Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKbH4TTImqenVAHxkFJp/XpPk1L/H3vMGwqMxG9jwOd8eJPG+b4DlKuAX44qu/vwzmc= on 07/29/2018 CLINICAL SCIENCE Comparative Costs of Inpatient Care for HIV-Infected and Uninfected Children and Adults in Soweto, South Africa Leena S. Thomas, MBBS, MPH, MMed, FCPHM(SA),* Arthur Manning, MBBCh,† Charles B. Holmes, MD, MPH,‡ Shan Naidoo, MBBCh, MMed,* Frans van der Linde,§ Glenda E. Gray, MBBCh, FCPaeds(SA),§ and Neil A. Martinson, MBBCh, MPH k Background: HIV/AIDS creates a massive burden of care for health systems. A better understanding of the impact of HIV infection on health care utilization and costs may enable better use of limited resources. Methods: We compared public sector inpatient costs of HIV- infected versus uninfected adults and children at a large hospital in Soweto, South Africa. Daily hotel costs estimated from hospital financial data and total patient visits were combined with utilization, abstracted from patients’ charts, and costed using government price lists to estimate total inpatient costs. Results: A total of 1185 eligible records were included over a 6- week period in 2005. Eight hundred twelve were from HIV-infected patients, and of these, 77 were on antiretroviral (ARV) therapy. The mean length of stay (LOS) and mean drug and intravenous fluid utilization of HIV-infected adults not on ARVs was greater than those of uninfected adults, resulting in a $200 higher total average admission cost. Patients on ARVs had longer LOS and incurred a total average admission cost of $750 more than HIV-infected adults not on ARVs. Conclusions: Inpatient costs were greater for this selected group of HIV-infected adults, and even higher for the small proportion of individuals receiving ARVs. Budget allocations should incorporate case mix by HIV and ARV status as a key determinant of hospital expenditure. Key Words: antiretrovirals, HIV, hospitalization, LOS, opportunistic infections, pediatric (J Acquir Immune Defic Syndr 2007;46:410–416) M ore than 5 million South Africans, or 11% of the population, are living with HIV/AIDS, 1 and by 2000, HIV/AIDS was responsible for 30% of all deaths, becoming the leading cause of death and years of life lost in South Africa. 2 Morbidity in the latter stages of untreated HIV disease is high, often as a result of life-threatening illnesses requiring hospitalization. The public health sector in South Africa, administered by provinces but funded from the national tax base, provides most inpatient care to HIV-infected patients. Johannesburg, the economic hub of South Africa, and Soweto, its dormitory city, are in Gauteng Province, where the HIV prevalence in 2005 was 32.4% 3 in an annual antenatal survey and 38.0% to 58.6% and 23.4% to 31.5% in adult and pediatric hospital wards, respectively. 4 Despite high rates in hospitalized patients, the national plan for HIV/AIDS care and antiretroviral therapy (ART) focuses on outpatients. 5 Responding to the plan, the South African government made substantial increases in budgetary allocations to provinces. 6 It is difficult for hospitals to access additional funding, however, because their financial allocations are based on previous years’ expenditure and do not directly react to or anticipate changes in disease profile or availability of novel treatment modalities like ART. Com- parative costs of providing inpatient care should inform adjustments to public hospital funding based on HIV case mix, allow cost comparisons between hospitals, and contribute to the estimation of cost-effectiveness assessments. The primary objective of this study was to compare the costs of providing care to HIV-infected and uninfected inpatients. METHODS Site The Chris Hani Baragwanath Hospital (CHBH) is a 2800-bed public sector tertiary institution serving Soweto and its environs. It has a 5-unit medical department with 776 beds, admitting approximately 100 adults per day, and a 4-unit pediatric department with 164 beds, admitting approximately 18 children per day. 7 Each unit consists of approximately 4 board-certified specialists, a similar number of specialists- in-training, and several junior doctors in their first years of employment after graduation. Adult medical units provide inpatient internal medicine care and have 2 gender-separated wards, each at 80% occupancy. Pediatric units occupy 1 ward each, and bed occupancy is often at 100% and occasionally reaches 200%. The remaining beds are allocated to a large Received for publication September 27, 2006; accepted July 30, 2007. From the *School of Public Health, University of the Witwatersrand, and Gauteng Department of Health, Johannesburg, South Africa; †Chris Hani Baragwanath Hospital, Gauteng Department of Health, South Africa; ‡Massachusetts General Hospital, Boston, MA; §Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa; and the k Johns Hopkins University Center for Tuberculosis Research, Baltimore, MD. C. B. Holmes is currently affiliated with Gilead Sciences, Foster City, CA. Funded by Perinatal HIV Research Unit, Chris Hani Baragwanath Hospital, and the Gauteng Department of Health. Data abstraction and management supported by National Institutes of Health grant RO1 AI058736-01A. Correspondence to: Neil Martinson, MBBCh, MPH, c/o Perinatal HIV Research Unit, PO Box 114, Diepkloof 1864, South Africa (e-mail: neil1. martinson@gmail.com). Copyright Ó 2007 by Lippincott Williams & Wilkins 410 J Acquir Immune Defic Syndr  Volume 46, Number 4, December 1, 2007 Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.