) HIV/AIDS treatment cost
breakdown, and 2) cost-effectiveness by CD4 levels.
2.1. Situational analysis of HIV/AIDS therapy costs in selected
provinces in Vietnam for 2009-2010
2.1.1. Sites, timing and subjects
2.1.1.1. Sites
The study takes place at 17 HIV/AIDS outpatient and inpatient
clinics located in 10 provinces and cities in Vietnam, including Hanoi,
Ho Chi Minh City, Thai Nguyen, Hai Duong, Ninh Binh, Haiphong,
Can Tho, An Giang, Dong Thap and Khanh Hoa.
These 17 clinics are purposefully selected from 30 therapeutic
facilities participating in the cohort ARV drug resistance follow-up
study by the HIV/AIDS Control Administration in 2009.
2.1.1.2. Timing
Cost estimating timeline: March 2009 – March 2010.
2.1.1.3. Subjects
Adult HIV/AIDS patients (of over 15 years of age) who are
known to be HIV-positive and have registered for inpatient and
outpatient clinical care, selected for the HIV/AIDS treatment sample,
including pre-ART patients, those on first year first line ART, those
on first line ART from the second year and those on second-line ART,
with periods in treatment meeting the timing requirements for costing.
2.1.2. Methodology
2.1.2.1. Study design
This is a cross-sectional study with retrospective data collection

and analysis on HIV/AIDS inpatient and outpatient treatment costs.
Inpatient treatment costs are calculated based on the cost per
patient per episode.
Inpatient costs encompass medications, supplies, tests,
diagnostic imaging, human resources, overheads, depreciation costs
incurred during the patient’s entire hospitalized period.
5
An inpatient episode is the entire amount of time following a
patient’s admission to discharge for all patients known to be HIV-
positive before or during inpatient treatment.
Outpatient costs are estimated based on the cost per patient per
year.
Outpatient costs include counseling, testing, medication,
opportunist infection treatment, human resources, overheads and
facility/equipment depreciation divided by the following periods:
- Pre-ART treatment (cost/person/year)
- First line ART Year 1 (cost/person/year)
- First line ART From Year 2 (cost/person/year)
- Second line ART (cost/person/year).
Outpatient treatment is identified based on the HIV/AIDS
treatment protocol using antiretroviral drugs (ARV) issued as part of
Decision 3003/2006/QĐ-BYT of June 9, 2009, of the Ministry of
Health, providing guidelines on HIV/AIDS diagnostics and treatment.
2.1.2.2. Cost breakdown perspective
Costs are considered from a supplier perspective, with public
health care facilities involved in HIV/AIDS therapy delivery,
including province/city hospitals, HIV/AIDS centers and district
health centers.
2.1.2.3. Costing methodology
Costing methodology is hybrid of top-down cost analysis (step

down) for labor, operating costs, depreciation, and a bottom-up
approach, which involves detailed breakdown for medication,
supplies, diagnostic imaging and testing. The method allows
estimation of average treatment costs by different stages.
2.1.2.4. Sample size
20 adult medical records with different treatment stages are
selected. From 16 outpatient clinics, the total number of outpatient
non-second-line regimen medical records selected is 960. From 5
second-line regimen clinics, a sample of 150 adult patients on a
second-line regimen is selected.
For inpatients, 40 adult medical records are collected from every
provincial and central level health care facilities. There are no patients
of this kind at the district level. From the 8 inpatient clinics in the
sample, a total of 320 inpatient medical records are selected.
The gross number of medical records collected for costing is
1430. Of these, 1401 inpatient and outpatient HIV/AIDS medical
records have been processed.
2.1.3. Study parameters
6
- Participant background indicators in the study include
demography, median CD4, percentages of patients by different CD4
counts and distribution of patients by levels of care and types of
clinics.
- Indicators for HIV/AIDS inpatient and outpatient costs and
changes of therapeutic expenses depending on relevant determinants
and the proportions of cost components include 27 items.
2.1.4. Toolkit and materials
The data collecting toolkit consists of: (i) a form to collect
providers’ outputs; (ii) a form to collect staffing cost data; (iii) a form
to collect overheads data; (iv) a form to collect depreciation cost data;

