Sexual health promotion and contraceptive services in local authorities: a systematic review of economic evaluations 2010-2015

Background Since 2013, health commissioners in England’s local authorities have been responsible for sexual health services, including contraception, HIV testing, STI testing and treatment, health education and specialist sexual health services. Effective commissioning requires information to indicate which interventions may, or may not, be cost-effective. However, current UK guidance and recent research on the cost-effectiveness of sexual health services provides patchy and fragmented evidence. This study aims systematically to review the evidence available on the cost-effectiveness of OECD-based interventions relevant to UK local authority-commissioned sexual health services. Methods Key informants, bibliographic database searches and reference lists of guidance documents and included studies were searched for potentially relevant research. Guided by key stakeholders, we sought economic evaluations of sexual health interventions within the responsibility of local authorities, and focused in the UK, on contraception and on health promotion, published between 2010 and 2015 in English. Eligible studies were full economic evaluations based in an OECD country. Studies were classified using a specifically developed tool and assessed for methodological risk of bias using one of three design-specific assessment tools. Descriptive frequencies of codes were analysed to provide a ‘map’ of research that informed stakeholder discussions to focus the subsequent synthesis. The characteristics of studies, quality ratings and cost outcomes from each included study were extracted into tables and findings summarised narratively. Studies were assessed for their relative cost-saving or cost-effectiveness according to NICE guidance. Results In total, 17,705 references were screened; of these, 29 met our inclusion criteria and were included in the synthesis. Nine studies were undertaken in the UK; the remainder were US based. Fifteen studies examined the economics of contraception and 14 evaluated health promotion. Overall, studies were of medium methodological quality. In general, economic evaluations of contraception reported cost-effectiveness or cost savings for ulipristal acetate (UPA) as emergency contraception, long-acting reversible contraceptives (LARCs) for regular, post-natal and post-abortion contraception, and targeting to high risk groups; none, however, reported costs per quality-adjusted life year (QALY) within NICE thresholds. Economic evaluations of sexual health promotion interventions indicated more mixed results. Only three interventions were found to be cost-effective according to the NICE thresholds for HIV or sexually transmitted infection (STI) outcomes: nurse-led rapid testing and tailored counselling; condom negotiations skills training for female sex workers; and a teacher-led STI prevention and skills training intervention. UK studies focused on health promotion and contraception, and supported the above findings. In general, there has been a reasonable amount of economic research into sexual health interventions since 2010, and these support current NICE sexual health guidance. Abstract Sexual health promotion and contraceptive services in local authorities: a systematic review of economic evaluations 2010-2015 vi Conclusions The broad nature of the research question posed in this systematic review resulted in the inclusion of a dataset very diverse in terms of populations, interventions, outcomes and types of economic evaluation designs. In considering the cost-effectiveness of these strategies in relation to their own commissioning climate, policy and decision makers should consider carefully the fit between their context and that of individual studies. Use of longer-term outcomes in trials used in economic evaluations would strengthen estimates of effects such as QALYs, as would the routine use of longitudinal cohort data

Designing a package of sexual and reproductive health and HIV outreach services to meet the heterogeneous preferences of young people in Malawi: results from a discrete choice experiment.

BACKGROUND: This article examines young people's preferences for integrated family planning (FP) and HIV services in rural Malawi. Different hypothetical configurations for outreach services are presented using a Discrete Choice Experiment (DCE). Responses are analysed using Random Parameters Logit and Generalised Mixed Logit (GMXL) models in preference space and a GMXL model parameterised in willingness-to-pay space. Simulations are used to estimate the proportion of respondents expected to choose different service packages as elements are varied individually and in combination. RESULTS: Responses were collected from 537 young people aged 15-24. Results show that when considering attending an outreach service to access family planning young people value confidentiality and the availability of HIV services including HIV counselling and testing (HCT) and HIV treatment, though significant observable and unobservable heterogeneity is present. Female respondents and those aged 20-24 were less concerned with service confidentiality compared to male respondents and those aged 15-19; respondents who were in a relationship at the time of the survey valued confidentiality more than those who reported being single. The addition of sports and recreation for young people may also be an attractive feature of a youth-friendly service; however, preferences for this attribute vary according to respondent gender. Results of the simulation modelling indicate that the most preferred service package is one that offers confidential services, both HCT and HIV treatment and sports for youth, with up to 32% of respondents expected to choose this service over a service where clients may have concerns over confidentiality, only HCT is available and there are no additional activities for young people. Estimates of willingness-to-pay for service attributes indicate that respondents were willing to pay up to USD$1.76 for confidentiality, USD$0.65 for a service offering both HCT and HIV treatment and USD$0.26 for a service including sports for youth. CONCLUSIONS: Young people were able to complete a complex DCE and appeared to trade between the different characteristics used to describe the outreach services. These findings may offer important insight to policy makers designing youth friendly SRH outreach services and providers aiming to improve the acceptability and uptake of FP services

