Similar costs and outcomes for differentiated service delivery models for HIV treatment in Uganda

Abstract

This cost-outcome study estimated, from the perspective of the service provider, the total annual cost per client on antiretroviral therapy (ART) and total annual cost per client virally suppressed (defined as < 1000 copies/ml at the time of the study) in Uganda in five ART differentiated service delivery models (DSDMs). These included both facility- and community-based models and the standard of care (SOC), known as the facility-based individual management (FBIM) model. The Ministry of Health (MOH) adopted guidelines for DSDMs in 2017 and sought to measure their costs and outcomes, in order to effectively plan for their resourcing, implementation, and scale-up. In Uganda, the standard of care (FBIM) is considered as a DSDM option for clients requiring specialized treatment and support, or for those who select not to join an alternative DSDM. Note that clients on second-line regimes and considered as “established on treatment” can join a suitable DSDM.Using retrospective client record review of a cohort of clients over a two-year period, with bottom-up collection of clients’ resource utilization data, top-down collection of above-delivery level and delivery-level providers’ fixed operational costs, and local unit costs. Forty-seven DSDMs located at facilities or community-based points in the four regions of Uganda were included in the study, with 653 adults on ART (> 18 years old) enrolled in a DSDM. The study found that retention in care was 98% for the sample as a whole [96–100%], and viral suppression, 91% [86-93%]. The mean cost to the provider (MOH or NGO implementers) was $152 per annum per client treated, ranging from $141 to $166. Differences among the models’ costs were largely due to clients’ ARV regimens and the proportions of clients on second line regimens. Service delivery costs, excluding ARVs, other medicines and laboratory tests, were modest, ranging from $9.66–16.43 per client per year. We conclude that differentiated ART service delivery in Uganda achieved excellent treatment outcomes at a cost similar to the standard of care. While large budgetary savings might not be immediately realized, the reallocation of “saved” staff time could improve health system efficiency and with their equivalent or better outcomes and large benefits to clients, client-centred differentiated models would nevertheless add great societal value.

Long-term retention and associated practices among Community Client Led Antiretroviral Distribution groups (CCLADs) in Uganda: A mixed methods study

“…Community-based group activities have shown to improve the sense of belonging (11) and connectedness (55). The ndings differ, however, from those of a study conducted in Uganda, which reported increasing retention in CCLADs from 97% at 12 months to 98% at 24 months (54). Due to the strict criteria for retention in our study, PLHIV who left their…”

“…Also, it was often mentioned that living near ART pick-up locations made access to re-lls easier and saved time and money. Findings are comparable with other studies conducted in SSA which found comparable or better retention rates of PLHIV in community groups (52)(53)(54). Community-based group activities have shown to improve the sense of belonging (11) and connectedness (55).…”

Cost‐Effectiveness and Budget Impact Analysis of the Implementation of Differentiated Service Delivery Models for HIV Treatment in Mozambique: a Modelling Study

“…Comparing our results to other studies in sub‐Saharan Africa is challenging because the costs are context‐driven and influenced by the characteristics of the models in each country. However, similar to what has been described, we found that some DSDMs are less and others more expensive than conventional care, depending on the services offered in each model, where they are offered, and when they are offered [ 4 – 7 , 15 , 16 , 24 ].…”

“…To calculate the cost per person per each AC meeting, we included the costs applicable to the Mozambique context based on the breakdown of costs found in the literature [ 4 , 11 , 15 ]. These included (1) nurse time, (2) pharmacy technician time, (3) club facilitators time, (4) ongoing club mentorship, and (5) infrastructure and overheads.…”

“…The total cost of visits per person‐year for clients using AC was calculated by multiplying the cost per club meeting by four (the number of club meetings per year). CAG interactions costs per person were estimated from the literature [ 13 , 15 , 16 , 17 ]. To calculate the cost per person‐year for CAG, we included costs for two conventional care interactions (required for clinical and laboratory follow‐up) and 10 CAG interactions.…”