(v) a form to collect inpatient care cost data; and (v) a form to collect
outpatient care cost data.
2.2. Cost-effectiveness analysis by different CD4 basiline
2.2.1. Sites, subjects, locations and timing
To estimate effectiveness as gained life years for patients with
different CD4 initiation, secondary data review is conducted using
clinical and immunological response studies for adult patients on ART
in Vietnam to understand the changes in the patients’ survival by
different CD4 baseline.
Clinical and immunological response studies on adult patients on
ART in Vietnam are conducted on 7758 adult HIV/AIDS patients.
The studies take place at 30 clinics randomly selected from 120
facilities nationwide having 50 or more patients on ART. These 30
clinics are located in 16 provinces/cities: Hanoi, Hung Yen, Thai
Nguyen, Bac Giang, Vinh Phuc, Bac Can, Lang Son, Dien Bien,
Quang Ninh, Haiphong, Thanh Hoa, Nghe An, Thai Binh, Binh
Duong, Long An and Ho Chi Minh City.
The study completed in 2010 was designed as a cohort study,
collecting retrospective data from medical records selected at the
clinics.
2.2.2. Methodology
2.2.2.1. Study design
HIV/AIDS treatment efficacy by CD4 baseline is measured by
the ratio of cost to treatment efficacy. Cost parameters are extracted
from the results of component 1 and the treatment efficacy is
measured by the life years gained by different CD4 baseline calculated
based on the patient’s survival chance by CD4 counts.
Survival chance by CD4 levels: The Kaplan Meier survival
estimator is used to calculate the survival chance of patients in early
7

treatment (CD4 >=100 cells/mm
3
) and patients in late treatment (CD4
<100 cells/mm
3
).
Mortality risk of participants in the sample: The Cox
multiparameter regression model is used to compare mortality-related
determinants.
The cost-effectiveness of interventions is measured by the
incremental cost-effectiveness ratio (ICER) by different CD4 levels.
2.2.3. Study parameters
Survival chance of participants by CD4 counts: 6 parameters.
Mortality risk of participants in the sample by different determinants:
4 parameters. Added life years by different CD4 levels: 3 parameters.
Cost-effectiveness by CD4: one parameter.
2.3. Ethics
The study outline was approved by the Ethics Board, National
Institute of Hygiene and Epidemiology, and Hanoi School of Public
Health.
Chapter III. FINDINGS
3.1. Situational analysis of HIV/AIDS therapy costs in selected
provinces in Vietnam for 2009-2010
3.1.1. Participant background
In total, there are 1401 participants, including inpatients and
outpatients. Of these, 319 people are inpatients and 1082 are
outpatients (305 pre-ART patients, 332 first year first line ARV
patients, 323 first line ARV patients from the second year and 122
second line ARV patients).
Male participants account for 64% of the total, with the other

36% being women. Mean ages of participants was 33.6 year (SE + 0.2
year).
3.1.2. HIV/AIDS inpatient costs
3.1.2.1. HIV/AIDS inpatient costs and changes in treatment costs
by relevant determinants
The HIV/AIDS inpatient cost is VND 4,341,253 per session (SE
+ VND 299,367).
a) HIV/AIDS inpatient cost and average length of stay at clinics
The average treatment cost/length of stay in national and
municipal level hospitals are higher than those of lower level hospitals
(Figure 3.3).
8
Figure 3.3. HIV/AIDS inpatient cost and average LOSat clinics
b) Percentage of opportunistic infections and respective
treatment costs
Respiratory tract infection is the most prevalent opportunistic
infection in the sample, followed by tuberculosis, diarrhea, pathogenic
fungi and some other symptoms. The most expensive treatment cost is
more than VND 10 million for such opportunist infections as
toxoplasmosis, though this disease is not as prevalent as the most
common conditions of respiratory infections and tuberculosis, which
both cost approximately VND 3.7 million for a treatment session.
c) Changes in treatment costs by gender and age group
Table 3.6 &3.7. HIV/AIDS inpatient cost by gender, age group
Description N %
Average
LOS
(days)
Mean
cost/episode

(VND)
Mean
cost/day
(VND)
Male 235 74.4 15 4,451,606 296,774
Cost
Cost (VND)
National
Tropical
Diseases
Hospital
HCMC
Tropical
Diseases
Hospital
Dong
Da
Hospital
Vietnam-
Czech
Hospital
Ninh
Binh
General
Hospital
Hai
Duong
AIDS
Center
Dong

Thap
General
Hospital
Can Tho
General
Hospital
Frequency to get the disease)
C
o
s
t
/
p
a
t
i
e
n
t
/
s
t
a
y

(
V
N
D
)

Length of stay
Fequency
Length
of stay
M
e
a
n

C
o
s
t
/
p
a
t
i
e
n
t

(
V
N
D
)
Aver. length of stay (days)
Respiratory
infections

Diherria P
Maneifei
Unidentifed
group
Tuberculo
sis
9
Female 81 25.6 17 3,936,423 231,554
<=25 24 7.5 11 2,766,480 251,498
26-30 99 31.2 18 4,052,258 225,125
31-35 101 31.8 17 5,596,973 329,234
36-40 46 14.5 13 3,208,808 246,831
41-45 25 7.8 12 4,210,865 350,905
46+ 23 7.2 11 4,227,326 384,302
d) Changes in treatment cost by conditions
42% of the patients in the sample are in serious
immunodeficiency conditions with CD4 count of less than 50
cells/mm
3
. The treatment cost for these patients is twice that of
patients with improved immunological conditions.
Table 3.8. HIV/AIDS inpatient costs by different CD4 levels
CD4
levels at
admission
N %
Average
LOS
(days)
Mean

