Efficiency Gains from Integration of HIV-Related Services:

Preliminary Findings

Sedona Sweeney, CarolDayo Obure, Anna VassallThe London School of Hygiene and Tropical Medicine was contracted by UNAIDS to conduct a literature review of the experience of

efforts to integrate HIV prevention or HIV treatment, care and support activities into more general health services, and of the impact that these efforts have had on the efficiency with which services are delivered, both for HIV and for health in general.

The in this presentation, is complementary to the Integra initiative, a research project that is managed by IPPF in collaboration with the LSHTM and the Population Council, and is supported by the Bill and Melinda Gates Foundation

Overview

Focus is this meeting Background Literature review methods Summary by each area Way forward

Background

Definition of integration is complex

For the purposes of this review, we use the UNAIDS definition of programme integration:

“joining together different kinds of services or operational programmes in order to maximize outcomes, e.g. by organizing referrals from one service to another or offering one-stop comprehensive and integrated services”

Types of integration

Integration of HCT/ ART into other services SRH/FP/ANC clinics/TB clinics Primary health clinics/Community health care

Integration of other services into services for HIV+ VCT clinics adding FP/SRH services VCT performing ICD/IPT for TB ART clinics adding FP/SRH/TB services

Services for high risk groups into general services

Chronic care models

Possible efficiency gains

Technical Efficiency ‘Economies of scope’ associated with sharing overhead,

HR, management and infrastructure costs Gains from ‘economies of scale’ associated with new

clients and higher workloads

Improvements in effectiveness, associated with: improved client experience (and adherence?) earlier treatment, reduction in mortality (TB/HIV)

Different levels of potential gains from integration

At program/systems level Reductions in systems and programme costs: joint

procurement, IEC, sharing of middle managers, training and supervision

At facility level Reductions in facility costs resulting from joint utilization of

fixed factors of production

At patient level Reductions in patient/community level costs resulting from

fewer visits to facilities, proximity of services and reduced delays

Methodology

Research question:

Does integration of HIV prevention or AIDS treatment, care and support activities into general health services have an impact on the efficiency with which services are delivered?

‘Finding a needle in a hay stack’

Comprehensive search of published and grey literature

Eldis Integrat* or converg* or linkage$, within topic headings “HIV and AIDS”,

“Health Systems and HIV and AIDS”

Pubmed Keywords: (integrat* or converg* or linkage$ or coordinat* or vertical or

scope[Title/Abstract]) AND (“Delivery of Health Care/organization and administration”[Majr] OR “Primary Health Care/organization and administration [Majr]) AND AIDS[sb]

Keywords: (((tuberculosis OR TB) AND AIDS[sb]) OR ((sexual and reproductive health OR SRH) AND AIDS[sb]) OR ((maternal and child health OR MCH) AND AIDS[sb]) AND (“Delivery of Health Care/organization and administration” OR “Primary Health Care/organization and administration”)[Majr] AND (efficien* OR cost-effective* OR cost-benefit OR economic*)

Methodology [3]

Global Health and EconLit Keywords: (integrat* or converg* or linkage$ or linked or

coordinat* or vertical or scope [Title]) AND( efficien* or cost-effective* or cost-benefit or economic*) AND (HIV or AIDS)  AND (program or programme or care or campaign or intervention or service)

Manual searches of websites for key organizations involved in sponsoring or reporting HIV-related research or cost-effectiveness studies: Abt Associates, PSI, FHI, HLSP, MSH, PATH, CSIS, PAI, R4D,

JSI, IPPF, PopCouncil, Options

‘Snowballing’ for further references

Methodology [4]

Integration of HIV with other health services is a complex intervention posing difficulties for systematic reviews (BMJ. Shepperd et al, 2009)

We therefore took the following methodological decisions: Inclusion of theoretical evidence where empirical

evidence is weak Evidence is synthesized in context, rather than

quantitatively Take into account qualitative reviews

Inclusion Criteria

Use of clearly identifiable economic or epidemiological measures to evaluate the effect of integration (but we did allow models)

