Background: Integrating HIV services into health insurance schemes can sustainably increase domestic resources available for HIV, though regulatory and financial mechanisms must be in place. A package of HIV services must be in the minimum benefits package of the insurance scheme. Results from select countries can illuminate options applicable for both generalized and concentrated epidemics.
Methods: In Tanzania and Indonesia, the PEPFAR- and USAID-funded Health Policy Plus project (HP+) assessed these options. Based on basic vs. comprehensive packages of HIV services, HP+ projected utilization rates through insurance. This involved analyses of the current proportion of people living with HIV (PLHIV) enrolled in schemes. Costs to the scheme of selected HIV services were estimated based on underlying unit costs to project the scheme''s total annual expenditure on HIV. This additional liability was compared to scheme revenues and expenditures, to assess sustainability. Sensitivity analyses considered variations in enrolment, utilization, reimbursement mechanisms and service delivery efficiency.
Results: In Tanzania, a basic package (excluding commodity costs) of ART, PMTCT, and HTC is estimated to cost an additional $23 million in Year 1 ($33 million with commodities). A comprehensive package of HIV services (including HIV support services and VMMC) would cost $34 million ($45 million with commodities). In Indonesia, a basic package may only include opportunistic infection prophylaxis, screening and treatment; while a comprehensive one includes ART, PMTCT and HTC. These packages would decrease projected scheme surpluses by 26%-34% in Year 1.
Conclusions: Based on the current cost of HIV services, our results suggest the financial impact on insurance schemes is manageable within the scope of existing pooled resources or through minor premium increases. While insurance schemes differ in design and implementation, this approach to analyzing integration of HIV services can be consistently applied in countries with established health insurance schemes and declining external resources for HIV. A key requirement is ensuring PLHIV are adequately covered and served by insurance schemes, especially key populations. The governments of Tanzania and Indonesia should adopt a two pronged approach - concurrently integrating HIV services into, and scaling up enrolment of PLHIV in, their major insurance schemes.

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