Fees for HIV treatment increase risk of death in developing countries

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People with HIV who have to pay fees for treatment in resource-limited settings are significantly more likely to die during the first year of follow-up than people who receive free treatment, according to findings from an international cohort study presented on Monday at the 2006 implementers` meeting of the US President’s Emergency Plan for AIDS Relief in Durban, South Africa.

The findings come from the ART-LINC collaboration, which pools data from 23 centres in South America, Africa and Asia in order to track the impact of HIV treatment in resource-limited settings. They were presented by Professor François Dabis of the University of Bordeaux, France.

Professor Dabis reported data from 4810 eligible patients who had initiated antiretroviral treatment with a known baseline CD4 cell count. 3744 patient years of follow-up were available for analysis, 2725 from cohorts with active follow-up of patients who did not keep appointments. The data came from 18 treatment centres, 12 of which provided free treatment. At the time of treatment initiation the median CD4 cell count was 108 cells/mm3. Seventy per cent of patients began treatment with an NNRTI-based drug combination.


loss to follow up

In a research study, participants who drop out before the end of the study. In routine clinical care, patients who do not attend medical appointments and who cannot be contacted.

virological suppression

Halting of the function or replication of a virus. In HIV, optimal viral suppression is measured as the reduction of viral load (HIV RNA) to undetectable levels and is the goal of antiretroviral therapy.


Having symptoms.


hazard ratio

Comparing one group with another, expresses differences in the risk of something happening. A hazard ratio above 1 means the risk is higher in the group of interest; a hazard ratio below 1 means the risk is lower. Similar to ‘relative risk’.


Expresses the risk that, during one very short moment in time, a person will experience an event, given that they have not already done so.

After six months of treatment 76% of patients had viral load below 500 copies/ml, a rate of viral suppression comparable to those seen in Europe and North America. The median CD4 cell increase was 106 cells/mm3. 165 deaths were recorded during the first six months on treatment, with a higher mortality rate recorded in centres with active follow-up (6.4% vs 2.3%). This difference is due to the fact that patients lost to follow up could be ascertained as dead by cohorts with active follow-up, rather than described as lost to follow-up.

Adjusted hazard ratios for death were 2.2 for patients who initiated treatment in WHO stages III and IV (symptomatic HIV disease) compared to WHO stage I, and 0.34 for patients with a CD4 cell count between 50 and 99 when compared with a CD4 count below 50.

Patients who did not pay for treatment had a 75% lower risk of death in the first year than patients who paid (HR 0.25).

How free is `free` treatment?

Although many programmes describe treatment as free, the practical reality is that obtaining treatment incurs substantial costs for many patients. Analysis of patient expenditures at one South African clinic showed that patients were incurring an average of US$75 a year in clinic fees, transport, food and lost wages in order to attend clinic appointments and take medicines properly.

The research was carried out by Sydney Rosen of Boston University and Mpefe Ketlhapile of the Health Economics Research Unit at the University of the Witwatersrand at three PEPFAR-funded clinics – the Themba Lethu clinic at Helen Joseph Hospital in Gauteng, an NGO clinic at the periurban informal settlement in Witkoppen, and a rural NGO clinic in Mpumalanga.

The study monitored expenditures for 597 patients attending the urban clinic, 292 attending the periurban clinic and 138 attending the rural clinic.

Patients attending the two NGO clinics paid a median fee of $6.22 for each clinic visit, but the top tenth paid more than $22 per clinic visit, nearly two days average wages for an unskilled worker in South Africa. The urban clinic waived its fees for 78% of patients, with employed patients significantly more likely to pay a fee.

Urban clinic patients had the highest transport costs (a median of $2.60 per visit), whilst periurban patients were most likely to report loss of income as a result of attending the clinic, reflecting the more casual and unstable nature of employment for people living in informal settlements on the outskirts of Johannesburg.

More than half of patients also reported spending money on non-prescription medicines or special food, and these costs contributed to the median expenditure of $75 a year incurred by people receiving treatment.

The authors highlighted the need to consider these costs in efforts to sustain adherence and expand access to treatment.


Braitstein P, Dabis F, et al. -for-treatment at point of care a key risk factor for mortality in a multi-national network of HIV/AIDS treatment programmes. The 2006 HIV/AIDS Implementers Meeting of the President’s Emergency Plan for AIDS Relief, Durban, South Africa, abstract 197.

Rosen S et al. Does free drugs mean free treatment? The patient-level costs of obtaining treatment for AIDS in South Africa. The 2006 HIV/AIDS Implementers Meeting of the President’s Emergency Plan for AIDS Relief, Durban, South Africa, abstract 523.