cost/episod
e
(VND)
Mean
cost/day
(VND)
<50 56 42.7 19 7,474,717 393,406
51-100 27 20.6 24 5,008,118 208,672
101-200 26 19.8 28 5,466,331 195,226
201+ 22 16.8 15 3,783,965 252,264
The mean cost per day for patients with CD4 < 50 cells/mm
3
is
VND 393,406, which is twice that of patients with CD4 count of 50-
101 cells/mm
3
and those with CD4 of 101-200 cells/mm
3
.
e) Changes in treatment cost by levels of care
Table 3.9. HIV/AIDS inpatient costs by levels of care
Patient
distribution by
N %
Average
LOS
(days)
Mean
cost/episode
(VND)

Mean
cost/day
(VND)
National level 80 25.1 12 7,197,176 599,765
Provincial level 195 61.1 11 3,225,616 293,238
Provincial AIDS
centers
44 13.8 38 4,092,966 107,710
The mean cost at national level inpatient clinics is 2.5 times
higher than that of provincial level clinics. The mean inpatient cost at
provincial AIDS centers is higher than that of other provincial level
clinics.
10
f) Changes in treatment cost by regions
Table 3.10. HIV/AIDS inpatient costs by regions
Region N %
Average
LOS
(days)
Mean
cost/episode
(VND)
Mean
cost/day
(VND)
North 203 33.5 18 4,576,128 254,229
South 116 66.5 10 3,930,222 393,022
The HIV/AIDS treatment cost in the North is VND
4,576,128/patient/treatment session, which is higher than the VND
3,930,222/patient/session in the South.

g) Changes in treatment costs by ART status
Table 3.11. HIV/AIDS inpatient costs by ART status
ART status N %
Average
LOS
(days)
Mean
cost/episo
de
(VND)
Mean
cost/day
(VND)
On ART 94 33.5 20 4,778,433 238,922
Not on ART 187 66.5 13 4,349,049 334,542
Only 33.5% of inpatients in the sample are on ART, and the
average treatment costs for patients on ART are higher (66.5%). The
average treatment cost for patients on ART is higher than that of those
not on ART.
h) Changes in treatment cost by treatment outcomes
Table 3.12. HIV/AIDS inpatient costs by treatment outcomes
Treatment
outcomes
N %
Average
LOS
(days)
Mean
cost/episod
e

(VND)
Mean
cost/day
(VND)
Cured 28 9.1 14 5,097,543 364,110
Improved 197 64.0 17 4,441,302 261,253
Not improved 57 18.5 6 2,185,549 364,258
More severe 19 6.2 12 6,698,141 558,178
Death 7 2.3 14 9,264,868 661,776
About 9% of the patients in the sample have been cured, with an
average treatment cost of VND 5,097,543/patient/session. 64% of the
patients achieved improved conditions with an average cost of VND
4,441,302/patient/stay. Mortality cases account for 2.3% of the
sample, with an average treatment cost of VND
11
9,264,868/patient/stay, which is nearly twice that of cured cases and
nearly 2.5 times higher than improved cases.
i) Changes in treatment cost by financial protection levels
Table 3.14. HIV/AIDS inpatient costs by insurance status
Description N %
Average
LOS
(days)
Mean
cost/episode
(VND)
Mean
cost/day
(VND)
With insurance 26 8.3 12 3,433,093 286,091

Without insurance 287 91.7 16 4,430,215 276,888
Only 8.3% of the patients in the sample have a health insurance
card, and the average treatment cost for this group is lower than that of
those without a health insurance card, who account for 91.7% of the
total.
3.1.2.2. Percentages of cost components in HIV/AIDS inpatient
cost
Figure 3.5. Components of HIV/AIDS inpatient cost
In the structure of HIV/AIDS inpatient cost, medicines, supplies,
subclinical services and labor are the key items that constitute the total
cost, accounting for about 70-85% of the grand total. The proportions
of medicines, supplies and subclinical services in the cost structure
decline as the immunological status is improved.
National
Tropical
Diseases
Hospital
HCMC
Tropical
Diseases
Hospital
Dong Da
Hospital
Vietnam-
Czech
Hospital
Ninh Binh
General
Hospital
Hai

Duong
AIDS
Center
Dong
Thap
General
Hospital
Can Tho
General
Hospital
Overhead
s
Depreciation Labor Paraclinical Medicines and supplies
12
Figure 3.6. Percentages of cost items by CD4 levels
3.1.3. HIV/AIDS outpatient cost
3.1.3.1. HIV/AIDS outpatient cost and changes in treatment cost
by determinants
The HIV/AIDS outpatient costs per patient a year are VND
2,138,931 (SE = + VND 1,548,073) for pre-ART patients; VND
6,421,893 (SE = + VND 420,366) for first year first line ARV
patients, and VND 6,005,153 (SE = + VND 209.296) for first line
ARV patients from the second year onward. Second line ART costs
VND 28,236,312 (SE= + VND 1,207.563).
a) Treatment cost by gender and age group
The mean costs for the pre-ART group are VND
2,189,339/patient/year for men and VND 2,087,011/patient/year for
women. The mean cost for first line ART in year 1 are VND
6,391,088/patient/year for men and VND 6,490,059/patient/year for
women. The mean costs for the first line ART from year 2 are VND

