Assessing the Costs of Medication-Assisted Treatment for HIV Prevention in Georgia

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This study assesses the unit costs of MAT provision in Georgia from the perspective of the two service providers in-country—the Ministry of Labor, Health, and Social Affairs (MOLHSA) and the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM). Both MOLHSA and GFATM-funded sites offer MAT in multiple facilities throughout urban and rural Georgia. Treatment protocols and personnel requirements are centrally mandated, thus allowing for little variation per patient characteristics. While service delivery tends to be comparable across MOLHSA and GFATM sites, there is one significant difference—the ministry requires that MAT clients pay for services while GFATM offers free services. The analysis found that a majority of HIV-positive patients are enrolled in the GFATM MAT program.

The study compared average unit costs between two years (2009 and 2010) and found a minimal increase. Unit costs increased only slightly at MOLHSA facilities from 229 GEL ($133 ) per month to 236 GEL ($137) per month. At GFATM sites, the monthly per patient cost of MAT rose slightly between 2009 and 2010 from 217 GEL ($126) to 229 GEL ($133). Further, data analysis revealed that GFATM programs are only slightly less expensive than at MOLHSA facilities. An important caveat—unit cost calculations for the MOLHSA sites include patient contributions that amount to 150 GEL ($87) per month for each patient. In the case of both providers, direct costs of MAT provision far exceed indirect costs. Three inputs—personnel, drugs/medical supplies, and utilities—account for a major portion of costs associated with running MAT programs in Georgia. The most significant budget item in both MOLSHA and GFATM programs is the cost of personnel (salaries of clinical and support staff).

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Assessing the Costs of Medication-Assisted Treatment for HIV Prevention in Georgia

