Cost of hospital care for HIV/AIDS infected patients in three general reference hospitals in Lubumbashi, DR Congo: prospective cohort study

Introduction This article analyses the composition of healthcare costs for HIV/AIDS infected patients in a country with limited resources and attempts to identify the factors that influence these costs. The aims are to calculate medical care costs, analysing how they vary depending on patients’ income, and to evaluate the factors explaining healthcare consumption. Methods This is a prospective cohort study focusing on patients who were admitted to hospital for a short stay between January 2010 and June 2011, before their integration into a specialised program. The patients were selected randomly. Free consent was obtained from all participants. Data were analysed using the SPSS 19.0 software. The significance threshold was set at 5% and the CI (Confidence Interval) at 95%. We used Kruskal-Wallis tests, Fisher's exact test and multiple linear regression. Results We monitored 209 patients. Their average age was 36.37 years (SD: 8.72). The sex ratio was 0.58 and the women patients were generally younger than the male ones (p=0.011). The overall cost of healthcare amounted to $US 41,922. The cost of Antiretroviral Therapy represented 21.6% ($US 9,045). The price of para-clinical examinations represented 46% ($US 19,136) of the overall cost. The patient's average monthly income was $US 157.40 whereas the average direct cost per patient was$US 201.45. Both monthly income (t=4.385; p=0.0000) and education level (t=3.703 p=0.0003) were statistically significant predictive factors for healthcare consumption. The medical care costs for patients with opportunistic infections were nine times higher than those for patients who presented none. The presence of opportunistic infections increased healthcare consumption by approximately 31$ US (CI 95%: 15-46.9). Conclusion The average direct cost for patients on each short-term stay was higher than the average monthly income. To be able to access the necessary services, the patients need additional resources, which are derived from various sources. Monthly income and the level of education were both statistically significant predictors for healthcare consumption. The analysis allows us to extend the study by using different analytical accounting approaches such as by case and by pathology.


Introduction
HIV/AIDS is a major health issue and in some countries the number of patients is increasing exponentially. We found many types of influences: cultural, economic and political [1,2]. Twenty-five million people live with HIV in sub-Saharan Africa and, in the DRC, the HIV/AIDS epidemic has reached a generalised level; its prevalence fluctuates between 1% and 15% [1][2][3][4][5][6]. AIDS is both an urgent problem and a developmental issue with longer term implications. Despite the increase in funding and in political engagement and despite the progress made to improve access to treatment, the epidemic is progressing faster than the world is fighting back [3,4,7].
A powerful combination of at least three drugs, termed Highly Active Antiretroviral Therapy (HAART) exists and is widely used [6][7][8][9][10][11][12][13]. The use of tri-therapy has led to a striking decrease in morbidity and mortality in patients infected with HIV [13,14]. Nevertheless, this progress has been made at the cost of important expenditures, estimated between 10,000 and 15,000 $US per patient per year in the US [8,10,15]. Several studies have estimated the monthly healthcare costs to patients and have studied the relationship between these costs and patient CD4 counts [7]. However, the demographic and socio-economic impact of AIDS is important especially in terms of the mortality affecting labour force, which is much needed for country's development, and in terms of the overall healthcare expenses, which remain precarious [2,4,16].
A macro-economic analysis of the DRC's national and international spending on the fight against AIDS showed that 96,365,322 $US was spent (38% of the amount needed); 11% of the funding was provided by households [2]. Considering that 71% of the population live under the poverty threshold, the national per capita income is 300 $US, and the country's human development index is 0.389 according the UNDP, a precise measure of patient expenditures is due [2,17].
Indeed, an understanding of the costs for hospital care associated with AIDS will not only allow the economic consequences of HIV infection for household or state budgets to be measured but will also provide the decision makers with precise information that they can then use to allocate financial resources efficiently. Our approach fits precisely into this framework.