Cost and/or cost-effectiveness studies Focus on low-income settings Included studies that did not have a ‘no

integration’ comparator, but presented incremental costs or cost-effectiveness from do nothing base case (ie ART in PHC)

Grading of literature

Not yet time to include formal grading, but examined:

Costing methods Source of effectiveness data Level of evidence:

Model Pilot study At scale Sustainably at scale

Types of studies found

41 studies met inclusion criteria

• 28 published cost / economic evaluations• 4 literature reviews• 8 project evaluations• 1 epidemiological model

Costs methods used

Costing Perspectives

Health service provider perspective adopted in all studies reviewed. 19 of 28 had comprehesive costing

Costing methods

Empirical (n=15)Modelled (n=4)

Financial (n=17)Economic (n=2)

Full (n=10)Incremental (n=9 )

Costs included

Capital: Start up, training, equipment and overhead.Recurrent: Staff, medical and non- medical supplies, drugs and maintenance.

Effectiveness data

Outcome Type Clinical /behavioural outcomes: n=13Service utilization: n=4

No outcomes: n=12

Outcome measurement

RCT: n=2Pre-Post : n=5

Modelled: n=10

Comparison with non-integrated

service

Control: n=4No comparison: n=7

Modelled control: n=5Previously published data: n=1

Measured at scale

Model: n=10Pilot: n=6At Scale: n=1

Results

VCT into SRH/PHC

Consistent , but limited evidence that HIV/AIDS counselling and testing integrated into SRH /PHC setting is less costly per person tested than in stand-alone VCT sites

Integrated VCT increases testing rates, (even tested – but no control Liambila)

Reference Integrated cost/client

Stand-alone cost/ client

Cost savings/client (%)

Twahir, et al. 1996Kenya

$8.6 (1994) $12.4 (1994) $3.8 (1994) (30%)

Forsythe, et al. 2002Kenya

$16 (1999) $26* (1999) $10 (1999) (38%)

Liambila, et al.2008 Kenya

$5.6 - $9.5 (2007)

$27* (2007) $17.5 – $21.4 (2007) (65% - 79%)

Das, et al. 2007India

144 INR (2006)

RH only: 129 INR (2006)VCT only: 86 INR (2006)

71 INR (2006) (49%)

*Cited from: Sweat, et al. 2000

VCT into SRH/PHC

Weak evidence on the comparative advantage of direct testing by the same service provider vs. referral to a different service provider within the facility

Reference Findings

Liambila, et al. 2008Kenya

Testing model: 5.6-9.5 USD/client (2007). Referral model: costs not presented. Both interventions were highly effective in increasing ‘ever tested’ proportions

Mullick, et al. 2008South Africa (RCT)

Testing model: 6,800 USD/clinic (2005); Referral model: 4,800 USD/clinic (2005)Sample size small but ‘ever had a test’ significant for referral group

Homan, et al. 2008South Africa

Fully integrating services could be more efficient if FP providers have the time to provide VCT to clients. Partial integration could be more efficient if FP providers are too busy to offer VCT to clients.

No clear evidence on comparative costs of where to integrate HCT

VCT into PHC/SRH

Reference Findings

Routh, et al. 2004Bangladesh

High additional travel/time costs for home-based testing. Inefficiencies in field staff time utilization for home-based testing/care

Menzies, et al. 2009Uganda

Hospital-based HCT is likely more effective for identifying HIV-infected individuals in need of immediate ART, but less likely to identify new clients

VCT + PHC/SRH Summary

Integration of VCT and SRH is feasible and affordable (Mullick, Reynolds)

Integration has been shown to be more less costly than stand-alone VCT at a small scale (2 - 23 facilities) (Twahir, Forsythe, Liambila)