6,105,861/patient/year for men and VND 5,814,251/patient/year for
women. The mean cost for the second line ART are VND
28,259,482/patient/year for men and VND 28,125,829/patient/year for
women.The highest mean cost in PRE-ART is at 41-45 (VND
3.647.230/person/year) and the lowest cost is at 36-40 (VND
1.552.160/person/year). The highest mean cost in first line ART year
1 is at 31-35(VND 6.903.630/person/year) and the lowest cost is at
41-45 (VND 5.433.696/persone/year). The highest mean cost in first
line ART from year 2 is at over 46 (VND 7.012.858 per person/year)
và the lowest cost is at 41-45 (VND 5.202.876/person/year). The
highest mean cost in second line ART is at below 25 (VND
31.452.388/person/year) and the lowest cost is at 41-45 (VND
25.517.383 /person/year).
b) Treatment cost by CD4 levels
Overheads
Labor
Medicines, supplies
Depreciation
Paraclinical
13
Figure 3.8. Outpatient costs by CD4 levels
Among the pre-ARV group, the average treatment cost is the
highest among patients with CD4 < 50 cells/mm
3
(VND
3,077,652/patient/year) and lowest among those with CD4 > 200
cells/mm
3
(VND 2,067,419/patient/year).
If the patients are on ART, the average treatment cost is the

highest among patients on first year first line ART with CD4 < 50
cells/mm3 (VND 7,138,766/patient/year) and lowest among those
with CD4 > 200 cells/mm3 (VND 5,685,899/patient/year).
To see the difference in costs, the study further looks at the costs by
different CD4 counts at levels < 100 cells/mm
3
and >= 100 cells/mm
3
as in Figure 3.9 below. The treatment cost diminishes as the patients’
immunological status improves.
Figure 3.9. HIV/AIDS outpatient cost by two CD4 levels
The cost for early treatment (CD4 >= 100 cells/mm
3
) is about
48% lower than late treatment (CD4 < 100 cells/mm
3
) among the pre-
ARV group; 21% among the first year first line ARV group and 4%
among those on first line ART from the second year onward.
To further understand the changes in treatment costs by different
immunological levels which are not affected by ARV, treatment costs
are looked at in different treatment stages, on the three key cost
1st line ART year 1 1st line ART from year 2
1st line ART Year 1 1st line ART from Year 2Pre-ART
1st year first line ARTPre-ART
14
components of secondary infection medication and diagnostic
imaging, labor, overheads and depreciation.
Figure 3.10. HIV/AIDS outpatient cost exclusive of ARV by
treatment stages and immunological status

The treatment cost is high when the patients are in more severe
stages as the CD4 count is below 50 cells/mm
3
, though the cost
difference remains unclear as CD4 is improved. Changes in cost also
remain unclear at CD4 levels > and ≤ 100 cells/mm
3
among the
second line ARV group.
Figure 3.17. Second-line outpatient cost by different CD4 levels
CD4 counts Number Percentage Mean cost SD
N
% VND VND
<50 25 26 29,059,634 1,050,346
51-100 26 27 27,703,494 1,419,615
101-200 31 32 29,035,075 869,015
201+ 15 15 28,299,783 574,856
<100 51 55.7 28,455,192 1,205,419
>=100 46 44.3 28,759,646 636,751
c) Changes in treatment cost by treatment regimen
Of the first line regimens, the most frequently used treatment
plan is regimen 1a (56%) for first year ART, and 41.5% for Art from
the second year onward and mixed plans (19.3% for first year ART
and 18.3% for ART from the second year). These two regimens
however have lower costs than the remaining.
In second line ART, The average treatment costs by different
regimens and percentages of patients adopting the regimens are
described in Figure 3.14 below.
15
Figure 3.11. HIV/AIDS outpatient costs by second line regimens and

