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Opuni M, Sanchez-Morales JE, Figueroa JL, Salas-Ortiz A, Banda LM, Olawo A, Munthali S, Korir J, DiCarlo M, Bautista-Arredondo S. Estimating the cost of HIV services for key populations provided by the LINKAGES program in Kenya and Malawi. BMC Health Serv Res 2023; 23:337. [PMID: 37016402 PMCID: PMC10071702 DOI: 10.1186/s12913-023-09279-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 03/13/2023] [Indexed: 04/06/2023] Open
Abstract
BACKGROUND Data remain scarce on the costs of HIV services for key populations (KPs). The objective of this study was to bridge this gap in the literature by estimating the unit costs of HIV services delivered to KPs in the LINKAGES program in Kenya and Malawi. We estimated the mean total unit costs of seven clinical services: post-exposure prophylaxis (PEP), pre-exposure prophylaxis (PrEP), HIV testing services (HTS), antiretroviral therapy (ART), sexually transmitted infection (STI) services, sexual and reproductive health (SRH) services, and management of sexual violence (MSV). These costs take into account the costs of non-clinical services delivered alongside clinical services and the pre-service and above-service program management integral to the LINKAGES program. METHODS Data were collected at all implementation levels of the LINKAGES program including 30 drop-in-centers (DICs) in Kenya and 15 in Malawi. This study was conducted from the provider's perspective. We estimated economic costs for FY 2019 and cost estimates include start-up costs. Start-up and capital costs were annualized using a discount rate of 3%. We used a combination of top-down and bottom-up costing approaches. Top-down methods were used to estimate the costs of headquarters, country offices, and implementing partners. Bottom-up micro-costing methods were used to measure the quantities and prices of inputs used to produce services in DICs. Volume-weighted mean unit costs were calculated for each clinical service. Costs are presented in 2019 United States dollars (US$). RESULTS The mean total unit costs per service ranged from US$18 (95% CI: 16, 21) for STI services to US$635 (95% CI: 484, 785) for PrEP in Kenya and from US$41 (95% CI: 37, 44) for STI services to US$1,240 (95% CI 1156, 1324) for MSV in Malawi. Clinical costs accounted for between 21 and 59% of total mean unit costs in Kenya, and between 25 and 38% in Malawi. Indirect costs-including start-up activities, the costs of KP interventions implemented alongside clinical services, and program management and data monitoring-made up the remaining costs incurred. CONCLUSIONS A better understanding of the cost of HIV services is highly relevant for budgeting and planning purposes and for optimizing HIV services. When considering all service delivery costs of a comprehensive HIV service package for KPs, costs of services can be significantly higher than when considering direct clinical service costs alone. These estimates can inform investment cases, strategic plans and other budgeting exercises.
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Affiliation(s)
| | - Jorge Eduardo Sanchez-Morales
- Division of Health Economics and Health Systems Innovations, National Institute of Public Health (INSP), Cuernavaca, Mexico
| | - Jose Luis Figueroa
- Division of Health Economics and Health Systems Innovations, National Institute of Public Health (INSP), Cuernavaca, Mexico
| | - Andrea Salas-Ortiz
- Division of Health Economics and Health Systems Innovations, National Institute of Public Health (INSP), Cuernavaca, Mexico
| | | | | | | | | | | | - Sergio Bautista-Arredondo
- Division of Health Economics and Health Systems Innovations, National Institute of Public Health (INSP), Cuernavaca, Mexico.
