Randomized evaluation and cost-effectiveness of HIV and sexual and reproductive health service referral and linkage models in Zambia

Abstract

BackgroundProvision of HIV prevention and sexual and reproductive health services in Zambia is largely characterized by discrete service provision with weak client referral and linkage. The literature reveals gaps in the continuity of care for HIV and sexual and reproductive health. This study assessed whether improved service delivery models increased the uptake and cost-effectiveness of HIV and sexual and reproductive health services.MethodsAdult clients 18+ years of age accessing family planning (females), HIV testing and counseling (females and males), and male circumcision services (males) were recruited, enrolled and individually randomized to one of three study arms: 1) the standard model of service provision at the entry point (N = 1319); 2) an enhanced counseling and referral to add-on service with follow-up (N = 1323); and 3) the components of study arm two, with the additional offer of an escort (N = 1321). Interviews were conducted with the same clients at baseline, six weeks and six months. Uptake of services for HIV, family planning, male circumcision, and cervical cancer screening at six weeks and six months were the primary endpoints. Pairwise chi-square and multivariable logistic regression statistical tests assessed differences across study arms, which were also assessed for incremental cost-efficiency and cost-effectiveness.ResultsA total of 3963 clients, 1920 males and 2043 females, were enrolled; 82 % of participants at six weeks were tracked and 81 % at six months; follow-up rates did not vary significantly by study arm. The odds of clients accessing HIV testing and counseling, cervical cancer screening services among females, and circumcision services among males varied significantly by study arm at six weeks and six months; less consistent findings were observed for HIV care and treatment. Client uptake of family planning services did not vary significantly by study arm. Integrated services were found to be more efficiently provided than vertical service provision; the cost-effectiveness for HIV/AIDS and cervical cancer was high in the enhanced service models.ConclusionsStudy results provide evidence for increasing the linkages and integration of a selection of HIV and sexual and reproductive health services. The study provided cost-effective service delivery models that enhanced the likelihood of clients accessing some additional needed health services.Trial registrationISRCTN84228514 Retrospectively registered.The study was retrospectively registered in the ISRCTN clinical trials registry on 06 October 2015. The first recruitment of participants occurred on 17 December 2013.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-016-3450-x) contains supplementary material, which is available to authorized users.

Interventions to increase uptake of cervical screening in sub-Saharan Africa: a scoping review using the integrated behavioral model

“…The systematic search returned 3704 unique entries, after duplicates were removed. Screening and application of eligibility criteria produced 19 studies for inclusion in the review [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33]. Figure 2 shows the results of the study selection process.…”

“…Pap smear or cytology-based cervical screening was assessed most often (n = 6, 31.6%) [16,17,21,26,31,33]. A quarter of studies (n = 5, 26.3%) did not specify which screening test was being performed [20,22,24,29,32]. Multiple screening methods were used in some studies, such as those that compared uptake of HPV self-sampling to facility-based visual inspection screening methods [19,25,27,28].…”

Integrating cervical cancer screening and preventive treatment with family planning and HIV‐related services

“…Integrating cervical cancer services into existing HIV and family planning programs promotes increased efficiencies through use of common health personnel and infrastructure, compared with vertical SRH programming . Significant global investments have been made to increase provision of HIV testing, treatment, and care, and these investments can be maximized by adding cervical cancer prevention services .…”

“…IntegratingcervicalcancerservicesintoexistingHIVandfamilyplanning programs promotes increased efficiencies through use of commonhealthpersonnelandinfrastructure,comparedwithverticalSRH programming. 11,12,16 Significant global investments have been made to increase provision of HIV testing, treatment, and care, and these investments can be maximized by adding cervical cancer prevention services. 4,12,16 In 2015, the Global Fund for AIDS, Tuberculosis andMalariaannouncedthatitwillallowcountriestoincludecervical cancerservicesintheirGlobalFundrequests, 27 openingthedoorto increasedfundingfortheseservices.…”

Comparison of patient flow and provider efficiency of two delivery strategies for HPV-based cervical cancer screening in Western Kenya: a time and motion study

“…Clinics could improve efficiency by reducing registration wait time through integration of cervical cancer screening as part of a larger package of maternal services; for example, integrating with HIV testing and care. One study in Zambia found that increasing linkages and improving integration of HIV and sexual and reproductive health services led to more cost-effective service delivery [31]. …”