number of patients adopting the regimens
d) Changes in treatment cost by levels of care and types of clinics
The average treatment cost per patient a year at a national level
hospital is VND 1.3 million, which is lower than that of a provincial
level hospital (VND 1.7 million), an HIV/AIDS center (VND 2.5
million) and a district level hospital/health center (VND 2.3 million).
The mean cost changes considerably when patient shift to 2nd year of
treatment. The mean cost reduces in all treatment sites which shows
the adaptation of patient to ARV drug.
e) Changes of supporting funds
Donors’ support as a percentage of the total cost ranges from
54% to 86%. Particularly for ARV drugs, the support percentage
accounts for 100%. Opportunist infection medications and clinical
diagnostic services account for more or less 90% of the total cost.
PEPFAR’s support ratio is very high, at 50-60% of the total cost,
while the Global Fund only covers about 10% of the financial support.
The costs for different regimens vary disproportionately between
national and project sources.
f) Changes in treatment cost by regions
The average treatment cost per patient a year among all groups
in the North is lower by 8-36% than that of patients in the Central and
South. The pre-ART costs for the Central and South are one third
higher than that of the North.
3.1.3.2.Percentages of cost components in HIV/AIDS outpatient
treatment
Table 3.23.Outpatient cost and percentages of cost component by
treatment stages
Other
regimens
Other

mixed
regimens
Percentage
P
e
r
c
e
n
t
a
t
e

o
f

r
e
g
i
m
e
n

u
s
e
Mean cost per regimen (VND)
Cost

16
Cost items
1
st
year
ART
%
ART
from
year 2+
%
2
nd
line
ART
%
ARV drugs 2,391,670 37.2
2,830,19
4
47.1
25,253,78
5
89.4
OI drugs 1,296,361 20.2 664,724 11.1 553,401 2.0
Tests and DI 991,627 15.4 1,016,384 16.9 1,422,535 5.0
Labor 1,242,551 19.3 1,098,176 18.3 862,381 3.1
Overheads 411,368 6.4 321,842 5.4 95,002 0.3
Depreciation 88,316 1.4 73,834 1.2 49,207 0.2
Total 6,421,892 100 6,005,153 100 28,236,311 100
Pre-ART patients: The cost components vary widely

between different clinics. Medicines, subclinical services and labor
account for a major part of the total cost. Subclinical services account
for 2-11%. Medicines account for 5-70%. For patients on ART for
the first year and from the second year onward, the composition of
ARV drugs seem relatively evenly distributed among the clinics.
Secondary infection drugs and subclinical services vary largely
between the clinics for both groups. Depreciation takes up a minor
share and is unevenly distributed among the clinics.
In this review, there are four stand-alone facilities which provide
only HIV services. Integrated health care facilities, namely hospitals
and health centers, provide medical care, including HIV services.
Figure 3.15. Changes of treatment costs by
stand-alone and integrated facilities
17
Second line ARV patients: In the second line ART regimen, ARV
drug costs account for the majority of the share, at 83-89%. These are
followed by subclinical services, labor, overheads and depreciation.
Figure 3.16. Percentages of cost items in second-line therapy
3.2. Cost-effectiveness analysis for HIV/AIDS therapy by different
CD4 levels
3.2.1. Life years gained by CD4 levels
Measurement of ART cost-effectiveness for HIV patients by
CD4 < 100 cells/mm
3
and CD4 >= 100 cells/mm
3
using the TreeAge
2011 software returns the following results.
Figure 3.26. Life years gained by CD4 levels
3.2.2. Cost-effectiveness by different CD4 levels

Table 3.30. Cost-effectiveness by different CD4 levels
CD4 levels Lifetime cost
for living
Living
years
Cost/
living
Increased
cost/living
LIE YEAR GAINED BY DIFFERENT CD4 BASELINE
Pre-ART
CD4 < 100
Pre-ART
CD4 ≥ 100
1st line ART
CD4 < 100
1st line ART
CD4 ≥ 100
2nd line ART
CD4 < 100
2nd line ART
CD4 ≥ 100
18
(cells/mm
3
)
years (VND) (years)
years
(VND)
year

C E C/E
Incr CE
CD4 < 100 326,455,952 17.98 18,155,576 -
CD4 >= 100 524,186,495 30.60 17,131,795
15,672,675
The cost for an added surviving year for early treatment, with
CD4 >= 100 cells/mm
3
is VND 17,131,795 compared to VND
18,155,576 for late treatment, with CD4 < 100 cells/mm
3
. The
incremental cost-effectiveness ratio (ICER) for an added year in
survival in cases of early treatment (CD4 >= 100 cells/mm
3
) as
opposed to late treatment (CD4 < 100 cells/mm
3
) is VND 15,672,675
per patient.
Chapter IV. DISCUSSION
4.1. HIV/AIDS treatment cost in Vietnam and changes in
HIV/AIDS treatment cost by determinants
The HIV/AIDS treatment cost in Vietnam is lower than that
presented in various studies previously published in Vietnam and
elsewhere.
4.1.1. HIV/AIDS inpatient cost
Inpatient treatment for HIV/AIDS patients costs VND 4,341,253
per stay. This is not much higher (14%) than the treatment cost for
chronic obstructive pulmonary disease (VND 3.7 million), but much