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Hendrickson C, Long LC, van Rensburg C, Claassen CW, Njelesani M, Moyo C, Mulenga L, O'Bra H, Russell CA, Nichols BE. The early-stage comprehensive costs of routine PrEP implementation and scale-up in Zambia. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0001246. [PMID: 36962684 PMCID: PMC10021804 DOI: 10.1371/journal.pgph.0001246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 10/10/2022] [Indexed: 11/07/2022]
Abstract
Pre-exposure prophylaxis (PrEP) is an effective HIV prevention option, but cost-effectiveness is sensitive to implementation and program costs. Studies indicate that, in addition to direct delivery cost, PrEP provision requires substantial demand creation and client support to encourage PrEP initiation and persistence. We estimated the cost of providing PrEP in Zambia through different PrEP delivery models. Taking a guidelines-based approach for visits, labs and drugs, we estimated the annual cost of providing PrEP per client for five delivery models: one focused on key populations (men-who-have-sex-with-men (MSM) and female sex workers (FSW), one on adolescent girls and young women (AGYW), and three integrated programs (operated within HIV counselling and testing services at primary healthcare centres). Program start-up and support costs were based on program expenditure data and number of PrEP sites and clients in 2018. PrEP clinic visit costs were based on micro-costing at two PrEP delivery sites (2018 USD). Costs are presented in 2018 prices and inflated to 2021 prices. The annual cost/PrEP client varied by service delivery model, from $394 (AGYW) to $655 (integrated model). Cost differences were driven largely by client volume, which impacted the relative costs of program support and technical assistance assigned to each PrEP client. Direct service delivery costs ranged narrowly from $205-212/PrEP-client and were a key component in the cost of PrEP, representing 35-65% of total costs. The results show that, even when integrated into full service delivery models, accessing vulnerable, marginalised populations at substantial risk of HIV infection is likely to cost more than previously estimated due to the programmatic costs involved in community sensitization and client support. Improved data on individual client resource usage and outcomes is required to get a better understanding of the true resource utilization, expected outcomes and annual costs of different PrEP service delivery programs in Zambia.
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Affiliation(s)
- Cheryl Hendrickson
- Health Economics and Epidemiology Research Office, Johannesburg, South Africa
- Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Medical Microbiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Lawrence C Long
- Health Economics and Epidemiology Research Office, Johannesburg, South Africa
- Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts, United States of America
| | - Craig van Rensburg
- Health Economics and Epidemiology Research Office, Johannesburg, South Africa
- Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Cassidy W Claassen
- Center for International Health, Education, and Biosecurity (CIHEB), Institute of Human Virology, University of Maryland School of Medicine, Lusaka, Zambia
| | | | | | | | - Heidi O'Bra
- United States Agency for International Development, Lusaka, Zambia
| | - Colin A Russell
- Department of Medical Microbiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Brooke E Nichols
- Health Economics and Epidemiology Research Office, Johannesburg, South Africa
- Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Medical Microbiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts, United States of America
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Meisner J, Roberts DA, Rodriguez P, Sharma M, Newman Owiredu M, Gomez B, de Mello MB, Bobrik A, Vodianyk A, Storey A, Githuka G, Chidarikire T, Barnabas R, Farid S, Essajee S, Jamil MS, Baggaley R, Johnson C, Drake AL. Optimizing HIV retesting during pregnancy and postpartum in four countries: a cost-effectiveness analysis. J Int AIDS Soc 2021; 24:e25686. [PMID: 33787064 PMCID: PMC8010369 DOI: 10.1002/jia2.25686] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 02/04/2021] [Accepted: 02/17/2021] [Indexed: 01/23/2023] Open
Abstract
INTRODUCTION HIV retesting during late pregnancy and breastfeeding can help detect new maternal infections and prevent mother-to-child HIV transmission (MTCT), but the optimal timing and cost-effectiveness of maternal retesting remain uncertain. METHODS We constructed deterministic models to assess the health and economic impact of maternal HIV retesting on a hypothetical population of pregnant women, following initial testing in pregnancy, on MTCT in four countries: South Africa and Kenya (high/intermediate HIV prevalence), and Colombia and Ukraine (low HIV prevalence). We evaluated six scenarios with varying retesting frequencies from late in antenatal care (ANC) through nine months postpartum. We compared strategies using incremental cost-effectiveness ratios (ICERs) over a 20-year time horizon using country-specific thresholds. RESULTS We found maternal retesting once in late ANC with catch-up testing through six weeks postpartum was cost-effective in Kenya (ICER = $166 per DALY averted) and South Africa (ICER=$289 per DALY averted). This strategy prevented 19% (Kenya) and 12% (South Africa) of infant HIV infections. Adding one or two additional retests postpartum provided smaller benefits (1 to 2 percentage point increase in infections averted versus one retest). Adding three retests during the postpartum period averted additional infections (1 to 3 percentage point increase in infections averted versus one retest) but ICERs ($7639 and in Kenya and $11 985 in South Africa) greatly exceeded the cost-effectiveness thresholds. In Colombia and Ukraine, all retesting strategies exceeded the cost-effectiveness threshold and prevented few infant infections (up to 31 and 5 infections, respectively). CONCLUSIONS In high HIV burden settings with MTCT rates similar to those seen in Kenya and South Africa, HIV retesting once in late ANC, with subsequent intervention, is the most cost-effective strategy for preventing infant HIV infections. In these settings, two HIV retests postpartum marginally reduced MTCT and were less costly than adding three retests. Retesting in low-burden settings with MTCT rates similar to Colombia and Ukraine was not cost-effective at any time point due to very low HIV prevalence and limited breastfeeding.
