Economic costs of antiretroviral treatment (ART) in Costa Rica as a low- middle-income country: trends, challenges, and sustainability prospects

Over the past decade, the cost of antiretroviral therapy (ART) has become an increasingly complex challenge
for health systems in low- and middle-income countries (LMICs). This article offers a comprehensive review
of the literature and key documents to explore both the direct and indirect costs associated with ART. It places
particular emphasis on comparing generic versus brand-name medications, the impact of international aid
programs—such as the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund—
and the role of public policies in shaping access and equity in healthcare. To conduct this analysis, we
conducted a narrative review of studies published between 2010 and 2023, drawing from indexed databases
like PubMed, Scielo, and LILACS, as well as reports from leading global health organizations including the
WHO, PAHO, and UNAIDS. The findings reveal a gradual reduction in drug costs, largely driven by the
introduction of generics. However, significant barriers remain, particularly in terms of out-of-pocket expenses
and unequal access to coverage. In Costa Rica, pilot initiatives involving pre-exposure prophylaxis (PrEP)
have provided valuable insights into the financial sustainability of HIV prevention efforts within the
framework of the Costa Rican Social Security Fund (CCSS), the country’s sole public healthcare provider.
This review contributes meaningful evidence to inform public health decision-making, highlighting the
importance of sustainable financing for comprehensive HIV prevention strategies and long-term ART access
in resource-constrained settings