lower than for diabetes treatment (USD 100-150/stay), cancer (VND
12.3 million) and myocardial infarction (VND 31.4 million).
Comparisons of HIV/AIDS inpatient cost with some other regional
countries of similar socioeconomic conditions indicate that Vietnam
has lower treatment costs. The treatment cost is higher in patients of
26-35 years of age who also has a higher average length of stay than
other age groups. This age group also has the majority of the sample,
at about 63%. As such, the most productive age group turns out to be
the one that is in need of treatment and has a higher rate of
hospitalization than other groups.
The average length of stay is 15.3 days (+ 0.94 days/stay), which
is higher than that of some other countries. The longer length of stay is
proof of late treatment in Vietnam as patients often seek medical help
when their conditions have progressed.
19
Nevertheless, the inpatient cost and length of stay also vary
significantly between different clinics. The HIV/AIDS inpatient cost
at national level health care facilities and those in major cities is
higher than that of provincial level clinics. The treatment cost for
patients with CD4 < 50 cells/mm
3
is twice that of those with improved
immunological status. This corresponds with the findings of a study in
the United States, where the treatment cost for patients with CD4 < 50
cells/mm
3
is 2.5 times higher than that of other groups.
4.1.2. HIV/AIDS outpatient cost
The HIV/AIDS outpatient cost is VND 2,138,931 (+ VND
1,548,073) for pre-ART patients; VND 6,421,893 (+ VND 420,366)

for year one first line ART, and VND 6,005,153 (+ VND 209,296)
for first line ART from the second year. The second line ART cost is
VND 28,236,312 (+ VND 1,207,563). Except for second line ART,
HIV/AIDS treatment in Vietnam has relatively modest costs
compared to some previous studies elsewhere in the world, given the
average treatment costs per person a year, for example, being USD
792, USD 932 and USD 1454 in low income, low middle income and
high middle income countries. In reference to a PEPFAR review’s
findings in Vietnam, the figures in this study are much lower.
4.1.3. HIV/AIDS treatment cost in Vietnam, cost
components and changes in treatment cost by determinants
4.1.3.1. Treatment cost components
a) ARV and opportunist infection drugs take up the largest
share in HIV/AIDS treatment cost, followed by subclinical services
and labor.
Given HIV-positive people’s vulnerable immune system, the
need for opportunist infection medications to contain symptoms and
ARV drugs to help recover the immune system is very high, thus
opportunist infection and ARV drugs consistently take up the largest
share in the treatment cost.
In respect of HIV/AIDS inpatient care, opportunist infection
drugs have the largest percentage of the total treatment cost. The
medicine cost as a percentage of the total expense grows as the
condition progresses. As the patient’s immunological status
deteriorates (CD4 < 50 cells/mm
3
), drugs account for nearly 50% of
the total cost, and when the patient’s condition is improved (CD4 >
200 cells/mm
3

), the drug cost as a percentage of the total medical care
expense drops to 25%. Meanwhile, the cost percentages of
subclinical services and labor remain relatively even between
20
different stages of the illness.
b) Cost differences between outpatient and inpatient clinics
These cost differences may be explained by: (i) differences in
the therapeutic models between programs and projects, (ii)
differences of the services package offered by programs and projects,
and (iii) different organizational and staffing structures between
therapeutic models.
4.1.3.2. Changes in treatment cost by determinants
a) HIV/AIDS treatment cost in Vietnam and changes in treatment
cost by clinical stages and immunological status: early access to
therapy helps reduce treatment cost in the future.
The findings of this review indicate that the more severe the
patient’s immunodeficiency conditions are (the lower the CD4
levels), the higher the treatment cost, particularly the percentage of
OI medicines. In HIV/AIDS inpatient care, treatment costs vary
between patients with CD4 < 50 cells/mm
3
and in the clinical stage 4.
The treatment cost is twice that of patients with CD4 > 200
cells/mm
3
, and similarly, the treatment cost for patients in the 4
th
clinical stage is often double that of patients in other stages.
b) HIV/AIDS treatment cost in Vietnam and changes in treatment
cost as the patients start their ARV therapy

Study findings indicate that the inpatient costs vary between
patients who are not on ART and those on ART. The treatment cost for
patients on ART is higher than those not yet on ART. The cost
difference is attributed to spending for the treatment of symptoms
generated by side-effect of drugs.
Outpatient costs also vary by different therapeutic stages. The pre-
ART cost is only one third of the cost for first line ART in the first year and
first line ART from the second year and beyond. The largest gap exists in
pre-ART settings where only opportunist infection prophylactic medications
are often used, and not ARV drugs.
c) HIV/AIDS treatment cost in Vietnam and changes in treatment
cost by types of clinics, levels of care, treatment outcomes and length of
treatment
Regarding HIV/AIDS inpatient costs, the expenses at the national
level of care is twice that of the provincial level. This is because national
level health care facilities are the last line of curative care for severe
cases, including severe opportunist infections and other severe illnesses
caused by side-effects of ARV drugs, which are beyond the capacity of
lower level clinics.
In case of HIV/AIDS outpatient care, the therapeutic model
21
applied in national level facilities incurs a lower average treatment cost
than provincial level health facilities, AIDS centers and district level
clinics. The lower treatment cost is possible since in the clinics in major
hospitals, the cost is distributed across large volumes of services
delivered, such as tests and diagnostic imaging services, resulting in
smaller unit costs compared to clinics having lower volume of services
delivered at lower tiers of the system.
The study provides a convincing evidence of the efficacy of
integrating HIV/AIDS treatment in the existing health system. It also

