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Kibel M, Nyambura M, Embleton L, Kiptui R, Galárraga O, Apondi E, Ayuku D, Braitstein P. Enabling Adherence to Treatment (EAT): a pilot study of a combination intervention to improve HIV treatment outcomes among street-connected individuals in western Kenya. BMC Health Serv Res 2023; 23:1331. [PMID: 38037045 PMCID: PMC10691070 DOI: 10.1186/s12913-023-10215-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 10/26/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Street-connected individuals (SCI) in Kenya experience barriers to accessing HIV care. This pilot study provides proof-of-concept for Enabling Adherence to Treatment (EAT), a combination intervention providing modified directly observed therapy (mDOT), daily meals, and peer navigation services to SCI living with HIV or requiring therapy for other conditions (e.g. tuberculosis). The goal of the EAT intervention was to improve engagement in HIV care and viral suppression among SCI living with HIV in an urban setting in Kenya. METHODS This pilot study used a single group, pre/post-test design, and enrolled a convenience sample of self-identified SCI of any age. Participants were able to access free hot meals, peer navigation services, and mDOT 6 days per week. We carried out descriptive statistics to characterize participants' engagement in EAT and HIV treatment outcomes. We used McNemar's chi-square test to calculate unadjusted differences in HIV outcomes pre- and post-intervention among participants enrolled in HIV care prior to EAT. We compared unadjusted time to initiation of antiretroviral therapy (ART) and first episode of viral load (VL) suppression among participants enrolled in HIV care prior to EAT vs. concurrently with EAT using the Wilcoxon rank sum test. Statistical significance was defined as p < 0.05. We calculated total, fixed, and variable costs of the intervention. RESULTS Between July 2018 and February 2020, EAT enrolled 87 participants: 46 (53%) female and 75 (86%) living with HIV. At baseline, 60 out of 75 participants living with HIV (80%) had previously enrolled in HIV care. Out of 60, 56 (93%) had initiated ART, 44 (73%) were active in care, and 25 (42%) were virally suppressed (VL < 1000 copies/mL) at their last VL measure in the 19 months before EAT. After 19 months of follow-up, all 75 participants living with HIV had enrolled in HIV care and initiated ART, 65 (87%) were active in care, and 44 (59%) were virally suppressed at their last VL measure. Among the participants who were enrolled in HIV care before EAT, there was a significant increase in the proportion who were active in HIV care and virally suppressed at their last VL measure during EAT enrollment compared to before EAT enrollment. Participants who enrolled in HIV care concurrently with EAT had a significantly shorter time to initiation of ART and first episode of viral suppression compared to participants who enrolled in HIV care prior to EAT. The total cost of the intervention over 19 months was USD $57,448.64. Fixed costs were USD $3623.04 and variable costs were USD $63.75/month/participant. CONCLUSIONS This pilot study provided proof of concept that EAT, a combination intervention providing mDOT, food, and peer navigation services, was feasible to implement and may support engagement in HIV care and achievement of viral suppression among SCI living with HIV in an urban setting in Kenya. Future work should focus on controlled trials of EAT, assessments of feasibility in other contexts, and cost-effectiveness studies.
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Affiliation(s)
- Mia Kibel
- MD Program, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Monicah Nyambura
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606-30100, Eldoret, Kenya
| | - Lonnie Embleton
- MD Program, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Global Health and Health System Design, Icahn School of Medicine Mount Sinai, New York, NY, USA
| | - Reuben Kiptui
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606-30100, Eldoret, Kenya
| | - Omar Galárraga
- Department of Health Services Policy and Practice, and International Health Institute, Brown University School of Public Health, Providence, RI, USA
| | - Edith Apondi
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606-30100, Eldoret, Kenya
- Department of Child Health and Paediatrics, College of Health Sciences, Moi University, Eldoret, Kenya
| | - David Ayuku
- Department of Mental Health and Behavioral Sciences, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Paula Braitstein
- MD Program, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606-30100, Eldoret, Kenya
- Department of Epidemiology and Medical Statistics, School of Public Health, College of Health Sciences, Moi University, Eldoret, Kenya
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d'Elbée M, Terris-Prestholt F, Briggs A, Griffiths UK, Larmarange J, Medley GF, Gomez GB. Estimating health care costs at scale in low- and middle-income countries: Mathematical notations and frameworks for the application of cost functions. HEALTH ECONOMICS 2023; 32:2216-2233. [PMID: 37332114 DOI: 10.1002/hec.4722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 04/13/2023] [Accepted: 05/12/2023] [Indexed: 06/20/2023]
Abstract
Appropriate costing and economic modeling are major factors for the successful scale-up of health interventions. Various cost functions are currently being used to estimate costs of health interventions at scale in low- and middle-income countries (LMICs) potentially resulting in disparate cost projections. The aim of this study is to gain understanding of current methods used and provide guidance to inform the use of cost functions that is fit for purpose. We reviewed seven databases covering the economic and global health literature to identify studies reporting a quantitative analysis of costs informing the projected scale-up of a health intervention in LMICs between 2003 and 2019. Of the 8725 articles identified, 40 met the inclusion criteria. We classified studies according to the type of cost functions applied-accounting or econometric-and described the intended use of cost projections. Based on these findings, we developed new mathematical notations and cost function frameworks for the analysis of healthcare costs at scale in LMICs setting. These notations estimate variable returns to scale in cost projection methods, which is currently ignored in most studies. The frameworks help to balance simplicity versus accuracy and increase the overall transparency in reporting of methods.