But questions remain on how integration impacts effectiveness and best method of implementation (Liambila, Mullick, Homan, Routh, Menzies) and whether gains made at scale

Concerns about over-loading health staff

Sufficient evidence to support further scale-up and sustainability of integration of VCT and SRH in a wide variety of settings (assuming evidence sufficient on effectiveness of VCT more generally)

Family Planning for HIV+ (integrated in PMTCT) Models estimated that meeting unmet FP

need of HIV-positive is cost-effective

Author, Year Intervention Unit Cost

Halperin et al., 2009139 countries(modeled)

‘meeting unmet FP need”

$543 / infection averted by PMTCT$359 / infection averted by FP$61 / unintended pregnancy averted

Stover, et al. 200314 countries(modeled)

FP added to existing PMTCT

$660 / child HIV infection averted$360 / child death averted$130 / orphan averted $2600 / mother's life saved

Reynolds et al. 2006Kenya

FP added to existing VCT

$351 annually per person trained(training costs only)

Family Planning for HIV+

Beyond this, models also estimate that meeting unmet FP need for HIV-positive women has cost-saving potential, but almost no information on whether FP should be added to ART clinics

Author/Year Intervention Potential Cost Savings

Stover et al. 200614 countries

Providing FP in PMTCT sites

$25 / dollar spent in 14 PEPFAR countries annually

Reynolds et al. 200815 countries

‘Meeting unmet FP need’

From $26,000 in Vietnam to$2.2 million in South Africa

Perchal et al, 2006Ethiopia and Ukraine

VCT added to existing MCH/FP

$34 / dollar spent in Ethiopia$10 / dollar spent in Ukraine

Family Planning for HIV+

No empirical information on cost-effectiveness on FP into ART clinics (condom use)

Reynolds 2006 – quality of care, but only includes training costs

Potential for significant cost-savings established. But no real evidence yet on how best to provide integrate services. Pilot and evaluate models of care.

ART + PHC and beyond

It is feasible and cost-effective to attach ART to PHC/ ANC, increased uptake of services, but difficult to establish whether (or when) integrated or non-integrated services are less costly

Yesterday Lori Bollingers presentation Mead Overs presentation (higher costs at clinics)

Reference Findings

WHO 2003South Africa

$536 (2003) per person year of treatment. Survival and health-related quality of life after 1 year on treatment were high, as were other clinical measures of ART clients.

Renaud et al. 2009Burundi

$258 (2007) per DALY averted by ARV treatment.

Badri et al. 2006South Africa

At public sector price, HAART: $1,324/PPT for non-AIDS patients, $1,513/PPT for AIDS patients. HAART is a cost-effective intervention in South Africa, and cost saving when HAART prices are further reduced

ART + PHC and beyond

Integration with primary health care may lead to better health outcomes, as well as broader health service benefits

Reference Health benefits

Price, et al.2009Rwanda

Increases in antenatal care, Fewer hospitalizations

Pfeiffer, et al. 2010Mozambique

Faster initiation of ART upon HIV-positive diagnosisBetter adherence in small clinicsStrengthening health workersTesting expanded to TB wards

Fatti, Grimwood and Bock 2010South Africa

Overall outcomes were found to be superior at PHC clinics when compared to hospitals, despite PHC patients having more advanced clinical stage disease when starting ART.

Relative costs of hospital vs primary health care vs home care Is TB an example (DOTs) – Five pronged model

Role of adherence in cost, Evidence some countries (middle-income countries/ concentrated

epidemics) Patient costs important

ART + PHC and beyond

Reference Findings

Marseille, et al. 2009Uganda

Home-based HAART in conjunction with basic care costs lie in the middle range of several facility-based cost estimates.

Babigumira, et al.2009Uganda

High CEA of MCC and HBC compared to facility-based care, due to a limited gain in effectiveness and high additional costs

TB/HIV - IPT

IPT is cost-effective in low-income settings, and potentially cost-saving. TST does not significantly affect the cost-effectiveness of IPT.

