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

OBJECTIVES/DESIGN:As antiretroviral therapy (ART) rapidly expands in sub-Saharan Africa using new efficient care models, data on costs of these approaches are lacking. We examined costs of a streamlined HIV care delivery model within a large HIV test-and-treat study in Uganda and Kenya. METHODS:We calculated observed per-person-per-year (ppy) costs of streamlined care in 17 health facilities in SEARCH Study intervention communities (NCT: 01864603) via micro-costing techniques, time-and-motion studies, staff interviews, and administrative records. Cost categories included salaries, ART, viral load testing, recurring goods/services, and fixed capital/facility costs. We then modeled costs under three increasingly efficient scale-up scenarios: lowest-cost ART, centralized viral load testing, and governmental healthcare worker salaries. We assessed the relationship between community-specific ART delivery costs, retention in care, and viral suppression. RESULTS:Estimated streamlined HIV care delivery costs were $291/ppy. ART ($117/ppy for TDF/3TC/EFV [40%]) and viral load testing ($110/ppy for 2 tests/year [39$51/ppy), recurring costs ($5/ppy), and fixed costs ($7/ppy). Optimized ART scale-up with lowest-cost ART ($100/ppy), annual viral load testing ($24/ppy), and governmental healthcare salaries ($27/ppy), lowered streamlined care cost to$163/ppy. We found clinic-to-clinic heterogeneity in retention and viral suppression levels versus streamlined care delivery costs, but no correlation between cost and either retention or viral suppression. CONCLUSIONS:In the SEARCH Study, streamlined HIV care delivery costs were similar to or lower than prior estimates despite including viral load testing; further optimizations could substantially reduce costs further. These data can inform global strategies for financing ART expansion to achieve UNAIDS 90-90-90 targets

The Mpumalanga Men's Study (MPMS): results of a baseline biological and behavioral HIV surveillance survey in two MSM communities in South Africa

The Mpumalanga Men's Study (MPMS) is the assessment of the Project Boithato HIV prevention intervention for South African MSM. Boithato aims to increase consistent condom use, regular testing for HIV-negative MSM, and linkage to care for HIV-positive MSM. The MPMS baseline examined HIV prevalence and associated risk behaviors, and testing, care, and treatment behaviors among MSM in Gert Sibande and Ehlanzeni districts in Mpumalanga province, South Africa in order to effectively target intervention activities. We recruited 307 MSM in Gert Sibande and 298 in Ehlanzeni through respondent-driven sampling (RDS) between September 2012-March 2013. RDS-adjusted HIV prevalence estimates are 28.3% (95% CI 21.1%-35.3%) in Gert Sibande, and 13.7% (95% CI 9.1%-19.6%) in Ehlanzeni. Prevalence is significantly higher among MSM over age 25 [57.8% (95% CI 43.1%-72.9%) vs. 17.9% (95% CI 10.6%-23.9%), P <0.001 in Gert Sibande; 34.5% (95%CI 20.5%-56.0%) vs. 9.1% (95% CI 4.6%-13.9%), P <0.001 in Ehlanzeni]. In Gert Sibande, prevalence is higher among self-identified gay and transgender MSM vs. other MSM [39.3% (95%CI, 28.3%-47.9%), P <0.01], inconsistent condom users [38.1% (18.1%-64.2%), P <0.05], those with a current regular male partner [35.0% (27.1%-46.4%), P<0.05], and those with lifetime experience of intimate partner violence with men [40.4%, (95%CI 28.9%-50.9%), P <0.05]. Prevalence of previous HIV testing was 65.8% (95%CI 58.8%-74.0%) in Gert Sibande, and 69.3% (95%CI 61.9%-76.8%) in Ehlanzeni. Regular HIV testing was uncommon [(34.6%, (95%CI 27.9%-41.4%) in Gert Sibande; 31.0% (95%CI 24.9%-37.8%) in Ehlanzeni]. Among HIV-positive participants, few knew their status (28.1% in Gert Sibande and 14.5% in Ehlanzeni), or were appropriately linked to care (18.2% and 11.3%, respectively), or taking antiretroviral therapy (13.6% and 9.6% respectively). MPMS results demonstrate the importance of implementing interventions for MSM to increase consistent condom use, regular HIV testing, and linkage and engagement in care for HIV-infected MSM

Associations between HIV infection and demographic and behavioural indicators in Mpumalanga Men's Study.

<p>*p<0.05, **p<0.01, ***p<0.001 NC  =  Not calculated due to small cell size.</p><p>Associations between HIV infection and demographic and behavioural indicators in Mpumalanga Men's Study.</p

Utilization of Testing and Care Among HIV+ MSM in Mpumalanga Men's Study.

<p>NB: Figures are not RDS-adjusted estimates; all variables other than rapid results are self-reported.</p><p>Utilization of Testing and Care Among HIV+ MSM in Mpumalanga Men's Study.</p

Plausibility Bounds of Undiagnosed HIV Infection.

<p>The graph indicates the upper and lower plausibility bounds of undiagnosed infection in Mpumalanga MSM. We estimate that between 16.3% and 20.6% of MSM in Gert Sibande, and 12.5% and 25.2% in Ehlanzeni, currently have an undiagnosed HIV infection. This range between lower and upper plausibility boundaries accounts for the small number of participants at each site who declined testing. The upper plausibility bound assumes all untested participants are HIV-positive, and the lower assumes all untested participants are HIV-negative.</p

Location of Gert Sibande and Ehlanzeni District Municipalities, Mpumalanga Province, South Africa.

<p>Location of Gert Sibande and Ehlanzeni District Municipalities, Mpumalanga Province, South Africa.</p

Demographic Indicators for Mpumalanga Men's Study.

<p>NC  =  Not calculated due to small cell size.</p><p>Demographic Indicators for Mpumalanga Men's Study.</p

Behavioural and HIV Indicators in Mpumalanga Men's Study.

<p>NC  =  Not calculated due to small cell size.</p>1<p>“Regular tester”:>1 lifetime HIV test & tests every 6 months.</p><p>Behavioural and HIV Indicators in Mpumalanga Men's Study.</p