proves that this is true not just for opportunist infection drugs, but also
labor and other expenses such as depreciation and operating costs, as all
clinics embedded in the existing health system incur lower costs than
stand-alone counterparts. The cost difference may be explained in this
way. First, service utilization in integrated clinics is higher than in stand-
alone facilities since these clinics not only serve HIV/AIDS patients, but
also provide other medical services, and hence overheads and
depreciation divided by the volume of clients served will be lower than
stand-alone sites. Second, the staffs of integrated clinics often work on a
part-time basis. They not only serve HIV/AIDS patients but also other
types of patients, and therefore, the labor cost of integrated clinics is
often lower than that of stand-alone facilities.
Treatment costs tend to reduce when patients enter more stable
stages of the condition. The cost is very high when the patients start their
ARV therapy. The treatment cost is often high in the first year and boils
down from the next year. When the patients have become accustomed to
ARV drugs and their conditions are more stable, the treatment cost will
be on the decrease from the second year onward.
4.1.3. HIV/AIDS treatment cost in Vietnam and available financial
resources
4.1.3.1. HIV/AIDS treatment cost and financial protection for
HIV-positive people against health care costs
It should be noted that illnesses with the highest prevalence are not
the most expensive to take care of. The two most common diseases –
pneumonia and tuberculosis – are relatively less expensive, costing just
one third of the most expensive illness, which is opportunistic
toxoplasmosis. This may be good news for those who want to convince
insurance agencies to cover HIV services by erasing the usual concerns
of costly and long-term HIV treatment.
HIV/AIDS inpatient care has now been paid for by out-of-pocket

money and in part by health insurance for insured patients. In the study
sample, however, only 8.3% of the participants have a health insurance
card, and the remaining 91.7% make out-of-pocket payments for their
22
treatment. The treatment cost for non-insured patients is 30% higher
than that of the insured patients, and added to that, the average length of
stay for the insured (12 days) is also often shorter than that of the non-
insured (16 days). It seems that patients without a health insurance card
may be more seriously ill, hence have to stay in the hospital for longer
periods of time and pay more than insured patients. At the admission
frequency of 1.6 times a year, the accumulated treatment cost can be
significant for HIV-positive people, putting them at risk of
impoverishment if they have no financial protection to fall back on.
4.1.3.2. HIV/AIDS therapy sustainability in Vietnam
The review provides very clear evidence of the strong
dependence on international support in the delivery of HIV/AIDS
treatment. International projects provide 100% of ARV drugs, 90% of
opportunist infection medications and diagnostic tests. In respect of
human resources support however, the Global Fund’s staffing model
has been able to show higher sustainability as the labor cost only
accounts for 6-15% of the treatment expenses. Meanwhile, the labor
cost as a percentage of treatment cost at PEPFAR supported clinics
takes up nearly 50% of the total.
4.2. Cost-effectiveness of HIV/AIDS treatment in Vietnam
4.2.1. HIV/AIDS patients’ survival by CD4 levels
The findings are relevant with another international study, as
men’s mortality risk is 1.94 times higher than women, since women
have better immunological recovery ability than men, and hence
higher survivability. Some other studies have also indicated the
difference between men and women in service seeking behaviors, and

that men often have poorer compliance than women.
The survivability rates at two CD4 bounds show difference
between age groups, though it is unclear whether survivability reduces
as the patients get older as another previous study in 9 countries
indicates. Follow-ups and compliance monitoring for older patients
are often more difficult than for younger ones. As the patients come to
the progression stage, or the clinical stages 3 or 4, the immune system
further deteriorates, and survivability starts to show a clear difference
between patients with CD4 < 100 cells/mm
3
and CD4 ≥ 100
cells/mm
3
.
4.2.2. Added life years by different CD4 levels
The study proves the efficiency of HIV/AIDS treatment in
Vietnam with longer life years by different CD4 levels than indicated
23
by other international reports. The added life years in this review are
reflected for patients with CD4 < 100 cells/mm
3
(18 years) and CD4 ≥
100 cells/mm
3
(30.6 years).
4.2.3. Cost-effectiveness by CD4
The lifetime cost for early treatment, with CD4 >= 100
cells/mm
3
is VND 524,186,495 compared to VND 326,455,952 for