Reference Unit Costs Unit Conclusion

Shrestha, et al. 2007Uganda

With IPT: $102 (2003)

Without IPT: $106 (2003)

QALY

QALY

Offering IPT, with or without TST, is cost-effective

Bell et al. 1999Sub-Saharan Africa

Medical care costs: $114 – $275 (1997)Social/secondary case costs:$5 – $24 saved (1997)

QALY

Person treated

TB preventive therapy is cost-saving, and should be provided for HIV-infected tuberculin skin reactors in SSA

Sutton et al.2009Cambodia

$955 (2006) TB case averted

Cost for IPT is less than the reported cost of treating a new smear-positive TB case

Intensified case detection (ICD) + IPT (the ProTEST Package)

Reference Unit Costs Unit Conclusion

Hausler et al.2006South Africa

CHC: $664 (2002)PHC clinic: $323 (2002)

CHC: $962 (2002)PHC clinic: $486 (2002)

TB case prevented through ICD

TB case prevented through IPT

The ProTEST package is cost-saving. IPT was equally cost-effective. VCT was less expensive than previously reported in Africa.

Terris-Prestholt et al. 2008Uganda

Chawama: $53 (2007)

Matero: $104 (2007)

Annually per client

It is feasible to integrate TB services with a package of care for PLWH

Cost per HIV infection averted by VCT was US$ 67–112 (Hausler 2006).

IPT / ICD/ HCT - Conclusions

ICD and IPT are cost-effective in a low income setting, The cost-effectiveness of the ProTEST package has been established at a small scale (2 and 12 facilities),

Larger potential benefits (58% in S. Africa of those with TB have HIV) – cost-effective in Hausler study

=> Potential for scale-up, but as with VCT needs to be evaluated

However, as smear negative diagnosis is limited (but will improve with new diagnostics), the added benefit in terms of numbers of TB cases still needs to be established

Xpert

New technology for point of care use to diagnose TB (including smear negative)

Paper presented at WHO on cost-effectiveness

Roll-out in South Africa and Brazil With co-ordinated effectiveness modelling Still other low cost options: presumptive

treatment of TB in ART initiation

Way forward

Methodological

Faced with high degree of variation, isolating the effect of integration (next slide)

Typical economies of scope analysis are econometric and look at numbers of services

Integration is more complex Integration index – use of latent variable

analysis on a number of different variables (resources, services, provided , physical location, client flow) – reveals breadth and sophistication

Quasi-experimental design Hard to control for at baseline and over time PARs to measure integration during the

project/ mixed methods/ cohort/ community surveys

Alternatives Comparative DEA (Kittelsen 2009) Econometric analysis of cost functions (Weaver

and Deolalikar, 2003; Weaver et al, 2009)

Other issues

Outcomes (and costs) associated with delay Externalities Missing health systems costs Impact on financing

The question is when? Few examine true additional cases at the

population level, demand side studies Tipping point, assuming HR constrained

Opportunity for comparison? Episode/unit costs (US$ 2009)

Intervention Episode Costs Unit Visit Costs

FP $7.84 - $18.76 $0.77 - $5.13

PNC $4.40 - $26.20 $0.72 - $4.25

Ca cervix screening $1.33 – $43.44 $ 1.19 - $2.56

PITC $3.90 - $12.53 $1.58 – $7.82

VCT $$5.00 - $31.06 $2.65 – 31.06

HIV Care $265 - $513.43 $8.34 - $19.44

Average visits per clinical staff FTE per day

1 3 4 7 9 10 11 12 13 16 24 25 26 270.00

5.00

10.00

15.00

20.00

25.00

30.00

Why?

Understand why certain facilities under-performing

Three layers (direct, management, system) Poor management/ management systems HR / capital planning/ global budgeting Engagement in

Decentralisation/management systems HSSPs/ (HS)MTEFs/ PERs

Integration key to efficiency at all levels