Assessing the costs and efficiency of HIV testing and treatment services in rural Malawi: implications for future "test and start" strategies

Vyas, S., Songo, J., Guinness, L., Dube, A., Geis, S., Kalua, T., Todd, J., Renju, J., Crampin, A. and Wringe, A. (2020) Assessing the costs and efficiency of HIV testing and treatment services in rural Malawi: implications for future "test and start" strategies. BMC Health Services Research, 20, 740. (doi: 10.1186/s12913-020-05446-5) (PMID:32787835) (PMCID:PMC7422472)

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Abstract

Background: Reaching the 90–90-90 targets requires efficient resource use to deliver HIV testing and treatment services. We investigated the costs and efficiency of HIV services in relation to HIV testing yield in rural Karonga District, Malawi. Methods: Costs of HIV services were measured over 12 months to September 2017 in five health facilities, drawing on recognised health costing principles. Financial and economic costs were collected in Malawi Kwacha and United States Dollars (US$). Costs were calculated using a provider perspective to estimate average annual costs (2017 US$) per HIV testing episode, per HIV-positive case diagnosed, and per patient-year on antiretroviral therapy (ART), by facility. Costs were assessed in relation to scale of operation and facility-level annual HIV positivity rate. A one-way sensitivity analysis was undertaken to understand how staffing levels and the HIV positivity rate affected HIV testing costs. Results: HIV testing episodes per day and per full-time equivalent HIV health worker averaged 3.3 (range 2.0 to 5.7). The HIV positivity rate averaged 2.4% (range 1.9 to 3.7%). The average cost per testing episode was US$2.85 (range US$1.95 to US$8.55), and the average cost per HIV diagnosis was US$116.35 (range US$77.42 to US$234.11), with the highest costs found in facilities with the lowest daily number of tests and lowest HIV yield respectively. The mean facility-level cost per patient-year on ART was approximately US$100 (range US$90.67 to US$115.42). ART drugs were the largest cost component averaging 71% (range 55 to 76%). The cost per patient-year of viral load tests averaged US$4.50 (range US$0.52 to US$7.00) with cost variation reflecting differences in the tests to ART patient ratio across facilities. Conclusion: Greater efficiencies in HIV service delivery are possible in Karonga through increasing daily testing episodes among existing health workers or allocating health workers to tasks in addition to testing. Costs per diagnosis will increase as yields decline, and therefore, encouraging targeted testing strategies that increase yield will be more efficient. Given the contribution of drug costs to per patient-year treatment costs, it is critical to preserve the life-span of first-line ART regimens, underlining the need for continuing adherence support and regular viral load monitoring.

Item Type:Articles
Additional Information:This research was part of the Strengthening Health Systems for the Application of Policy to Enable Universal Test and Treat (SHAPE UTT) project and funded through the MRC Joint Funded Research Initiative: MR/P014313/1 The views expressed in this publication are those of the author(s) and not necessarily those of the MRC.
Status:Published
Refereed:Yes
Glasgow Author(s) Enlighten ID:Crampin, Professor Mia
Authors: Vyas, S., Songo, J., Guinness, L., Dube, A., Geis, S., Kalua, T., Todd, J., Renju, J., Crampin, A., and Wringe, A.
College/School:College of Medical Veterinary and Life Sciences > School of Health & Wellbeing > Public Health
Journal Name:BMC Health Services Research
Publisher:BioMed Central
ISSN:1472-6963
ISSN (Online):1472-6963
Copyright Holders:Copyright © 2020 The Authors
First Published:First published in BMC Health Services Research 20: 740
Publisher Policy:Reproduced under a Creative Commons License

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