At present, there is no universal standard to measure the scale of the cost of AIDS prevention and treatment. In the international community, the PCE of AIDS is often discussed from the perspective of financing structure. In recent years, China’s government has continuously increased its investment in the prevention and control of AIDS. In 2017, China's fiscal expenditure was almost 7 billion RMB on its AIDS response, an increase of more than 5.4% from 2016. Taking Hunan Province as an example, 94.42% PCE of AIDS came from the central government and local governments. It showed that the government played a crucial role in the prevention and treatment of AIDS. Compared with some countries and regions that need to rely on social donations, China has a stable financing structure for AIDS prevention and control. According to the Regulations on the Prevention and Control of Infectious Diseases of China, AIDS prevention services are mainly provided by public health institutions, while treatment services are provided by medical institutions. Our results showed that prevention costs mainly go to public health institutions, and treatment costs almost all go to hospitals. It can be seen that the institutional allocation of AIDS prevention and control costs is reasonable.
From the flow of expenditure, the expenditure of AIDS was more spent on prevention than treatment, consistent with the research of Li based on NASA. It also demonstrated that the work of AIDS control in Hunan Province conforms to the principle of "prevention first" that the World Health Organization and China have always adhered to. However, from the use of the preventive expenditure, AIDS prevention in China is still taking a more conservative approach, and some advanced prevention technologies such as pre-exposure prophylaxis (PrEP) for HIV high-risk groups have not yet been applied in clinic. The 2015 world health organization report informed us that clinical trials in Africa, Asia, Europe, South America and the United States have demonstrated that oral PrEP had a high-quality inhibitory effect on the occurrence of HIV infection[ 21 ]. Drawing on international experiences, it is suggested to integrate traditional with advanced methods to improve the effectiveness of AIDS prevention by adjusting the allocation of the expenditure of AIDS prevention.
People living with HIV may have to bear part of the cost of services other than antiretroviral treatment. When the funding structure of CCE by age group were compared, the proportion of the family health expenditure were found to be diverse between different age groups. Patients of 40-49 y had the highest proportion of family health expenditure, which may be affected by factors that patients were not insured or co-infected. Of the patients of aged 40-49 y we surveyed, 36% received treatment by self-paying and 48.23% had comorbidity. It is worth noting that the family health expenditure of patients aged 0-9 y exceeds 30%. Children infected with AIDS mainly through mother-to-child transmission. Catastrophic health spending is inevitable if their families have to pay for the treatment of two or more patients. In recent years, the Chinese government has set up special funds to support a series of measures to block mother-to-child transmission of AIDS. Through these measures, such as free AIDS testing and antiviral treatment for infected pregnant women and babies, the mother-to-child transmission rate of AIDS has dropped to 4.9% in 2017[ 22 ]. Simultaneously, the family medical burden problems can not be ignored. It is necessary to bring such families into the scope of government medical assistance while further strengthening measures to block mother-to-child transmission.
Concerning the treatment cost, the result of ordered logistic regression showed that non insurance, co-infection and length of stay were risk factors. Si Cunwu's research found that by using different payment methods of medical insurance, medical insurance can play a role in controlling the increase of costs for the suppliers and needs of AIDS treatment. Patients who have not moved to medical insurance are not only lack of awareness of cost estimation, but also medical institutions are more likely to have excessive medical practices. It can be seen that incorporating uninsured patients into social basic insurance schemes is the most direct way to reduce the OOPs of patients. Moreover, commercial medical insurance can be encouraged to join the AIDS medical insurance system. With the abundant actuarial data of insurance, we can estimate the risk of infection of high-risk groups and the general population, and integrate AIDS into commercial insurance by adjusting insurance costs. In this way, once people are infected with AIDS, commercial insurance can be used to share the burden of medical treatment.
AIDS patients are vulnerable to pathogens with weaker virulence than healthy people. The resulting infectious diseases are called opportunistic infections of AIDS. Many researches showed that with the opportunistic infection would bring more difficulties and costs for affected people. With regard to the medical security of AIDS patients in opportunistic infections, a series of measures have been introduced in China, including the inclusion of opportunistic infections treatment drugs in the list of essential medicines and the inclusion of AIDS opportunistic infections in the coverage of major diseases in the New Rural Cooperative Medical System. But according to relevant policies, only part of the cost of treatment for opportunistic infections can be reimbursed. In addition, patients with opportunistic infections need to spent more on the treatment, but the reimbursement rate and capping line have not been adjusted. Therefore, in order to reduce the burden of AIDS patients with co-infection, the government should consider to adjust the coverage and proportion of insurance reimbursement appropriately.
With regard to the influence of hospitalization days, Xie claimed that "the longer the length of hospitalization, the higher the cost of hospitalization"[ 27 ], which is accordant with our study. Hospitals should control unnecessary large-scale instrument examination under the premise of ensuring medical quality, reduce or eliminate invalid examination items, so as to shorten hospitalization days and alleviate the economic burden of patients. Meanwhile, the early diagnosis and treatment can shorten the length of stay. On the other hand, psychological counseling should be strengthened to avoid the fear caused by the lack of knowledge of AIDS and reduce the avoidable cost of hospitalization due to fear.
Regarding the hospitalization expenses of different age groups, our statistical analysis results showed that the hospitalization expenses of group over 60 y were higher than those in the group under 30 y. There were several reasons to explain this cost gap. The elderly have relatively little awareness of AIDS or AIDS testing. A family survey data indicated that people over 50 y were less likely to have been tested for HIV than those aged 15-49 y. These elderly cannot find out that they have been infected in time unless they have clinical symptoms of AIDS. Once clinical symptoms occur, the treatment becomes more difficult and costly. Meanwhile, the elderly with AIDS are at the high risk of comorbidity. The research of Negin found that the rates of chronic disease were higher among older adults compared with those aged 18-49 y. Of those aged 50 y or more, 29.6% suffered from two or more of the seven chronic conditions compared with 8.8% of those aged 18-49 y. Futhermore, aging AIDS patients may experience a gradual decline in immunity, who are likely to be co-infected. The increasing complexity of patients' illness necessitates more hospital stay. These may lead to an increase in the cost of treatment for elderly AIDS patients. As for OOPs, patients over 60 y are less than patients under 30 y, which may be the impact of medical insurance compensation and medical assistance policy. According to the study of Xu , the proportion of AIDS patients under 40 y of age participating in medical insurance in China is significantly lower than that of people over 60 y. From the medical aid policy, the elderly with no fixed income and no working ability can meet the requirements of applying for medical assistance. So their OOPs is significantly lower than that of other groups.
To our knowledge, this study is the first one to give a comprehensive report about expenditures of AIDS in China at the subnational level based on SHA2011. In this study, not only the scale and flow of PCE for AIDS were calculated from a macro point of view, but also the factors affecting the medical burden of AIDS patients were statistically analyzed from a micro point of view. However, it is undeniable that the study has two main limitations. Compared with the actual situation, the AIDS preventive expenditure based on the SHA2011 framework could be underestimated, because the condoms at patients' own expense was not taken into account. In addition, in the calculation of CCE, only considered direct medical expenses were considered, excluding indirect expenses (such as transportation fee and loss of medical working hours, etc). Therefore, our calculation of OOPs could not fully reflect the actual economic burden of AIDS families.