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Affiliation(s)
- Marc d'Elbée
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
- University of Bordeaux, National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Centre, Bordeaux, France
- Ceped UMR 196, Université Paris Cité, Research Institute for Sustainable Development (IRD), Inserm, Paris, France
| | - Fern Terris-Prestholt
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Andrew Briggs
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Ulla Kou Griffiths
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
- Health Section, Program Group, UNICEF, New York, New York, USA
| | - Joseph Larmarange
- Ceped UMR 196, Université Paris Cité, Research Institute for Sustainable Development (IRD), Inserm, Paris, France
| | - Graham Francis Medley
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Gabriella Beatriz Gomez
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
- IAVI, New York, New York, USA
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Nance N, Salas-Ortiz A, Ogungbemi K, Akeju D, Oluwayinka AG, Ezirim I, Anenih J, Amanze O, Omoregie G, Aliyu SH, Bautista-Arredondo S. Costs of HIV prevention services provided by community-based organizations to female sex workers in Nigeria. PLoS One 2023; 18:e0282826. [PMID: 36913371 PMCID: PMC10010541 DOI: 10.1371/journal.pone.0282826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 02/17/2023] [Indexed: 03/14/2023] Open
Abstract
BACKGROUND Nigeria has been consistently targeted in sub-Saharan Africa as an HIV-priority country. Its main mode of transmission is heterosexual, and consequently, a key population of interest is female sex workers (FSWs). While HIV prevention services are increasingly implemented by community-based organizations (CBOs) in Nigeria, there is a paucity of evidence on the implementation costs of these organizations. This study seeks to fill this gap by providing new evidence about service delivery unit cost for HIV education (HIVE), HIV counseling and testing (HCT), and sexually transmitted infection (STI) referral services. METHODS In a sample of 31 CBOs across Nigeria, we calculated the costs of HIV prevention services for FSWs taking a provider-based perspective. We collected 2016 fiscal year data on tablet computers during a central data training in Abuja, Nigeria, in August 2017. Data collection was part of a cluster-randomized trial examining the effects of management practices in CBOs on HIV prevention service delivery. Staff costs, recurrent inputs, utilities, and training costs were aggregated and allocated to each intervention to produce total cost calculations, and then divided by the number of FSWs served to produce unit costs. Where costs were shared across interventions, a weight proportional to intervention outputs was applied. All cost data were converted to US dollars using the mid-year 2016 exchange rate. We also explored the cost variation across the CBOs, particularly the roles of service scale, geographic location, and time. RESULTS The average annual number of services provided per CBO was 11,294 for HIVE, 3,326 for HCT, and 473 for STI referrals. The unit cost per FSW tested for HIV was 22 USD, the unit cost per FSW reached with HIV education services was 19 USD, and the unit cost per FSW reached by STI referrals was 3 USD. We found heterogeneity in total and unit costs across CBOs and geographic location. Results from the regression models show that total cost and service scale were positively correlated, while unit costs and scale were consistently negatively correlated; this indicates the presence of economies of scale. By increasing the annual number of services by 100 percent, the unit cost decreases by 50 percent for HIVE, 40 percent for HCT, and 10 percent for STI. There was also evidence that indicates that the level of service provision was not constant over time across the fiscal year. We also found unit costs and management to be negatively correlated, though results were not statistically significant. CONCLUSIONS Estimates for HCT services are relatively similar to previous studies. There is substantial variation in unit costs across facilities, and evidence of a negative relationship between unit costs and scale for all services. This is one of the few studies to measure HIV prevention service delivery costs to female sex workers through CBOs. Furthermore, this study also looked at the relationship between costs and management practices-the first of its kind to do so in Nigeria. Results can be leveraged to strategically plan for future service delivery across similar settings.
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Affiliation(s)
- Nerissa Nance
- National Institute of Public Health, Mexico (INSP), Cuernavaca, Mexico
- University of California, Berkeley, Berkeley, CA, United States of America
| | - Andrea Salas-Ortiz
- National Institute of Public Health, Mexico (INSP), Cuernavaca, Mexico
- Centre for Health Economics, University of York, York, United Kingdom
| | | | - David Akeju
- University of Lagos (UNILAG), Lagos, Nigeria
| | | | - Idoteyin Ezirim
- National Agency for the Control of AIDS (NACA), Abuja, Nigeria
| | - James Anenih
- National Agency for the Control of AIDS (NACA), Abuja, Nigeria
| | - Ogbonna Amanze
- National Agency for the Control of AIDS (NACA), Abuja, Nigeria
| | | | - Sani H. Aliyu
- National Agency for the Control of AIDS (NACA), Abuja, Nigeria
| | - Sergio Bautista-Arredondo
- National Institute of Public Health, Mexico (INSP), Cuernavaca, Mexico
- University of California, Berkeley, Berkeley, CA, United States of America
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Jaradeh K, Van Fleet Kingery T, Cheruiyot J, Odhiambo F, Bukusi EA, Cohen CR, Shade SB. Cost comparison of a rapid results initiative against standard clinic-based model to scale-up voluntary medical male circumcision in Kenya. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0000817. [PMID: 36989245 PMCID: PMC10057778 DOI: 10.1371/journal.pgph.0000817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 02/23/2023] [Indexed: 03/30/2023]
Abstract
Voluntary male medical circumcision (VMMC) reduces HIV acquisition by up to 60%. Kenya has successfully scaled up VMMC to an estimated 91% of eligible men and boys in certain regions in combination due to VMMC and cultural circumcisions. VMMC as a program is implemented regionally in traditionally non-circumcising counties where the prevalence is still below 91%, ranging from 56.4% to 66.7%. Given that funding toward VMMC is expected to decline in the coming years, it is important to identify what models of service delivery are most appropriate and efficient to sustainably meet the VMMC needs of new cohorts' eligible men. To this end, we compared the costs of facility-based VMMC and one within a rapid results initiative (RRI), a public health service scheduled during school holidays to perform many procedures over a short period. We employed activity-based micro-costing to estimate the costs, from the implementer perspective, of facility-based VMMC and RRI-based VMMC conducted between October 2017 and September 2018 at 41 sites in Kisumu County, Kenya supported by the Family AIDS care & Education Services (FACES). We conducted site visits and reviewed financial ledger and programmatic data to identify and quantify resources consumed and the number of VMMC procedures performed during routine care and RRIs. Ledger data were used to estimate fixed costs, recurring costs, and cost per circumcision (CPC) in United States dollar (USD). A sensitivity analysis was done to estimate CPC where we allocated 6 months of the ledger to facility-based and 6 months to RRI. Overall, FACES spent $3,092,891 toward VMMC services and performed 42,139 procedures during the funding year. This included $2,644,910 in stable programmatic costs, $139,786 procedure costs, and $308,195 for RRI-specific activities. Over the year, 49% (n = 20,625) of procedures were performed as part of routine care and 51% (n = 21,514) were performed during the RRIs. Procedures conducted during facility-based cost $99.35 per circumcision, those conducted during the RRIs cost $48.51 per circumcision, and according to our sensitivity analysis, CPC for facility-based ranges from $99.35 to $287.24 and for RRI costs ranged from $29.81 to $48.51. The cost of VMMC during the RRI was substantially lower than unit costs reported in previous costing studies. We conclude that circumcision campaigns, such as the RRI, offer an efficient and sustainable approach to VMMC.
