COST EFFECTIVENESS ANALYSIS & INFECTIONS AVERTED OF PMTCT SERVICES BY COMMUNITY AND FACILITY STRENGTHENING IN MASHONALAND CENTRAL PROVINCE, ZIMBABWE

Ravikanthi Rapiti¹, Angela Mushavi2 , Ann Levine3, Julie Pulerwitz1 & Ibou Thior 3

1Population Council, 2Zimbabwe Ministry of Health, 3 PATH

International AIDS Economic Network

19 July 2014

Melbourne, Australia

PMTCT in Zimbabwe

• In 2009– Pregnant women attended ANC—54%1 – ANC HIV prevalence—16% (20% in Mashonaland

Central)– MTCT rate—30%2

• Roll out of 2010 WHO Option A guidelines in 2011

• Health facilities required significant training and mentoring to provide these newer, more complicated regimens

• To increase uptake, communities, families and males also needed to be engaged

1World Health Organization. Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: towards universal access. Available at: http://www.who.int/hiv/pub/mtct/antiretroviral2010/en/index.html Accessed 29 April 2013.

2UNAIDS Global AIDS Response Progress Report, 2012: Zimbabwe Country Report. Available at: http://www.unaids.org/en/dataanalysis/knowyourresponse/countryprogressreports/2012countries/ce_ZW_Narrative_Report.pdf. Accessed 29 April 2013.

Objectives

• Evaluation of the Arise PMTCT project implemented in 21 sites in Mashonaland Province, Zimbabwe that sought to address whether a strengthened PMTCT package could improve:– PMTCT coverage– Outcomes – Cost and cost effectiveness

• Could a paediatric infection be averted in <500USD per infection?

Arise study sites

Project timeline (45 months)

2012 2013April

2014Aug-Sept

2011

Baseline survey

Aug-Sept 2011

End line survey

April 2014

ARISE intervention

initiatedDec 2011

ARISE intervention concludes

March 2014

May

2014Sept

2010

Project closure

May 2014

Project start up

Sept 2010

Components of intervention

• Facility level– Provision of point-of-care CD4 machines – Training & mentoring of providers– Strengthening completion of routine PMTCT registers– Strengthening links with central laboratory

• Community level– Awareness campaigns, dramas– Follow up with clients who missed scheduled visits in

the PMTCT cascade– Sensitizing community leader & faith healers– Establishing support groups– Outreach and targeting of men – Strengthening community and health facility linkages

Data sources for the evaluation

• Financial reports on expenditures for costing

• An activity-based costing approach

• Costing templates were developed

• Types of costs were defined

• Infections averted were calculated

• Sensitivity analysis was conducted

• Costing was determined

How many HIV infections were averted over the intervention period?

Estimating infant HIV infections averted

• Modeled estimates of infant HIV infections. – Estimated number of HIV-exposed

infants were derived from the HIV prevalence rate times the estimated number of live births per year in the project catchment area.

– Validated data from routinely completed PMTCT facility registers

Estimated number of infections averted

Lower Limit Upper Limit

# deliveries per year 15,968 20,508

HIV prevalence in pregnant women (as proportion) 16% 20%

Total number of HIV+ pregnant women delivering per year 2,554.9 4,101.6

Year 1 Year 2 Year 3Year 4

(Quarter 1)Total

Lower Limit 361 626 649 187 1,822

Upper Limit 580 1,005 1,041 300 2,925

What were the costs per infection averted?

Describing costsType of cost Cost category/cost items Data

sourcesStart up Recurrent Indirect programmatic

costs

Financial (programmatic costs defined as DFATD funded financial expenditure used to deliver the services to beneficiaries)

Micro-planning,developing materials, training & mentoring, sensitization

Health commodities & storage/transport, personnel, capital (annualized), transport & travel, office facilities, admin, & meetings

Cell phone & communication costs for non-direct staff, rent & office bills, office repairs & upkeep

Project expense reports (ZAPP, CHAI & PC);Facility data; Ministry of Finance;MoHEconomic

(financial costs plus the value of shared project costs and the value of all donated goods and services)

Start-up financial costs value of all donated goods and services, and of resources already financed to provide comprehensive care and treatment

Recurrent economic costs and other shared costs including HCW costs and the laboratory and ARV health commodity costs

Financial indirect programmatic costs plus that were shared with other programs, including rent for the CHAI office

Costing Period (2011–2013)

Cost category DFATD upfront financial

Start-up 233,555

Recurrent 363, 986

Indirect programmatic costs 58,014

Total costs (no indirect programmatic costs) 867,120

Total costs (with indirect programmatic costs) 655,555

Costing Period (2013-2014)

Cost category DFATD upfront financial

Start-up 34,500

Recurrent 235,079

Capital costs 21,443

Indirect programmatic costs 58,014

Total costs (no indirect programmatic costs) 291,022

Total costs (with indirect programmatic costs) 349,036

Final Costing

• The front line costs for 2011–2013 included both the facility and the community intervention.

• The community intervention continued until the end of the project (February 2014).

• The cost of infections averted during 2013–2014 is a range between $ 537.81 and $ 335.30 when the prevalence is varied between 16 percent and 20 percent respectively.

Conclusions

• This project demonstrated that a combined community and health facility approach has the potential to improve access and retention across the PMTCT cascade.

• Community strategies on retention and male involvement as well as cost data will be important contributions as Zimbabwe now moves to Option B+.

Conclusions (con’t)

• Use of routine real world programmatic data for estimating infections averted is a strength of this study.

• Even though a more efficacious PMTCT program, Option A, costs more than previous regimens, the cost of averting infections are lower compared to lifetime treatment costs.

Considerations

• Lack of control facilities.

• Contributions of other stakeholders and other donors to national and provincial level efforts.

• Investments in infrastructure and human capacity development will remain.

Acknowledgements

This presentation was produced under Arise—Enhancing HIV Prevention Programs for At-Risk Populations, through financial support provided by the Canadian Government through Foreign Affairs, Trade and Development Canada, and via financial and technical support provided by PATH. Arise implements innovative HIV prevention initiatives for vulnerable communities, with a focus on determining cost-effectiveness through rigorous evaluations.