  1. 1. Costing MAT for HIV Prevention among PWIDs in Georgia 1Veena Menon & Irma Kirtadze 07/20/12
  2. 2. Outline• Background• Study Design• Findings 2
  3. 3. Background●  One of the first countries to adopt Christianity, in the early 4th century, remains strongly Georgian Orthodox●  From 1921 to 1991, the Georgian Soviet Socialist Republic was one of the 15 soviet republics of the USSR●  Suffered from civil war and economic crisis during the 1990s●  Rose Revolution of 2003, at which time the new government introduced democratic and economic reforms●  It covers a territory of 69,700 square kilometers●  Its current population is almost 4.5 million 3
  4. 4. Study Goal Evaluate costs of MAT programs in Georgia to improve budgeting and planning related to MAT programs 4
  5. 5. Study Objectives•  Estimate unit costs of MAT provision for one patient (per month)•  Optimize current capacity to include more PWIDs 5
  6. 6. Background MSM MTCT Other 3% 2% 2%•  PWID population approximately 40,000•  Estimated number of HIV+ people in Georgia - 4000 PWID Hetero- 56%•  Injecting drug use sexual identified as primary 37% cause of transmission Source: AIDS and Clinical Immunology Research Centre (2011). 6
  7. 7. Program Characteristics GFATM - Start year 2005 - 5 sites in total - Free for clients MATproviders MOHLSA - Start year 2008 - 11 sites in total - 150 GEL/pm/patient 7
  8. 8. Program Characteristics (2) GFATM MAT centers MOLHSA MAT centers GFATM prison centers 8
  9. 9. Program Characteristics (3)•  MAT treatment protocol/personnel centrally-mandated and identical for all service providers – Key treatment parameters include •  Daily methadone dosage •  STI testing (HIV, Hepatitis B/C) •  Individual psychotherapy •  Group counseling 9
  10. 10. Program Characteristics (4)•  Staffing at MAT sites is regulated by Georgian law: – 3 medical doctors – 1 psychologist – 1 social worker – 1 head of department/chief doctor/ coordinator –  1-3 nurses – Other support staff (data entry specialist, consultants, toxicologist, pharmacist and etc.) 10
  11. 11. Study Details•  Study design – samples from each provider –  MOHLSA – 7 of 11 sites (sites chosen to ensure representation from small and large population centers) –  GFATM – 4 of 5 sites (excluded prison site)•  Study period –  Qualitative data collected on treatment parameters – March, April and May 2011 –  Financial program data – 2009, 2010 11
  12. 12. Study Details (2)•  Collected cost and quantity data on: • Personnel • Drugs and supplies • Furniture and equipment • Land and buildings • Consumables • Utilities 12
  13. 13. Results MAT Dosages Across Sites Below 60 mg Above 60 mg% of patients within each dose range 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 13
  14. 14. Distribution of HIV+ patients 800 1.5% 700 Total Number of Patients 600 1.1% 500 400 12.2% 12.7% 98.5% 300 98.9% 200 87.8% 87.3% 100 0 GF 2009 GF 2010 MOLHSA 2009 MOLHSA 2010 HIV Negative HIV Positive 14
  15. 15. Increase in Average # Patients800700600500400300200100 0 GF—MAT MOLHSA—MAT 15
  16. 16. Unit cost for 1 month treatment 2010 $ GFATM Average number of PWID in 1 364 month Unit cost for one month 229 GEL $133 MOHLSA Average number of PWID in 1 689 month Unit cost for one month 236 GEL $137 16
  17. 17. Cost Drivers Share of direct and indirect costs in MAT facilities 250 21.1% 20.9% 200 23.2% 24.6%Unit Cost (GEL) 150 100 78.9% 79.1% 76.8% 75.4% 50 0 MoLHSA 2009 MoLHSA 2010 GF 2009 GF 2010 Direct Costs Indirect Costs 17
  18. 18. Key cost drivers MOLHSA—2010 Drugs and GFATM—2010 Bank/ medical Rental cost Drugs and 5% Utilities insurance Rental cost supplies fees medical 13% 5% 21% 0.44% supplies Utilities 28% 14%Stationary Bank/ Non office insurance Stationary medical supply 0% office supply equipment 0% 1% 5% Non medical Regional equipmentmonitoring 2% Regional 0% Salaries of monitoring clinical & 0.41% support Salaries of staff clinical & 51% support staff 55% 18
  19. 19. Economies of Scale GFATM Shida GFATM Kartli Batumi Narcological Narcological MoLHSA MOLHSA Center Center Division 3 Division 6Averagepatientsper 45 117 18 142monthUnit cost 291 GEL 161 GEL 702 GEL 122 GELpatient/month ($169) ($93) ($407) ($71) 19
  20. 20. Potential for Service Expansion•  1382 maximum PWID capacity at MOLHSA sites•  500 maximum PWID capacity at GFATM sites (currently at capacity)•  Modelled 2 scenarios to assess potential for expanding MAT coverage within existing facilities: –  Scenario A: Increase coverage by 15 percent until maximum available existing capacity is reached. –  Scenario B: Graduated expansion in MAT coverage over five years (five, seven, nine, 11 and 13 percent increases) using existing sites until maximum available capacity is reached. 20
  21. 21. Scenario A – 15% increase Increase in average # MOLHSA   of patients   2010—11 MAT sites   898   2011—15% increase   1,033   2012—15% increase   1,187   2013—15% increase   1,366   21
  22. 22. Scenario A – Decreasing unit costs 1600 1366 450 1400 400 1187Number of Patients 350 1200 1033 Unit Cost (GEL) 898 300 1000 250 800 235.8 200 600 213.21 193.58 176.5 150 400 100 200 50 0 0 2010 extrapolated 2011 2012 2013 number of patients unit cost 22
  23. 23. Scenario A – Share of direct/indirect costs MOLHSA   Direct Indirect costs (%)   costs (%)   2010—11 MAT 79.10   20.90   facilities   2011—15% increase   79.90   20.10   2012—15% increase   80.75   19.25   2013—15% increase   81.64   18.36   23
  24. 24. Scenario B – graduated increase Graduated increase in average MOLHSA   # of patients   2010—11 MAT sites   898   2011—5% increase   943   2012—7% increase   1009   2013—9% increase   1100   2014—11% increase   1221   2015—13% increase   1379   24
  25. 25. Scenario B – Decreasing Unit Costs 1600 450 1379.2 400 1400 1220.5 350 Number of Patients Unit Cost (GEL) 1200 1099.6 1008.8 300 1000 897.9 942.8 250 800 235.8 200 225.6 213.2 600 200.7 189.1 179.4 150 400 100 200 50 0 0 2010 2011 2012 2013 2014 2015 extrapolated 25 Number of Patients Unit cost
  26. 26. Scenario B – Share of direct/indirect costs MOLHSA   Direct costs Indirect costs (%)   (%)   2010—11 MAT facilities   79.10   20.90   2011—5% increase   79.47   20.53   2012—7% increase   79.88   20.13   2013—9% increase   80.43   19.57   2014—11% increase   81.11   18.89   2015—13% increase   81.94   18.06   26
  27. 27. Limitations•  We were unable to include certain costs in this analysis, primarily due to lack of data.•  Accurate patient tracking was a challenge in some MOLHSA methadone facilities, particularly Tbilisi, where patients may have moved from one MAT site to another.•  Finally, this analysis focused on the costs incurred by facilities offering MAT services. As such, it does not include the costs incurred by patients as they sought and received services or the opportunity costs of time spent travelling to and seeking services. 27
  28. 28. Recommendations•  Specify clear indicators for successful treatment outcomes.•  Integration/co-location of PWID/HIV services for better patient follow-up (currently no data on recidivism)•  Greater autonomy for MAT sites on protocol/ personnel 28
  29. 29. Acknowledgements  USAID funded project HPI costing•  Veena Menon, Kip Beardsley, Stiven Forsythe (Futures Group) & data collectors team : Natia Topuria, Nino Balanchivadze, Tea Kordzade (Alternative Georgia), Lela Sturua (NCDC)  Staff of participant MAT centers’  Authors declaring no conflict of interest 29
  30. 30. Thank youirma@altgeorgia.ge 30

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