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Affiliation(s)
- Katrin Jaradeh
- School of Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Tyler Van Fleet Kingery
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, United States of America
| | - Jackline Cheruiyot
- Centre for Microbiology Research, Kenya Medical Research Institute, Nyakach, Kenya
| | - Francesca Odhiambo
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Elizabeth A Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nyakach, Kenya
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Craig R Cohen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Starley B Shade
- School of Medicine, University of California, San Francisco, San Francisco, California, United States of America
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, United States of America
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Okal JO, Awiti JO, Matheka J, Oluoch-Madiang D, Obanda R, Mathur S. Unit costs of a community-based girl-centered HIV prevention program: a case study of Determined, Resilient, Empowered, AIDS-Free, Mentored, and Safe program. AIDS 2022; 36:S109-S117. [PMID: 35766580 DOI: 10.1097/qad.0000000000003217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We compare the unit costs of providing Determined, Resilient, Empowered, AIDS-Free, Mentored, and Safe (DREAMS) interventions to adolescent girls and young women (AGYW) reached across two sites, an urban (Nyalenda A Ward) and peri-urban (Kolwa East Ward) setting, in Kisumu County of Kenya. DESIGN Micro-costing, using the average cost concept during project initiation and early implementation. METHODS Adopting the implementer's (provider's) perspective, we computed and classified costs in the following categories for each sub-implementing partner: medical and professional staff, administrative and support staff, materials and supplies, building space and utilities, equipment, establishment, and miscellaneous. These costs were summed across sub-implementing partners in a site to obtain the site-level total costs. These are then divided by the total number of AGYW reached in each site to obtain the unit costs. Data were collected from July to September 2017. RESULTS The unit costs in the peri-urban area were about 1.9 times of those in the urban area. It cost about US$67 [or 170 International Dollars] to deliver the DREAMS intervention package to each AGYW reached in the urban area as compared with approximately US$129 (or 327 International Dollars) in the peri-urban area. CONCLUSION First, it was generally more expensive to deliver DREAMS interventions in the peri-urban setting as compared with the urban setting. Second, the difference in unit costs was mainly driven by the building space and utilities. Strategies to lower intervention costs are needed in the peri-urban setting, such as using existing infrastructure (either governmental or nongovernmental) or other innovative ways to deliver the services.
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Affiliation(s)
| | | | | | | | - Rael Obanda
- APHIAPlus Western Kenya, PATH, Kisumu, Kenya
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Wamuti B, Sharma M, Kariithi E, Lagat H, Otieno G, Bosire R, Masyuko S, Mugambi M, Weiner BJ, Katz DA, Farquhar C, Levin C. Cost of integrating assisted partner services in HIV testing services in Kisumu and Homa Bay counties, Kenya: a microcosting study. BMC Health Serv Res 2022; 22:69. [PMID: 35031037 PMCID: PMC8759219 DOI: 10.1186/s12913-022-07479-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 12/30/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND HIV assisted partner services (aPS), or provider notification and testing for sexual and injecting partners of people diagnosed with HIV, is shown to be safe, effective, and cost-effective and was scaled up within the national HIV testing services (HTS) program in Kenya in 2016. We estimated the costs of integrating aPS into routine HTS within an ongoing aPS scale-up project in western Kenya. METHODS We conducted microcosting using the payer perspective in 14 facilities offering aPS. Although aPS was offered to both males and females testing HIV-positive (index clients), we only collected data on female index clients and their male sex partners (MSP). We used activity-based costing to identify key aPS activities, inputs, resources, and estimated financial and economic costs of goods and services. We analyzed costs by start-up (August 2018), and recurrent costs one-year after aPS implementation (Kisumu: August 2019; Homa Bay: January 2020) and conducted time-and-motion observations of aPS activities. We estimated the incremental costs of aPS, average cost per MSP traced, tested, testing HIV-positive, and on antiretroviral therapy, cost shares, and costs disaggregated by facility. RESULTS Overall, the number of MSPs traced, tested, testing HIV-positive, and on antiretroviral therapy was 1027, 869, 370, and 272 respectively. Average unit costs per MSP traced, tested, testing HIV-positive, and on antiretroviral therapy were $34.54, $42.50, $108.71 and $152.28, respectively, which varied by county and facility client volume. The weighted average incremental cost of integrating aPS was $7,485.97 per facility per year, with recurrent costs accounting for approximately 90% of costs. The largest cost drivers were personnel (49%) and transport (13%). Providers spent approximately 25% of the HTS visit obtaining MSP contact information (HIV-negative clients: 13 out of 54 min; HIV-positive clients: 20 out of 96 min), while the median time spent per MSP traced on phone and in-person was 6 min and 2.5 hours, respectively. CONCLUSION Average facility costs will increase when integrating aPS to HTS with incremental costs largely driven by personnel and transport. Strategies to efficiently utilize healthcare personnel will be critical for effective, affordable, and sustainable aPS.
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Affiliation(s)
- Beatrice Wamuti
- Department of Global Health, University of Washington, 325 9th Avenue, Box 359909, Seattle, WA, 98104, USA.
| | - Monisha Sharma
- Department of Global Health, University of Washington, 325 9th Avenue, Box 359909, Seattle, WA, 98104, USA
| | | | | | | | - Rose Bosire
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Sarah Masyuko
- Department of Global Health, University of Washington, 325 9th Avenue, Box 359909, Seattle, WA, 98104, USA
- Ministry of Health, Nairobi, Kenya
| | | | - Bryan J Weiner
- Department of Global Health, University of Washington, 325 9th Avenue, Box 359909, Seattle, WA, 98104, USA
| | - David A Katz
- Department of Global Health, University of Washington, 325 9th Avenue, Box 359909, Seattle, WA, 98104, USA
| | - Carey Farquhar
- Department of Global Health, University of Washington, 325 9th Avenue, Box 359909, Seattle, WA, 98104, USA
- Department of Epidemiology, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
| | - Carol Levin
- Department of Global Health, University of Washington, 325 9th Avenue, Box 359909, Seattle, WA, 98104, USA
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Soe KM, Hauck K, Jiamton S, Kongsin S. The cost of community outreach HIV interventions: a case study in Thailand. BMC Public Health 2022; 22:20. [PMID: 34991550 PMCID: PMC8740331 DOI: 10.1186/s12889-021-12416-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 12/13/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND There was an estimated 440,000 people living with HIV in Thailand in 2018. New cases are declining rapidly thanks to successful prevention programs and scaling up of anti-retroviral therapy (ART). Thailand aims to achieve its commitment to end the HIV epidemic by 2030 and implemented a cascade of HIV interventions through the Reach-Recruit-Test-Treat-Retain (RRTTR) program. METHODS This study focused on community outreach HIV interventions implemented by Non-Governmental Organizations (NGOs) under the RRTTR program in 27 provinces. We calculated unit cost per person reached for HIV interventions targeted at key-affected populations (KAPs) including men who have sex with men/ transgender (MSM/TG), male sex workers (MSW), female sex workers (FSW), people who inject drugs (PWID) and migrants (MW). We studied program key outputs, costs, and unit costs in variations across different HIV interventions and geographic locations in Thailand. We used these estimates to determine costs of HIV interventions and evaluate economies of scale. RESULTS The interventions for migrants in Samut Sakhon was the least costly with a unit cost of 21.6 USD per person to receive services, followed by interventions for migrants in Samut Prakan 23.2 USD per person reached, MSM/TG in Pratum Thani 26.5USD per person reached, MSM/TG in Nonthaburi 26.6 USD per person reached and, MSM/TG in Chon Buri with 26.7 USD per person. The interventions yielded higher efficiency in large metropolitan and surrounding provinces. Harm reduction programs were the costliest compare with other interventions. There was association between unit cost and scale of among interventions indicating the presence of economies scale. Implementing HIV and TB interventions jointly increased efficiency for both cases. CONCLUSION This study suggested that unit cost of community outreach HIV and TB interventions led by CSOs will decrease as they are scaled up. Further studies are suggested to follow up with these ongoing interventions for identifying potential contextual factors to improve efficiency of HIV prevention services in Thailand.
