The role of costing in the introduction and scale‐up of HIV pre‐exposure prophylaxis: evidence from integrating PrEP into routine maternal and child health and family planning clinics in western Kenya

Abstract

Introduction Understanding the cost of strategies to reach and deliver pre‐exposure prophylaxis (PrEP) to priority populations is essential to assess the cost‐effectiveness and budget impact of HIV prevention programmes. Providing PrEP through maternal and child health and family planning clinics offers a promising strategy to reach women in high HIV burden settings. We estimated incremental costs and explored the cost drivers of integrating PrEP delivery into routine maternal and child health and family planning services in Kenya. Methods We conducted a costing study from the provider perspective within the PrEP Implementation for Young Women and Adolescents programme in western Kenya. We identified all within‐ and above‐facility activities supporting PrEP delivery and measured clinical service time using time‐and‐motion studies. We obtained input costs from programme budgets, expenditure records and staff interviews. We estimated changes in costs if creatinine testing were postponed from initiation to first follow‐up visit and if PrEP were prioritized to clients at high HIV risk using a behavioural risk assessment tool. We also projected costs under Ministry of Health (MOH) implementation assuming MOH salaries and programme supervision. We estimated annual numbers of PrEP visits from programme data abstracted from 16 facilities between November 2017 and June 2018. We report the cost per client‐month of PrEP dispensed in 2017 USD. Results For an annual programme output of 24,005 screenings, 4198 PrEP initiations and 4427 follow‐up visits, the average cost per client‐month of PrEP dispensed in the study was $26.52. Personnel, drugs and laboratory tests comprised 43%, 25% and 14% of programme costs respectively. Postponing creatinine testing and prioritizing PrEP delivery to clients at high HIV risk reduced total programme costs by 8% and 14% respectively. In the MOH scenario assuming no changes in outputs, the projected cost per client‐month of PrEP dispensed decreased to $16.54 and total programme costs decreased by 38%. Conclusions Incremental PrEP costs are sensitive to the service delivery strategy used to engage priority populations. Postponing creatinine testing and prioritizing PrEP delivery to clients at high HIV risk may reduce costs. Context‐specific cost data are crucial to assess the cost‐effectiveness and affordability of PrEP delivery models.

HIV pre‐exposure prophylaxis for adolescent girls and young women in Africa: from efficacy trials to delivery

“…Integration of PrEP into platforms that provide health care, such as family planning services and STI testing, can share administrative costs thus decreasing the cost of PrEP delivery. Routine programme evaluation, including costing, can be used to estimate the cost of streamlined PrEP delivery within and outside facilities .…”

Cost of pre-exposure prophylaxis delivery in family planning clinics to prevent HIV acquisition among adolescent girls and young women in Kisumu, Kenya

“…We obtained facility staff and ministry of health (MoH) salaries from communication with site staff and publicly-available information on job groups and basic allowances (housing and commuter) per job cadre [ 11 ]. Public sector cost per bottle of tenofovir disoproxil fumarate/emtricitabine (TDF/FTC, $6.25 in 2017 US dollars) was obtained from recently published data from Kenya [ 8 ]. We conducted time-and-motion observations to record the time spent by providers during each direct PrEP delivery activity.…”

“…However, these models had fixed assumptions about the cost of PrEP per person-year and did not use data from real-world implementation settings. To date, only one study has reported the cost of delivering PrEP to AGYW in sub-Saharan Africa using practical data from implementation [ 8 ], and more evidence is needed on the cost of delivering PrEP to this population.…”

Maximizing the impact of HIV prevention technologies in sub‐Saharan Africa

“…They estimate that up to 70% of all new HIV infections could have been averted if sex work interventions had achieved complete coverage in 2010; while they recognize the limitations of this as a model, the paper raises an important point by showing that appropriate scaling of interventions is essential if they are to have impact at a population level. One obstacle to such scale‐up for programmes is cost, and this is addressed in the paper by Roberts and colleagues . Using data from a PrEP implementation project in Kenya, they identified costs of the programme and explored different scenarios to show that incremental costs were sensitive to the delivery approach and the extent to which monitoring, for example routine creatinine testing, were included.…”