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Affiliation(s)
| | - D Allen Roberts
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
| | - Patricia Rodriguez
- The Comparative Health Outcomes Policy & Economics InstituteUniversity of WashingtonSeattleWAUSA
| | - Monisha Sharma
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | | | - Bertha Gomez
- Pan American Health Organization/World Health OrganizationColombia OfficeBogotáColombia
| | - Maeve B de Mello
- Department of Communicable Diseases and Environmental Determinants of HealthPan American Health Organization/World Health OrganizationWashingtonDCUSA
| | - Alexey Bobrik
- Global Fund to Fight AIDS, Tuberculosis and MalariaGenevaSwitzerland
| | | | | | | | - Thato Chidarikire
- HIV Prevention ProgrammesNational Department of HealthPretoriaSouth Africa
| | - Ruanne Barnabas
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of MedicineUniversity of WashingtonSeattleWAUSA
| | - Shiza Farid
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | | | - Muhammad S Jamil
- Global HIV, Hepatitis and STI programmeWorld Health OrganizationGenevaSwitzerland
| | - Rachel Baggaley
- Global HIV, Hepatitis and STI programmeWorld Health OrganizationGenevaSwitzerland
| | - Cheryl Johnson
- Global HIV, Hepatitis and STI programmeWorld Health OrganizationGenevaSwitzerland
| | - Alison L Drake
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
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Lee EH, Ganesan K, Khamadi SA, Meribe SC, Njeru D, Adamu Y, Magala F, Crowell TA, Akom E, Agaba P, Desai P, Hamm T, Teyhen D, Ake JA, Polyak CS, Shaffer D, Sawe F, Hickey PW. Attaining 95-95-95 through Implementation Science: 15 Years of Insights and Best Practices from the Walter Reed Army Institute of Research's Implementation of the U.S. President's Emergency Plan for AIDS Relief. Am J Trop Med Hyg 2021; 104:12-25. [PMID: 33241783 PMCID: PMC7790083 DOI: 10.4269/ajtmh.20-0541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
The Walter Reed Army Institute of Research (WRAIR) supports more than 350,000 people on lifesaving HIV treatment in Kenya, Nigeria, Tanzania, and Uganda through funding from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). Here, we review and synthesize the range of impacts WRAIR’s implementation science portfolio has had on PEPFAR service delivery for military and civilian populations since 2003. We also explore how investments in implementation science create institutional synergies within the U.S. Department of Defense, contributing to broad global health engagements and improving health outcomes for populations served. Finally, we discuss WRAIR’s contributions to PEPFAR priorities through use of data to drive and improve programming in real time in the era of HIV epidemic control and public health messaging that includes prevention, the 95-95-95 goals, and comorbidities.
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Affiliation(s)
- Elizabeth H Lee
- 1U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland.,2The Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Kavitha Ganesan
- 1U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland.,3Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Samoel A Khamadi
- 1U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland.,4HJF Medical Research International, Mbeya, Tanzania
| | | | - Dorothy Njeru
- 6U.S. Army Medical Research Directorate-Africa, Nairobi, Kenya
| | - Yakubu Adamu
- 5U.S. Army Medical Research Directorate-Africa, Abuja, Nigeria
| | - Fred Magala
- 7Makerere University Walter Reed Project, Kampala, Uganda
| | - Trevor A Crowell
- 1U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland.,2The Uniformed Services University of the Health Sciences, Bethesda, Maryland.,3Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Eniko Akom
- 1U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland.,3Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Patricia Agaba
- 1U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland.,3Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Priyanka Desai
- 1U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland.,3Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Tiffany Hamm
- 1U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland.,3Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Deydre Teyhen
- 1U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland
| | - Julie A Ake
- 1U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland
| | - Christina S Polyak
- 1U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland.,3Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Douglas Shaffer
- 8U.S. Department of Health and Human Services, Nairobi, Kenya
| | - Fredrick Sawe
- 6U.S. Army Medical Research Directorate-Africa, Nairobi, Kenya.,9HJF Medical Research International, Kericho, Kenya
| | - Patrick W Hickey
