6. Cost considerations

Since counselling and voluntary testing for HIV has so rarely been offered as a routine part of pregnancy-related services in developing countries, there are few data upon which to base discussions of cost.

Even the cost of therapy is uncertain in this rapidly developing field. Short course therapy requires no very sophisticated monitoring or delivery equipment. The WHO has added ZDV to the Essential Drug List, and the drug’s manufacturer Glaxo-Wellcome is in the process of cutting the price of ZDV (under the generic name zidovudine) to developing countries. Month-long therapy for one women is expected to cost around US$ 50 in the poorest countries, although countries with more resources can expect to pay more. Even shorter regimens now being tested are likely to be considerably cheaper.

The cost of breastmilk substitutes varies considerably from country to country (from US$ 60 to US$ 450 per 6 months)¹. Often, high import duties on infant formula milk raise the price to the consumer considerably. Additional costs associated with the use of breastmilk substitutes are the costs of fuel, clean water, clean implements and preparation time.

¹ HIV and Infant Feeding: A guide for health care managers and supervisors. UNAIDS/98.4

There is virtually no information at all to quantify non-monetary costs and benefits associated with interventions to reduce HIV transmission from mother to child; costs such as increased stigma or improved child survival. In this section, “costs” refers only to monetary costs.

Some work has been done to investigate the costs of providing counselling and voluntary testing, although not in reproductive health settings. The cost per person counselled ranges between US$ 4 and 12. The majority of that is in training and salaries for staff. Since it is here suggested that as much counselling as possible be done by regular staff in reproductive health settings, the cost may be expected to be rather low.

What is clear is that the costs will be shared between service providers and their clients. The extent to which service providers pass costs on to their clients will depend on many factors, including market demand.

Costs and benefits to pregnant women and their families

In most situations, pregnant women and their families will bear the bulk of the monetary costs associated with interventions to reduce transmission of HIV to their infants. For women who test HIV-positive, that includes the cost of therapy as well as the cost of two years’ worth of replacement feeding and the time, water, fuel and implements needed to prepare and deliver them.

Women may also have to pay for testing and post-test counselling - the demand for these services will certainly be influenced by the cost.

The major financial return for a family in averting the transmission of HIV from mother to child is the savings in medical bills and care for sick children, and funeral costs. The non-monetary benefits of bearing and raising a healthy child are incalculable.

Costs and benefits to the service provider

If providers of pregnancy-related services are to integrate counselling and voluntary testing for HIV into their routine work, they will have to absorb most of the costs of establishing the service.

The bulk of those costs are likely to be in staff training, and in the recruitment of staff to help with the extra workload implicit in providing an integrated counselling and testing service. Test kits must be procured or laboratory services contracted; these costs may or may not be passed on to the client, although the service is unlikely to be sustainable unless some cost recovery is planned for. Some investment will also be required in setting up systems to ensure the confidential treatment of HIV-related data.

Where health services are provided by the public sector, a return can be expected in terms of lower costs of caring for HIV-infected children. This is especially the case in countries where health services are routinely provided free to infants and children under the age of five.