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Affiliation(s)
- Kyaw Min Soe
- Research Centre for Health Economics and Evaluation, Faculty of Public Health, Mahidol University, 420/1 Ratchawithi Rd, Khet Ratchathewi, Bangkok, 10400, Thailand
- Department of Infectious Disease Epidemiology, Faculty of Medicine, School of Public Health, Imperial College London, London, UK
| | - Katharina Hauck
- Department of Infectious Disease Epidemiology, Faculty of Medicine, School of Public Health, Imperial College London, London, UK
| | - Sukhum Jiamton
- Research Centre for Health Economics and Evaluation, Faculty of Public Health, Mahidol University, 420/1 Ratchawithi Rd, Khet Ratchathewi, Bangkok, 10400, Thailand
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sukhontha Kongsin
- Research Centre for Health Economics and Evaluation, Faculty of Public Health, Mahidol University, 420/1 Ratchawithi Rd, Khet Ratchathewi, Bangkok, 10400, Thailand.
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Adawiyah RA, Saweri OPM, Boettiger DC, Applegate TL, Probandari A, Guy R, Guinness L, Wiseman V. The costs of scaling up HIV and syphilis testing in low- and middle-income countries: a systematic review. Health Policy Plan 2021; 36:939-954. [PMID: 33693731 PMCID: PMC8227996 DOI: 10.1093/heapol/czab030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2021] [Indexed: 12/18/2022] Open
Abstract
Around two-thirds of all new HIV infections and 90% of syphilis cases occur in low- and middle-income countries (LMICs). Testing is a key strategy for the prevention and treatment of HIV and syphilis. Decision-makers in LMICs face considerable uncertainties about the costs of scaling up HIV and syphilis testing. This paper synthesizes economic evidence on the costs of scaling up HIV and syphilis testing interventions in LMICs and evidence on how costs change with the scale of delivery. We systematically searched multiple databases (Medline, Econlit, Embase, EMCARE, CINAHL, Global Health and the NHS Economic Evaluation Database) for peer-reviewed studies examining the costs of scaling up HIV and syphilis testing in LMICs. Thirty-five eligible studies were identified from 4869 unique citations. Most studies were conducted in Sub-Saharan Africa (N = 17) and most explored the costs of rapid HIV in facilities targeted the general population (N = 19). Only two studies focused on syphilis testing. Seventeen studies were cost analyses, 17 were cost-effectiveness analyses and 1 was cost-benefit analysis of HIV or syphilis testing. Most studies took a modelling approach (N = 25) and assumed costs increased linearly with scale. Ten studies examined cost efficiencies associated with scale, most reporting short-run economies of scale. Important drivers of the costs of scaling up included testing uptake and the price of test kits. The 'true' cost of scaling up testing is likely to be masked by the use of short-term decision frameworks, linear unit-cost projections (i.e. multiplying an average cost by a factor reflecting activity at a larger scale) and availability of health system capacity and infrastructure to supervise and support scale up. Cost data need to be routinely collected alongside other monitoring indicators as HIV and syphilis testing continues to be scaled up in LMICs.
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Affiliation(s)
- Rabiah Al Adawiyah
- The Kirby Institute, University New South Wales, High St, Kensington 2052, New South Wales, Australia
| | - Olga P M Saweri
- The Kirby Institute, University New South Wales, High St, Kensington 2052, New South Wales, Australia.,Population Health and Demography, Papua New Guinea Institute of Medical Research, PO Box 60 Homate Street, Goroka, Papua New Guinea
| | - David C Boettiger
- The Kirby Institute, University New South Wales, High St, Kensington 2052, New South Wales, Australia
| | - Tanya L Applegate
- The Kirby Institute, University New South Wales, High St, Kensington 2052, New South Wales, Australia
| | - Ari Probandari
- Department of Public Health, Faculty of Medicine, Universitas Sebelas Maret, Jl. Ir. Sutami 36A. Surakarta, 57126, Indonesia
| | - Rebecca Guy
- The Kirby Institute, University New South Wales, High St, Kensington 2052, New South Wales, Australia
| | - Lorna Guinness
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK.,Centre for Global DevelopmentEurope, Great Peter House, Great College St, London SW1P 3SE, UK
| | - Virginia Wiseman
- The Kirby Institute, University New South Wales, High St, Kensington 2052, New South Wales, Australia.,London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
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d'Elbée M, Gomez GB, Sande LA, Mwenge L, Mangenah C, Johnson C, Medley GF, Neuman M, Hatzold K, Corbett EL, Meyer-Rath G, Terris-Prestholt F. Modelling costs of community-based HIV self-testing programmes in Southern Africa at scale: an econometric cost function analysis across five countries. BMJ Glob Health 2021; 6:e005554. [PMID: 34275875 PMCID: PMC8287624 DOI: 10.1136/bmjgh-2021-005554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 05/25/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Following success demonstrated with the HIV Self-Testing AfRica Initiative, HIV self-testing (HIVST) is being added to national HIV testing strategies in Southern Africa. An analysis of the costs of scaling up HIVST is needed to inform national plans, but there is a dearth of evidence on methods for forecasting costs at scale from pilot projects. Econometric cost functions (ECFs) apply statistical inference to predict costs; however, we often do not have the luxury of collecting large amounts of location-specific data. We fit an ECF to identify key drivers of costs, then use a simpler model to guide cost projections at scale. METHODS We estimated the full economic costs of community-based HIVST distribution in 92 locales across Malawi, Zambia, Zimbabwe, South Africa and Lesotho between June 2016 and June 2019. We fitted a cost function with determinants related to scale, locales organisational and environmental characteristics, target populations, and per capita Growth Domestic Product (GDP). We used models differing in data intensity to predict costs at scale. We compared predicted estimates with scale-up costs in Lesotho observed over a 2-year period. RESULTS The scale of distribution, type of community-based intervention, percentage of kits distributed to men, distance from implementer's warehouse and per capita GDP predicted average costs per HIVST kit distributed. Our model simplification approach showed that a parsimonious model could predict costs without losing accuracy. Overall, ECF showed a good predictive capacity, that is, forecast costs were close to observed costs. However, at larger scale, variations of programme efficiency over time (number of kits distributed per agent monthly) could potentially influence cost predictions. DISCUSSION Our empirical cost function can inform community-based HIVST scale-up in Southern African countries. Our findings suggest that a parsimonious ECF can be used to forecast costs at scale in the context of financial planning and budgeting.