late treatment, with CD4 <100 cells/mm
3
, and the cost for each added
life year in case of early treatment, with CD4 >= 100 cells/mm
3
is
VND 17,131,795 compared to VND 18,155,576 for late treatment,
with CD4 < 100 cells/mm
3
. These cost figures are reasonable
compared to other international studies mentioned above.
The lifetime incremental cost-effectiveness ratio (ICER) for
early treatment, with CD4 >= 100 cells/mm
3
compared to late
treatment, with CD4 < 100 cells/mm
3
is VND 15,672,675.
CONCLUSIONS
5.1. HIV/AIDS treatment cost in Vietnam
- The HIV/AIDS inpatient cost is VND 4,341,253/stay (about
USD 230). The HIV/AIDS outpatient cost per patient a year is VND
2,138,931 (SE = + VND 1,548,073) for pre-ART patients (about
USD 116); VND 6,421,893 (SE = + VND 420,366, or about USD
348) for first line ART in the first year, and VND 6,005,153 (SE =
+ VND 209,296, or USD 325) for first line ART from the second
year. The second line ART cost is VND 28,236,312 (SE = + VND
1,207,563, or USD 1529).
- ARV drugs account for the largest share in the HIV/AIDS
treatment cost structure, ranging between 37% and 89% depending

on the regimen. This is followed by opportunist infection medicines
(2-20%), testing and diagnostic imaging (5-15%) and labor cost (3-
19%).
- The HIV/AIDS cost becomes higher as the condition
progresses (when the immune system deteriorates to a CD4 count <
100 cells/mm3 or when the patient is in the 3
rd
or 4
th
stages). The
cost for early treatment (CD4 >= 100 cells/mm3) is 38% lower than
for late treatment (CD4 < 100 cells/mm3 ) among the pre-ART
group, 21% in the first year first line ART group, and 4% those on
first line ART from the second year and beyond.
- The HIV/AIDS treatment cost is the highest among patients
24
in the 4
th
clinical stage in all treatment phases, and is 26% higher
than the first clinical stage for pre-ART stage, 16% higher than first
year first line ART, 11% higher than first line ART from the second
year, and 14% higher than second line ART.
- In respect of HIV/AIDS outpatient costs at clinics with large
volumes of patients such as national level hospitals, the average
treatment cost is often lower than other types of clinics in various
treatment stages. The HIV/AIDS treatment cost varies significantly
between outpatient and inpatient clinics. The cost difference is
attributed to the percentages of costs for opportunist infection drugs,
testing, diagnostic imaging and labor.
5.2. Cost-effectiveness of HIV/AIDS treatment by different

CD4 levels
- The survivability of patients in severe immunological
conditions (CD4 < cells/mm3) is lower by a statistically significant
extent than that of patients with better immunological status (CD4
>= 100 cells/mm3). Survivability varies and shows a statistically
significant difference when comparing relevant factors like gender
(male vs. female), age groups, clinical stages and levels of care.
- Patients with CD4 >= 100 cells/mm3 have a mortality risk of
0.4 times that of those with CD4 < 100 cells/mm3, with a statistical
significance difference (HR = 0.40, 95% CI: 0.32-0.50).
- Over a 5-year follow-up period, the life year difference
between those with CD4 < 100 cells/mm3 and those with CD4 >=
100 cells/mm3 is 0.63 years. Early treatment at CD4 >= 100
cells/mm3 may help lengthen life expectancy by 30.6 years
compared to 18 years in case of late treatment, with CD4 < 100
cells/mm3.
- The cost for each added life year in case of early treatment,
with CD4 >= 100 cells/mm3 is VND 17,131,795 compared to VND
18,155,576 for late treatment, with CD4 < 100 cells/mm3.
- The lifetime incremental cost-effectiveness ratio (ICER) for
early treatment, with CD4 >= 100 cells/mm3 compared to late
treatment, with CD4 < 100 cells/mm3 is VND 15,672,675. This
ratio is smaller than the per capita income of Vietnamese (USD
1300), which reveals that early treatment is a highly cost-effective
option compared to late treatment.
25
RECOMMENDATIONS
With tangible evidence of the relationship between the cost and
effectiveness of HIV/AIDS treatment based on CD4 levels, the
following recommendations are proposed:

1. Promoting alternatives to widen as much as possible the
HIV/AIDS care and treatment program to help HIV-positive people to
get easier access to therapeutic services at the soonest possible and
maintain in treatment with low-cost regimens;
2. Educating and communicating with people with HIV/AIDS on
the benefits of early treatment for them to consciously get access to
available HIV/AIDS treatment services while their immunological
status is still stable (CD4 counts at recommended levels respective of
treatment timing);
3. Developing case-based therapy packages to be used as
uniform benchmarks for pooling resources between different
programs and projects, and making sure that services are provided
consistently by HIV/AIDS clinics;
4. Exploring ways to cut the costs for ARVs and other
opportunist infection medicines to minimize treatment cost, conserve
resources and help improve access to HIV/AIDS treatment.