- 2The Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Montori-Palacín E, Ramon J, Compta Y, Insa M, Prieto-González S, Carrasco-Miserachs I, Vidal-Serra RX, Altes-Capella J, López-Soto A, Bosch X. Quick diagnosis units: predictors of time to diagnosis and costs. Medicine (Baltimore) 2020; 99:e21241. [PMID: 32791698 PMCID: PMC7386954 DOI: 10.1097/md.0000000000021241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Financial crisis has forced health systems to seek alternatives to hospitalization-based healthcare. Quick diagnosis units (QDUs) are cost-effective compared to hospitalization, but the determinants of QDU costs have not been studied.We aimed at assessing the predictors of costs of a district hospital QDU (Hospital Plató, Barcelona) between 2009 and 2016.This study was a retrospective longitudinal single center study of 404 consecutive outpatients referred to the QDU of Hospital Plató. The referral reason was dichotomized into suggestive of malignancy vs other. The final diagnosis was dichotomized into organic vs nonorganic and malignancy vs nonmalignancy. All individual resource costs were obtained from the finance department to conduct a micro-costing analysis of the study period.Mean age was 62 ± 20 years (women = 56%), and median time-to-diagnosis, 12 days. Total and partial costs were greater in cases with final diagnosis of organic vs nonorganic disorder, as it was in those with symptoms suggestive or a final diagnosis of cancer vs noncancer. Of all subcosts, imaging showed the stronger correlation with total cost. Time-to-diagnosis and imaging costs were significant predictors of total cost above the median in binary logistic regression, with imaging costs also being a significant predictor in multiple linear regression (with total cost as quantitative outcome).Predictors of QDU costs are partly nonmodifiable (i.e., cancer suspicion, actually one of the goals of QDUs). Yet, improved primary-care-to-hospital referral circuits reducing time to diagnosis as well as optimized imaging protocols might further increase the QDU cost-effectiveness process. Prospective studies (ideally with direct comparison to conventional hospitalization costs) are needed to explore this possibility.
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Affiliation(s)
| | | | - Yaroslau Compta
- Neurology Service, Hospital Clínic de Barcelona/Department of Medicine
| | | | - Sergio Prieto-González
- Department of Internal Medicine, Hospital Clínic de Barcelona, University of Barcelona, Biomedical Research Institute August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | | | | | | | - Alfons López-Soto
- Department of Internal Medicine, Hospital Clínic de Barcelona, University of Barcelona, Biomedical Research Institute August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Xavier Bosch
- Department of Internal Medicine, Hospital Clínic de Barcelona, University of Barcelona, Biomedical Research Institute August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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Moucheraud C, Lenz C, Latkovic M, Wirtz VJ. The costs of diabetes treatment in low- and middle-income countries: a systematic review. BMJ Glob Health 2019; 4:e001258. [PMID: 30899566 PMCID: PMC6407562 DOI: 10.1136/bmjgh-2018-001258] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 01/04/2019] [Accepted: 01/12/2019] [Indexed: 01/24/2023] Open
Abstract
Introduction The rising burden of diabetes in low- and middle-income countries may cause financial strain on individuals and health systems. This paper presents a systematic review of direct medical costs for diabetes (types 1 and 2) in low- and middle-income countries. Methods Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, databases (PubMed, International Bibliography of Social Science, EconLit) were searched for publications reporting direct medical costs of type 1 and 2 diabetes. Data were extracted from all peer-reviewed papers meeting inclusion criteria, and were standardised into per-patient-visit, per-patient-year and/or per-complication-case costs (2016 US$). Results The search yielded 584 abstracts, and 52 publications were included in the analysis. Most articles were from Asia and Latin America, and most focused on type 2 diabetes. Per-visit outpatient costs ranged from under $5 to over $40 (median: $7); annual inpatient costs ranged from approximately $10 to over $1000 (median: $290); annual laboratory costs ranged from under $5 to over $100 (median: $25); and annual medication costs ranged from $15 to over $500 (median: $177), with particularly wide variation found for insulin. Care for complications was generally high-cost, but varied widely across countries and complication types. Conclusion This review identified substantial variation in diabetes treatment costs; some heterogeneity could be mitigated through improved methods for collecting, analysing and reporting data. Diabetes is a costly disease to manage in low- and middle-income countriesand should be a priority for the global health community seeking to achieve Universal Health Coverage.
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Affiliation(s)
- Corrina Moucheraud
- Health Policy and Management, University of California Fielding School of Public Health, Los Angeles, California, USA
| | - Cosima Lenz
- Health Policy and Management, University of California Fielding School of Public Health, Los Angeles, California, USA
| | - Michaella Latkovic
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Veronika J Wirtz
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
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