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Affiliation(s)
- Marc d'Elbée
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Gabriela B Gomez
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Linda Alinafe Sande
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
- Department of HIV/AIDS & TB, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - Collin Mangenah
- Department of Health Economics, Centre for Sexual Health HIV/AIDS Research, Harare, Zimbabwe
| | - Cheryl Johnson
- Global HIV, Hepatitis and STI Programme, World Health Organisation, Geneva, Switzerland
| | - Graham F Medley
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Melissa Neuman
- MRC International Statistics and Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Karin Hatzold
- Population Services International, Washington, DC, USA
| | - Elizabeth Lucy Corbett
- Department of HIV/AIDS & TB, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Gesine Meyer-Rath
- Department of Internal Medicine, Health Economics and Epidemiology Research Office (HE2RO) - University of the Witwatersrand, Johannesburg, South Africa
- Center for Global Health and Development, Boston University, Boston, Massachusetts, USA
| | - Fern Terris-Prestholt
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
- Department of Global Health & Development, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland
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Gomez GB, Mudzengi DL, Bozzani F, Menzies NA, Vassall A. Estimating Cost Functions for Resource Allocation Using Transmission Models: A Case Study of Tuberculosis Case Finding in South Africa. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:1606-1612. [PMID: 33248516 DOI: 10.1016/j.jval.2020.08.2096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 08/22/2020] [Accepted: 08/25/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Cost functions linked to transmission dynamic models are commonly used to estimate the resources required for infectious disease policies. We present a conceptual and empirical approach for estimating these functions, allowing for nonconstant marginal costs. We aim to expand on the current approach which commonly assumes linearity of cost over scale. METHODS We propose a theoretical framework adapted from the field of transport economics. We specify joint functions of production of services within a disease-specific program. We expand these functions to include qualitative insights of program expansion patterns. We present the difference in incremental total costs between an approach assuming constant unit costs and alternative approaches that assume economies of scale, scope and homogeneous or heterogeneous facility recruitment into the programme during scale-up. We illustrate the framework's application in tuberculosis, using secondary data from the literature and routine reporting systems in South Africa. RESULTS Economies of capacity and scope substantially change cost estimates over time. Cost data requirements for the proposed approach included standardized and disaggregated unit costs (for a limited number of outputs) and information on the facilities network available to the program. CONCLUSIONS The defined functional form will determine the magnitude and shape of costs when outputs and coverage are increasing. This in turn will impact resource allocation decisions. Infectious diseases modelers and economists should use transparent and empirically based cost models for analyses that inform resource allocation decisions. This framework describes a general approach for developing these models.
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Affiliation(s)
- Gabriela B Gomez
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
| | | | - Fiammetta Bozzani
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Nicholas A Menzies
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA; Center for Health Decision Science, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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11
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Olwanda EE, Kahn JG, Choi Y, Islam JY, Huchko M. Comparison of the costs of HPV testing through community health campaigns versus home-based testing in rural Western Kenya: a microcosting study. BMJ Open 2020; 10:e033979. [PMID: 33109637 PMCID: PMC7592277 DOI: 10.1136/bmjopen-2019-033979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 07/29/2020] [Accepted: 09/21/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To estimate the cost of human papillomavirus (HPV)-based screening through community health campaigns (CHCs) and home-based testing. SETTING CHCs and home-based testing in six communities in rural Western Kenya. PARTICIPANTS CHCs and home-based screening reached 2297 and 1002 women aged 25-65 years, respectively. OUTCOME MEASURES Outcome measures were overall cost per woman screened achieved through the CHCs and home-based testing and the cost per woman for each activity comprising the screening intervention. RESULTS The mean cost per woman screened through CHCs and home-based testing were similar, at $37.7 (range $26.4-$52.0) and $37.1 (range $27.6-$54.0), respectively. For CHCs, personnel represented 49% of overall cost, supplies 25%, services 5% and capital goods 23%. For home-based testing, these were: personnel 73%, supplies 25%, services 1% and capital goods 2%. A greater number of participants was associated with a lower cost per participant. CONCLUSIONS The mean cost per woman screened is comparable for CHC and home-based testing, with differences in type of input. The CHCs generally reached more eligible women in the six communities, whereas home-based strategies more efficiently reached populations with low screening rates. TRIAL REGISTRATION NUMBER NCT02124252.
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Affiliation(s)
| | - James G Kahn
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA
| | - Yujung Choi
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Duke University, Department of Obstetrics and Gynecology, Durham, NC, USA
| | - Jessica Yasmine Islam
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Megan Huchko
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Duke University, Department of Obstetrics and Gynecology, Durham, NC, USA
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12
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Integrating Economic Evaluation and Implementation Science to Advance the Global HIV Response. J Acquir Immune Defic Syndr 2020; 82 Suppl 3:S314-S321. [PMID: 31764269 DOI: 10.1097/qai.0000000000002219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Numerous cost-effectiveness analyses have indicated good value for money from a wide array of interventions for treatment and prevention of HIV/AIDS. There is limited evidence, however, regarding how cost-effectiveness information contributes to better decision-making around investment and action in the global HIV response. METHODS We review challenges for economic evaluation relevant to the global HIV response and consider how the practice of cost-effectiveness analysis could integrate approaches and insights from implementation science to enhance the impact and efficiency of HIV investments. RESULTS In light of signals that cost-effectiveness analyses may be vulnerable to systematic bias toward overly optimistic conclusions, we emphasize two priorities for advancing the field of economic evaluation in HIV/AIDS and more broadly in global health: (1) systematic reevaluation of the cost-effectiveness literature with reference to ex-post empirical evidence on costs and effects in real-world programs and (2) development and adoption of good-practice guidelines for incorporating implementation and delivery aspects into economic evaluations. Toward the latter aim, we propose an integrative approach that focuses on comparative evaluation of strategies, which specify both technologies/interventions as well as the delivery platforms, complementary interventions, and actions needed to increase coverage, quality, and uptake of those technologies/interventions. Specific recommendations draw on several existing implementation science models that provide systematic frameworks for understanding implementation barriers and enablers, designing and choosing specific implementation and policy actions, and evaluating outcomes. DISCUSSION These preliminary steps aimed at bridging the divide between economic evaluation and implementation science can help to advance the practice of economic evaluation toward a science of comparative strategy evaluation.