Methods
This observational study was for analytical purposes. The study used an activity-based costing (ABC) method to calculate the cost of the patient's course [18][19][20][21][22]. The English authors have shown that the chosen hospitals are situated in favourable environments and are good candidates for applying the ABC method used to calculate costs [23]. The ABC method is being used increasingly in hospital settings as an alternative to the traditional costing method [24][25][26][27][28].
This prospective cohort study focused on patients who were admitted to hospital for the first time and who agreed to participate. Data were collected in a double-blind manner using Epi Info 3.5.3 2011 software. We also used SPSS 19.0 for data analysis. The significance threshold was set at 5% and the CI at 95%. Kruskal-Wallis tests, Fisher´s exact test and progressive linear regression were used to test the relationship between the variables found in this study.

Results
Between January 2010 and June 2011, we interviewed and monitored 209 HIV-infected patients who were admitted to hospital for the first time. Our study focused on healthcare costs that did not get into a specialised program or were not subsidised by Non-Governmental Organizations (NGOs) or the Ministry of Health. The socio-demographic characteristics of the patients are shown in Table 1. For all patients, the average stay was seven days. The cohort was dominated by female patients; the age difference between the two sex groups was significant (p=0.011). The breakdown of the resources consumed by the patients during their hospital stay enabled us to describe the composition of the various costs and identify the hospital services paid for by this homogeneous group of patients. These are presented in Table 2.
The overall cost of the patient's medical care reached ($US 41,922. The price of Para-clinical examinations represented 46% ($19,136) of the total cost. These results show that expenses were eight times greater for patients whose CD4 count was below 300 cells /µL than for patients who had a CD4 count over 300 cells /µL. The results indicate that the overall cost was greater than the cost to the institutions. This observation relates to the fact that these The results summarised in Table 3 on the specification model for linear regression as used to analyse variables that could explain healthcare consumption. Monthly income (test t=4.385; p=0.000) and patient education level (test t=3.707; p=0.000) were statistically significant predictive factors for healthcare consumption.
Considering the observation that disease stage and the presence of opportunistic infections are linked (x ² =14, 3118; p=0.0008) we built the following in Table 4 in order to measure the impact of opportunistic infections on healthcare costs. From these results we can see that medical care costs for patients who carried opportunistic infections were nine times higher than for patients who presented no opportunistic infections.

Discussion
The overall medical care costs for these patients amounted to $US Our results indicate that the total cost of medical care was eight times higher for patients who had a CD4 count below 300 cells/ µL than for those who had a CD4 count over 300 cells/ µL. The Our observations lead to the hypothesis that patient adherence to tri-therapy will improve immune recovery and CD4 count and will lead to a decrease in the cost of healthcare. This is in agreement with observations made by Ray et al. (2006), who noticed that a decrease in the CD4 count was associated with an increase in spending; this increase was statistically significant for patients whose CD4 counts fell within 50-199 cells/ µL (p=0.003).These observations lead us to confirm the economic advantage of tritherapy, which is currently recommended as treatment for HIV/AIDS patients [6,7,[29][30][31][32].  Altogether these observations indicate that, on the one hand, this disease is increasingly affecting women, and on the other hand patients are generally fairly young.
We noticed that patients tend to be diagnosed at an advanced disease stage (stages II or III for 87.5% of them). This fits with observations from authors who found that patients tend to seek medical help when immunodeficiency has become pronounced and when they are at a very advanced stage of infection [32][33]35].
This highlights the need to intensify screening campaigns, raise awareness in afflicted communities and promote early admission of HIV/AIDS patients. These measures will not only improve the clinical well-being of patients and decrease contagiousness but will also reduce healthcare costs.

Conclusion
HIV/AIDS has become a complex problem with consequences that go beyond issues of public health to include all sectors of socioeconomic development. For a short hospital stay, the average cost of medical care per patients is greater than the average monthly income. To be able to access the necessary services, the patients need additional resources, which are derived from various sources.
Monthly income and education level are both statistically significant predictive factors for healthcare consumption; however, the presence of opportunistic infections increases the cost of medical care.
To fight stigma and discrimination that will affect female patients, it is important to take action against the numerous factors that contribute to their vulnerability regarding HIV/AIDS, such as gender inequalities, socioeconomic factors and sexual violence.
It is important to extend studies that have looked at cost/effectiveness of various healthcare programs for HIV infected patients. This analysis allows us to objectively consider the use of different analytical accounting approaches such as by case and by pathology. and the hospital staff as well as the patients who participated in this study.