1. Iman Wanis, Cushla Coffey, Shaffiq Essajee, and Philippa Easterbrook World Health Organization, HIV Department (ATC) Geneva, Switzerland July 2011 COSTING AND AVAILABILITY OF DRUG THERAPY AND DIAGNOSTIC ASSAYS FOR CRYPTOCOCCAL INFECTION

2. CRYPTOCOCCAL DRUGS AND DIAGNOSTICS

3. Funding and Supply/Distributors for Drugs UNITAID/CHAI The Global Fund PEPFAR National Government NGOs e.g. MSF Self-pay

4. Challenges in the use of supplied medicines Orders were low Stock went unused Countries had difficulty predicting need Countries were not able to track cases or monitor use Lack of consistent country practice and the need for clear guidance

5. UNITAID/CHAI Progress of the projects Performance of suppliers Achievement of key objectives * Source: A meeting with UNITAID/CHAI Pediatrics ARVs Project Coordinator

6. Programmatic Experience in UNITAID/CHAI Pediatric Amphotericin Donation Programme Underutilised, orders were low Clinicians not well informed about programme (reports of unused or expiring stock in pharmacy) Not clear whether drugs are used for children or adults No standardisation of process e.g. Tracking and monitoring of use Liaison with clinics Forecasting/product quantifications Need for consistent country practice and guidance

7. Data Sources for Drug Costs 1. International Drug Price Indicator Guide (IDPI) -Published by Management Sciences for Health (MSH) since 1986 -Annually updated -Prices from pharmaceutical suppliers, international development organizations, and government agencies 2. Global Price Reporting Mechanism (GPRM) http://www.who.int/hiv/amds/gprm/en/ -Web-based database launched by the AMDS in April 2005 -Reports of price quotes from pharmaceutical companies, and other sources. -Price monitoring tool -Prices of drugs purchased and supplied by various procuring agencies for different countries: CHAI, Mission Pharma, MSH, PFSCMS, UNDP, UNFPA, UNICEF, UNITAID 4. Telephone Country Survey: 8 HIV clinicians, 1 laboratory director, 1 clinical microbiologist, 1 pharmacist, NAP director and 1 Information Management advisor.

8. Amphotericin B (ampho) + Fluconazole (fluc) Costs in Sub Saharan Africa (GPRM) Uganda (2009) $2.6/50mg ampho $0.7/200mg fluc Angola (2008) $12.31/50mg ampho $0.174/200mg fluc Burundi (2009) $2.6/50mg ampho $0.07/200mg fluc Malawi (2009) $2.48/50mg ampho $0.07/200mg fluc

9. Comparison of Costs of Amphotericin B and Fluconazole in IDPI (2010) & GPRM (2006-2010) Databases & Field Data Amphotericin B (50mg) 1vial/day x 14 days Fluconazole (200mg) 800mg/day x 14 days Median Price (unit price) Lowest Price (unit price) Highest Price (unit price) Median Price (unit price) Lowest Price (unit price) Highest Price (unit price) IDPI Supplier 2010 $88.90 ($6.350) $49.14 ($3.510) $110.08 ($7.863) $1.22 ($0.087) $1.08 ($0.077) $1.36 ($0.097) IDPI Buyer 2010 $73.79 ($5.271) $59.22 ($4.230) $170.80 ($12.200) $9.07 ($0.162) $2.24 ($0.040) $18.87 ($0.337) GPRM 2006-2009 $36.40 ($2.60) $29.82 ($2.13) $173.88 ($12.42) $3.92 ($0.07) $1.12 ($0.02) $18.48 ($0.33) Field Data South Africa $14 ($1 – BMS) $1400 ($100–Generic) $69.86 ($4.99) (Private/Public sectors) South Africa Ambisone $278.77 (Generic- Private) >$143.24 (Public) Uganda $81.9- $109.34 ($5.85 - $7.81) $140-$168 ($10-$12) Botswana $ 50/month

10. Flucytosine Cost estimates from World Wide Web resources Oral capsules IV infusion Brand nameAncobon 500mgAncobonAncotil 2.5g/250ml Solution for Infusion CompanyValeant Pharmaceuticals Ltd. California, USA ICN PharmaceuticalsMeda Pharmaceuticals Ltd United Kingdom Strength500mg250 mg 100/caps 500 mg 100/caps Flucytosine Ph. Eur. 2.5g in 250 ml.) Unit price$49.05$22.64 $43.81 $48.86 (10mg/ml) Treatment course (100mg/50kg/day)x14 $6,867 $3,169.60 $6,133.40 Other sourcesJohn Bell Croydon Pharmacy in London: $ 24.16/day Treatment course (100mg/50kg/day)x14 $210 $3.22/tablet ($ 32.22/day) Treatment course (100mg/50kg/day)x14 $280

11. Diagnostics Cost Estimates from the field India InkCRAG LACRAG LFACulture South Africa$5.79$2 Uganda$5.85 or $1.92 $7.81 - 11.71 Malwai$2.82 - 4.24 Immy Diagnostic Tests manufacturer <$1$2 <$1 Manufacturer Immy Meridian Biosciences Remel BioRad Alere (Inverness) Supplier SCMS National governments PEPFAR LA= CRAG Latex Agglutination LFA= CRAG Lateral Flow Assay SCMS= Supply Chain Management System

12. Cost estimates from Literature Meya et al. Uganda 2010 Micol et al. Cambodia (MSF) (3 month costs) Parkes-Ratanshi et al. Uganda 2011 Cotrimoxazole prophylaxis$0.89 Fluconazole prophylaxis$3.47 cART$91.50 CM/pulmonary cryptococcosis treatment and care $245 per course (amphotericin B) $187.90 Other opportunistic infection treatment and care $187.90 CrAg screening test$16.75$6.63$16 Fluconazole prophylaxis unit price is $0.15(200mg capsule $0.45 per week, 35 weeks)$15.75 Administration and dispensing costs (per patient)$2 Training costs (per patient)$2 Other costs (per patient)$2 Total costs of FCP:$21.75

13. Data Limitations GPRM  Data ranges from 2004 – 2010, so comparisons between countries difficult  Data from only a few manufacturers. Comparisons between IDPI, GPRM unreliable because:  Multiple sources of data from manufacturers (GPRM), suppliers and buyers  Data from different years.