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Pineda-Antunez C, Martinez-Silva G, Cerecero-Garcia D, Alexander L, Cameron DB, Chiwevu C, Dandona L, Obure CD, Forsythe S, Nguyen VT, Settumba S, Tchuenche M, Van Minh H, Kahn JG, Gomez G, Sweeney S, Vassall A, Bollinger L, Levin C, Bautista-Arredondo S. Meta-analysis of average costs of HIV testing and counselling and voluntary medical male circumcision across thirteen countries. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2020; 18:341-349. [PMID: 31779565 DOI: 10.2989/16085906.2019.1679850] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective: Explore facility-level average costs per client of HIV testing and counselling (HTC) and voluntary medical male circumcision (VMMC) services in 13 countries.Methods: Through a literature search we identified studies that reported facility-level costs of HTC or VMMC programmes. We requested the primary data from authors and standardised the disparate data sources to make them comparable. We then conducted descriptive statistics and a meta-analysis to assess the cost variation among facilities. All costs were converted to 2017 US dollars ($).Results: We gathered data from 14 studies across 13 countries and 772 facilities (552 HTC, 220 VMMC). The weighted average unit cost per client served was $15 (95% CI 12, 18) for HTC and $59 (95% CI 45, 74) for VMMC. On average, 38% of the mean unit cost for HTC corresponded to recurrent costs, 56% to personnel costs, and 6% to capital costs. For VMMC, 41% of the average unit cost corresponded to recurrent costs, 55% to personnel costs, and 4% to capital costs. We observed unit cost variation within and between countries, and lower costs in higher scale categories in all interventions.
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Affiliation(s)
- Carlos Pineda-Antunez
- Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Mexico
| | - Gisela Martinez-Silva
- Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Mexico
| | - Diego Cerecero-Garcia
- Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Mexico
| | - Lily Alexander
- Department of Global Health, University of Washington, Seattle, USA
| | - Drew B Cameron
- Health Policy and Management, University of California Berkeley, Berkeley, USA
| | - Chris Chiwevu
- Center for Population Health Sciences, Hanoi University of Public Health, Hanoi, Vietnam
| | - Lalit Dandona
- Public Health Foundation of India, Gurugram, National Capital Region, India
| | - Carol Dayo Obure
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Stella Settumba
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | | | - Hoang Van Minh
- Center for Population Health Sciences, Hanoi University of Public Health, Hanoi, Vietnam
| | - James G Kahn
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, California, USA
| | - Gabriela Gomez
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Sedona Sweeney
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Carol Levin
- Department of Global Health, University of Washington, Seattle, USA
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14
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Atkins K, Yeh PT, Kennedy CE, Fonner VA, Sweat MD, O’Reilly KR, Baggaley R, Rutherford GW, Samuelson J. Service delivery interventions to increase uptake of voluntary medical male circumcision for HIV prevention: A systematic review. PLoS One 2020; 15:e0227755. [PMID: 31929587 PMCID: PMC6957297 DOI: 10.1371/journal.pone.0227755] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 12/27/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Voluntary medical male circumcision (VMMC) remains an essential component of combination HIV prevention services, particularly in priority countries in sub-Saharan Africa. As VMMC programs seek to maximize impact and efficiency, and to support World Health Organization guidance, specific uptake-enhancing strategies are critical to identify. METHODS We systematically reviewed the literature to evaluate the impact of service delivery interventions (e.g., facility layout, service co-location, mobile outreach) on VMMC uptake among adolescent and adult men. For the main effectiveness review, we searched for publications or conference abstracts that measured VMMC uptake or uptake of HIV testing or risk reduction counselling within VMMC services. We synthesized data by coding categories and outcomes. We also reviewed studies assessing acceptability, values/preferences, costs, and feasibility. RESULTS Four randomized controlled trials and five observational studies were included in the effectiveness review. Studies took place in South Africa, Tanzania, Uganda, Zambia, and Zimbabwe. They assessed a range of service delivery innovations, including community-, school-, and facility-based interventions. Overall, interventions increased VMMC uptake; some successfully improved uptake among age-specific subpopulations, but urban-rural stratification showed no clear trends. Interventions that increased adult men's uptake included mobile services (compared to static facilities), home-based testing with active referral follow-up, and facility-based HIV testing with enhanced comprehensive sexual education. Six acceptability studies suggested interventions were generally perceived to help men choose to get circumcised. Eleven cost studies suggested interventions create economies-of-scale and efficiencies. Three studies suggested such interventions were feasible, improving facility preparedness, service quality and quantity, and efficiencies. CONCLUSIONS Innovative changes in male-centered VMMC services can improve adult men's and adolescent boys' VMMC uptake. Limited evidence on interventions that enhance access and acceptability show promising results, but evidence gaps persist due to inconsistent intervention definition and delivery, due in part to contextual relevance and limited age disaggregation.
