Implementation and Operational Research: Cost and Efficiency of a Hybrid Mobile Multidisease Testing Approach With High HIV Testing Coverage in East Africa

Abstract

Background In 2013-14, we achieved 89% adult HIV testing coverage using a hybrid testing approach in 32 communities in Uganda and Kenya (SEARCH: NCT01864603). To inform scalability, we sought to determine: 1) overall cost and efficiency of this approach; and 2) costs associated with point-of-care (POC) CD4 testing, multi-disease services, and community mobilization. Methods We applied micro-costing methods to estimate costs of population-wide HIV testing in 12 SEARCH Trial communities. Main intervention components of the hybrid approach are census, multi-disease community health campaigns (CHC), and home-based testing (HBT) for CHC non-attendees. POC CD4 tests were provided for all HIV-infected participants. Data were extracted from expenditure records, activity registers, staff interviews, and time and motion logs. Results The mean cost per adult tested for HIV was $20.5 (range: $17.1 - $32.1) [2014 US$], including a POC CD4 test at $16 per HIV+ person identified. Cost per adult tested for HIV was $13.8 at CHC vs. $31.7 via HBT. The cost per HIV+ adult identified was $231 ($87 - $1,245), with variability due mainly to HIV prevalence among persons tested (i.e., HIV positivity rate). The marginal costs of multi-disease testing at CHCs were $1.16/person for hypertension and diabetes, and $0.90 for malaria. Community mobilization constituted 15.3% of total costs. Conclusions The hybrid testing approach achieved very high HIV testing coverage, with POC CD4, at costs similar to previously reported mobile, home-based, or venue-based HIV testing approaches in sub-Saharan Africa. By leveraging HIV infrastructure, multi-disease services were offered at low marginal costs.

Comparison of the costs of HPV testing through community health campaigns versus home-based testing in rural Western Kenya: a microcosting study

“…Personnel costs were modest for both strategies, $9.6 for home-based testing and $9.3 for CHCs. Our findings are consistent with studies that found personnel costs for home-based testing of HIV programmes to be higher than that of CHCs 30 and facilities. 34 Both strategies achieved lower personnel costs, using different approaches.…”

“…For example, evaluations of HIV screening among hard-to-reach populations in rural sub-Saharan Africa have found home-based testing to be substantially more expensive than CHC and facility-based testing, primarily when used for CHC non-attendees. 30 31 However, our findings are consistent with other studies that found the cost of home-based HIV testing to be lower than facility-based testing. 32–34 Several factors that reduce the costs of home-based strategies include the use of low cost equipment such as motorbikes instead of a motor vehicle for results notification and low demand for operations and maintenance services such as tent assembly, security, mobilisation and car hire during screening.…”

Expanding HIV testing and linkage to care in southwestern Uganda with community health extension workers

“…While the variance in cost estimates depends on coverage achieved, HIV prevalence, and services offered (i.e., CD4 count), this programme is among the lowest cost HIV testing interventions reported. Despite the comparatively low HIV positivity rate (2.2%), the cost of identifying one HIV-positive person was $135.70, which is lower than most previously published estimates [ 28 ]. As government spending on health is estimated to be $9 US dollars per capita annually, this figure likely exceeds the current public funds available for HIV testing.…”

“…The estimated cost per person tested was $3.02. A recent review of the costs of community-based testing found that home-based HCT costs ranged from $2.70 to $14.70 per person tested, whereas cost estimates for venue- and mobile-based approaches ranged from $8.30 to $42 [ 28 ]. While the variance in cost estimates depends on coverage achieved, HIV prevalence, and services offered (i.e., CD4 count), this programme is among the lowest cost HIV testing interventions reported.…”

Costs of streamlined HIV care delivery in rural Ugandan and Kenyan clinics in the SEARCH Study

“…We collected information on resources required to support streamlined HIV care during 2-week site visits to 17 clinics located in the 16 SEARCH Study intervention communities from July 2015–June 2016 (second year of intervention) using previously published methods [ 11 , 37 ]. Study teams in the three regions (West Uganda, East Uganda, and Kenya) collected cost data using standardized tools.…”