The impact of HIV/SRH service integration on workload: analysis from the Integra Initiative in two African settings.

BACKGROUND: There is growing interest in integration of HIV and sexual and reproductive health (SRH) services as a way to improve the efficiency of human resources (HR) for health in low- and middle-income countries. Although this is supported by a wealth of evidence on the acceptability and clinical effectiveness of service integration, there is little evidence on whether staff in general health services can easily absorb HIV services. METHODS: We conducted a descriptive analysis of HR integration through task shifting/sharing and staff workload in the context of the Integra Initiative - a large-scale five-year evaluation of HIV/SRH integration. We describe the level, characteristics and changes in HR integration in the context of wider efforts to integrate HIV/SRH, and explore the impact of HR integration on staff workload. RESULTS: Improvements in the range of services provided by staff (HR integration) were more likely to be achieved in facilities which also improved other elements of integration. While there was no overall relationship between integration and workload at the facility level, HIV/SRH integration may be most influential on staff workload for provider-initiated HIV testing and counselling (PITC) and postnatal care (PNC) services, particularly where HIV care and treatment services are being supported with extra SRH/HIV staffing. Our findings therefore suggest that there may be potential for further efficiency gains through integration, but overall the pace of improvement is slow. CONCLUSIONS: This descriptive analysis explores the effect of HIV/SRH integration on staff workload through economies of scale and scope in high- and medium-HIV prevalence settings. We find some evidence to suggest that there is potential to improve productivity through integration, but, at the same time, significant challenges are being faced, with the pace of productivity gain slow. We recommend that efforts to implement integration are assessed in the broader context of HR planning to ensure that neither staff nor patients are negatively impacted by integration policy

The Costs of Delivering Integrated HIV and Sexual Reproductive Health Services in Limited Resource Settings.

OBJECTIVE: To present evidence on the total costs and unit costs of delivering six integrated sexual reproductive health and HIV services in a high and medium HIV prevalence setting, in order to support policy makers and planners scaling up these essential services. DESIGN: A retrospective facility based costing study conducted in 40 non-government organization and public health facilities in Kenya and Swaziland. METHODS: Economic and financial costs were collected retrospectively for the year 2010/11, from each study site with an aim to estimate the cost per visit of six integrated HIV and SRH services. A full cost analysis using a combination of bottom-up and step-down costing methods was conducted from the health provider's perspective. The main unit of analysis is the economic unit cost per visit for each service. Costs are converted to 2013 International dollars. RESULTS: The mean cost per visit for the HIV/SRH services ranged from $Int 14.23 (PNC visit) to$Int 74.21 (HIV treatment visit). We found considerable variation in the unit costs per visit across settings with family planning services exhibiting the least variation ($Int 6.71-52.24) and STI treatment and HIV treatment visits exhibiting the highest variation in unit cost ranging from ($Int 5.44-281.85) and ($Int 0.83-314.95), respectively. Unit costs of visits were driven by fixed costs while variability in visit costs across facilities was explained mainly by technology used and service maturity. CONCLUSION: For all services, variability in unit costs and cost components suggest that potential exists to reduce costs through better use of both human and capital resources, despite the high proportion of expenditure on drugs and medical supplies. Further work is required to explore the key drivers of efficiency and interventions that may facilitate efficiency improvements