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Affiliation(s)
- Kaitlyn Atkins
- Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Ping Teresa Yeh
- Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Caitlin E. Kennedy
- Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Virginia A. Fonner
- Division of Global and Community Health, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Michael D. Sweat
- Division of Global and Community Health, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Kevin R. O’Reilly
- Division of Global and Community Health, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Rachel Baggaley
- Department of HIV, World Health Organization, Geneva, Switzerland
| | - George W. Rutherford
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, United States of America
| | - Julia Samuelson
- Department of HIV, World Health Organization, Geneva, Switzerland
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15
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Joseph RH, Musingila P, Miruka F, Wanjohi S, Dande C, Musee P, Lugalia F, Onyango D, Kinywa E, Okomo G, Moth I, Omondi S, Ayieko C, Nganga L, Zielinski-Gutierrez E, Muttai H, De Cock KM. Expanded eligibility for HIV testing increases HIV diagnoses-A cross-sectional study in seven health facilities in western Kenya. PLoS One 2019; 14:e0225877. [PMID: 31881031 PMCID: PMC6934319 DOI: 10.1371/journal.pone.0225877] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 11/14/2019] [Indexed: 11/18/2022] Open
Abstract
Homa Bay, Siaya, and Kisumu counties in western Kenya have the highest estimated HIV prevalence (16.3-21.0%) in the country, and struggle to meet program targets for HIV testing services (HTS). The Kenya Ministry of Health (MOH) recommends annual HIV testing for the general population. We assessed the degree to which reducing the interval for retesting to less than 12 months increased diagnosis of HIV in outpatient departments (OPD) in western Kenya. We conducted a retrospective analysis of routinely collected program data from seven high-volume (>800 monthlyOPD visits) health facilities in March-December, 2017. Data from persons ≥15 years of age seeking medical care (patients) in the OPD and non-care-seekers (non-patients) accompanying patients to the OPD were included. Outcomes were meeting MOH (routine) criteria versus criteria for a reduced retesting interval (RRI) of <12 months, and HIV test result. STATA version 14.2 was used to calculate frequencies and proportions, and to test for differences using bivariate analysis. During the 9-month period, 119,950 clients were screened for HIV testing eligibility, of whom 79% (94,766) were eligible and 97% (92,153) received a test. Among 92,153 clients tested, the median age was 28 years, 57% were female and 40% (36,728) were non-patients. Overall, 20% (18,120) of clients tested met routine eligibility criteria: 4% (3,972) had never been tested, 10% (9,316) reported a negative HIV test in the past >12 months, and 5% (4,832) met other criteria. The remaining 80% (74,033) met criteria for a RRI of < 12 months. In total 1.3% (1,185) of clients had a positive test. Although the percent yield was over 2-fold higher among those meeting routine criteria (2.4% vs. 1.0%; p<0.001), 63% (750) of all HIV infections were found among clients tested less than 12 months ago, the majority (81%) of whom reported having a negative test in the past 3-12 months. Non-patients accounted for 45% (539) of all HIV-positive persons identified. Percent yield was higher among non-patients as compared to patients (1.5% vs. 1.2%; p-value = <0.001) overall and across eligibility criteria and age categories. The majority of HIV diagnoses in the OPD occurred among clients reporting a negative HIV test in the past 12 months, clients ineligible for testing under the current MOH guidelines. Nearly half of all HIV-positive individuals identified in the OPD were non-patients. Our findings suggest that in the setting of a generalized HIV epidemic, retesting persons reporting an HIV-negative test in the past 3-12 months, and routine testing of non-patients accessing the OPD are key strategies for timely diagnosis of persons living with HIV.
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Affiliation(s)
- Rachael H. Joseph
- Division of Global HIV&TB, U.S. Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Paul Musingila
- Division of Global HIV&TB, U.S. Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Fredrick Miruka
- Division of Global HIV&TB, U.S. Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Stella Wanjohi
- HIV Prevention and Community Services, Center for Health Solutions, Kisumu, Kenya
| | - Caroline Dande
- HIV Testing and Counseling Services, University of California, San Francisco (FACES), Kisumu, Kenya
| | - Polycarp Musee
- HIV Testing and Counseling Services, Elizabeth Glaser Pediatric AIDS Foundation, Homa Bay, Kenya
| | - Fillet Lugalia
- HIV Testing and Counseling Services, Columbia University, ICAP, Kisumu, Kenya
| | - Dickens Onyango
- Kisumu County Department of Health, County Government of Kisumu, Kisumu, Kenya
| | - Eunice Kinywa
- Kisumu County Department of Health, County Government of Kisumu, Kisumu, Kenya
| | - Gordon Okomo
- Homa Bay County Department of Health, County Government of Homa Bay, Homa Bay, Kenya
| | - Iscah Moth
- Homa Bay County Department of Health, County Government of Homa Bay, Homa Bay, Kenya
| | - Samuel Omondi
- Siaya County Department of Health, County Government of Siaya, Siaya, Kenya
| | - Caren Ayieko
- Siaya County Department of Health, County Government of Siaya, Siaya, Kenya
| | - Lucy Nganga
- Division of Global HIV&TB, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | | | - Hellen Muttai
- Division of Global HIV&TB, U.S. Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Kevin M. De Cock
- Division of Global HIV&TB, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
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Zhao Y, Fitzpatrick T, Wan B, Day S, Mathews A, Tucker JD. Forming and implementing community advisory boards in low- and middle-income countries: a scoping review. BMC Med Ethics 2019; 20:73. [PMID: 31623624 PMCID: PMC6796331 DOI: 10.1186/s12910-019-0409-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 09/16/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Community advisory boards (CABs) have expanded beyond high-income countries (HICs) and play an increasing role in low- and middle-income country (LMIC) research. Much research has examined CABs in HICs, but less is known about CABs in LMICs. The purposes of this scoping review are to examine the creation and implementation of CABs in LMICs, including identifying frequently reported challenges, and to discuss implications for research ethics. METHODS We searched five databases (PubMed, Embase, Global Health, Scopus, and Google Scholar) for publications describing or evaluating CABs in LMICs. Two researchers independently reviewed articles for inclusion. Data related to the following aspects of CABs were extracted from included publications: time, country, financial support, research focus, responsibilities, and challenges. Thematic analyses were used to summarize textual data describing challenges. RESULTS Our search yielded 2005 citations, 83 of which were deemed eligible for inclusion. Most studies (65) were published between 2010 and 2017. Upper-middle-income countries were more likely to have studies describing CABs, with South Africa (17), China (8), and Thailand (7) having the greatest numbers. The United States National Institutes of Health was the main source of financial support for CABs. Many CABs (53/88, 60%) focused on HIV research. Thirty-four studies reported how CABs influenced the informed consent process for clinical trials or other aspects of research ethics. CAB responsibilities were related to clinical trials, including reviewing study protocols, educating local communities about research activities, and promoting the ethical conduct of research. Challenges faced by CABs included the following: incomplete ethical regulations and guidance; limited knowledge of science among members of communities and CABs; unstable and unbalanced power relationships between researchers and local communities; poor CAB management, including lack of formal participation structures and absence of CAB leadership; competing demands for time that limited participation in CAB activities; and language barriers between research staff and community members. Several challenges reflected shortcomings within the research team. CONCLUSIONS Our findings examine the formation and implementation of CABs in LMICs and identify several ethical challenges. These findings suggest the need for further ethics training among CAB members and researchers in LMICs.
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Affiliation(s)
- Yang Zhao
- University of North Carolina at Chapel Hill - Project China, No.2 Lujing Road, Guangzhou, 510095 China
| | - Thomas Fitzpatrick
- University of North Carolina at Chapel Hill - Project China, No.2 Lujing Road, Guangzhou, 510095 China
- University of Washington School of Medicine, Seattle, USA
| | - Bin Wan
- Department of Maternal and Child Health, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Suzanne Day
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Allison Mathews
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Joseph D. Tucker
- University of North Carolina at Chapel Hill - Project China, No.2 Lujing Road, Guangzhou, 510095 China
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, USA
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, USA
- Faculty of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, UK
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Homan R, Bratt J, Marchand G, Kansembe H. Leveraging existing program data for routine efficiency measurement in Zambia. Gates Open Res 2019; 2:40. [PMID: 31131366 PMCID: PMC6480548 DOI: 10.12688/gatesopenres.12851.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2018] [Indexed: 11/20/2022] Open
Abstract
Rationale: As donor contributions for HIV/AIDS stagnate globally, national governments must seek ways to improve use of existing resources through interventions to drive efficiency at the facility level. But program managers lack routine information on unit expenditures at points of care, and higher-level planners are unable to assess resource use in the health system. Thus, managers cannot measure current levels of technical efficiency, and are unable to evaluate effectiveness of interventions to increase technical efficiency. Phased Implementation of REMS: FHI 360 developed the Routine Efficiency Monitoring System (REMS)-a relational database leveraging existing budget, expenditure and output data to produce quarterly site-level estimates of unit expenditure per service. Along with the Government of the Republic of Zambia (GRZ) and implementation partner Avencion, we configured REMS to measure technical efficiency of Ministry of Health resources used to deliver HIV/AIDS services in 326 facilities in 17 high-priority districts in Copperbelt and Central Provinces. REMS allocation algorithms were developed through facility assessments, and key informant interviews with MoH staff. Existing IFMIS and DHIS-2 data streams provide recurring flows of expenditure and output data needed to estimate service-specific unit expenditures. Trained users access REMS output through user-friendly dashboards delivered through a web-based application. REMS as a Solution: District health managers use REMS to identify “outlier” facilities to test performance improvement interventions. Provincial and national planners are using REMS to seek savings and ensure that resources are directed to geographic and programmatic areas with highest need. REMS can support reimbursement for social health insurance and provide time-series data on facility-level costs for modeling. Conclusions and Next Steps: REMS gives managers and planners substantially-improved data on how programs transform resources into services. The GRZ is seeking funding to expand REMS nationally, covering all major disease areas. Improved technical efficiency supports the goal of a sustainable HIV/AIDS response.
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Affiliation(s)
- Rick Homan
- Health Services Research, FHI 360, Durham, North Carolina, 27701, USA
| | - John Bratt
- Health Services Research, FHI 360, Durham, North Carolina, 27701, USA
| | | | - Henry Kansembe
- Planning Department, Ministry of Health, Government of the Republic of Zambia, Lusaka, Zambia
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Galárraga O, Shah P, Wilson-Barthes M, Ayuku D, Braitstein P. Cost and cost-effectiveness of voluntary medical male circumcision in street-connected youth: findings from an education-based pilot intervention in Eldoret, Kenya. AIDS Res Ther 2018; 15:24. [PMID: 30497481 PMCID: PMC6264043 DOI: 10.1186/s12981-018-0207-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 11/08/2018] [Indexed: 01/06/2023] Open
Abstract
Background Voluntary medical male circumcision (VMMC) is a critical component of HIV prevention. VMMC policies have achieved initial targets in adult men yet continue to fall short in reaching younger men and adolescents. Setting We present the cost and scale-up implications of an education-based, VMMC intervention for adolescent street-connected males, for whom the street has become their home and/or source of livelihood. The intervention was piloted as part of the Engaging Street Youth in HIV Interventions Project in Eldoret, Kenya. Methods We used a micro-costing approach to estimate the average cost of a VMMC intervention in 116 street-connected youth. Average cost was estimated per individual and per cohort by dividing total cost per intervention by number of clients accessing the intervention over a 30-day period. Total average costs included direct and support procedure costs, educational costs, and direct research costs. Cost-effectiveness was measured in cost per DALYs averted over a 5 and 10-year period. Results The total cost of the intervention was $12,526 over the 30-day period, with an average cost per individual of $108. The direct VMMC procedure cost was approximately $9 per individual. Personnel costs contributed the greatest percentage to the total intervention cost (38.2%), with mentors and social workers representing the highest wage earners. Retreat-related and education costs contributed 51% and 13% respectively to the total average cost, with surgical equipment costs contributing less than 1%. At a cost of $108 per individual, the intervention averted 60166 DALYs in 5 years resulting in a cost per DALY averted of $267. Conclusion The VMMC intervention was highly cost-effective in Kenya, despite the additional costs incurred to reach SCY. Further scale-up may be warranted to effectively apply this intervention in comparable populations. Electronic supplementary material The online version of this article (10.1186/s12981-018-0207-x) contains supplementary material, which is available to authorized users.
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Homan R, Bratt J, Marchand G, Kansembe H. Leveraging existing program data for routine efficiency measurement in Zambia. Gates Open Res 2018. [DOI: 10.12688/gatesopenres.12851.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: As donor contributions for HIV/AIDS stagnate globally, national governments must seek ways to improve use of existing resources through interventions to drive efficiency at the facility level. But program managers lack routinely available information on unit expenditures at points of care, and higher-level planners are unable to assess how resources are used throughout the health system. Thus, managers cannot measure current levels of technical efficiency, and are unable to evaluate effectiveness of interventions to increase technical efficiency. Methods: FHI 360 developed the Routine Efficiency Monitoring System (REMS), a relational database that leverages existing budget, expenditure and output data to produce quarterly site-level estimates of unit expenditure per service. Along with the Government of the Republic of Zambia (GRZ) and implementation partner Avencion, we configured REMS to measure technical efficiency of Ministry of Health resources used to deliver HIV/AIDS services in 326 facilities in 17 high-priority districts in Copperbelt and Central Provinces. REMS allocation algorithms were developed through facility assessments and key informant interviews with MoH staff. Existing IFMIS and DHIS-2 data streams provide recurring flows of expenditure and output data needed to estimate service-specific unit expenditures. Trained users access REMS output through user-friendly dashboards delivered through a web-based application. Results: District health management teams are using REMS to identify “outlier” facilities to test performance improvement interventions. Provincial and national planners are using REMS to seek savings and ensure that resources are directed to geographic and programmatic areas with highest need. REMS can support reimbursement for social health insurance and provide time-series data on facility-level costs for modeling purposes. Conclusions: REMS gives managers and planners substantially-improved data on how programs transform resources into services. The GRZ is seeking funding to expand REMS nationally, covering all major disease areas. Improved technical efficiency supports the goal of a sustainable HIV/AIDS response.
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