Understanding school-going adolescent's preferences for accessing HIV and contraceptive care: findings from a discrete choice experiment among learners in Gauteng, South Africa.

BACKGROUND: Many Adolescents in Sub-Saharan Africa do not access HIV and reproductive health services optimally. To improve uptake of these services, it is important to understand the Learners' preferences for how services are delivered so that implementation strategies can reflect this. METHODS: A discrete choice experiment (DCE) was used to elicit preferences. The DCE was completed between 07/2018 and 09/2019 and conducted in 10 high schools situated in neighbourhoods of varying socio-economic status (SES) in Gauteng (South Africa). Learners aged ≥ 15 years (Grades 9-12) were consented and enrolled in the DCE. Parental consent and assent were required if < 18 years old. Conditional logistic regression was used to determine preferred attributes for HIV and contraceptive service delivery. Results were stratified by gender and neighbourhood SES quintile (1 = Lowest SES; 5 = Highest SES). RESULTS: 805 Learners were enrolled (67% female; 66% 15-17 years; 51% in grades 9-10). 54% of Learners in quintile 1 schools had no monthly income (family support, grants, part-time jobs etc.); 38% in quintile 5 schools had access to R100 ($7.55) per month. Preferences for accessing HIV and contraceptive services were similar for male and female Learners. Learners strongly preferred services provided by friendly, non-judgmental staff (Odds ratio 1.63; 95% Confidence Interval: 1.55-1.72) where confidentiality was ensured (1.33; 1.26-1.40). They preferred services offered after school (1.14; 1.04-1.25) with value-added services like free Wi-Fi (1.19; 1.07-1.32), food (1.23; 1.11-1.37) and youth-only waiting areas (1.18; 1.07-1.32). Learners did not have a specific location preference, but preferred not to receive services within the community (0.82; 0.74-0.91) or school (0.88; 0.80-0.96). Costs to access services were a deterrent for most Learners irrespective of school neighbourhood; female Learners were deterred by costs ≥$3.85 (0.79; 0.70-0.91); males by costs ≥ R100 ($7.55) (0.86; 0.74-1.00). CONCLUSIONS: Preferences that encourage utilisation of services do not significantly differ by gender or school neighbourhood SES. Staff attitude and confidentiality are key issues affecting Learners' decisions to access HIV and contraceptive services. Addressing how healthcare providers respond to young people seeking sexual and reproductive health services is critical for improving adolescents' uptake of these services.

The health system costs of post abortion care in Tanzania.

BACKGROUND: Unsafe abortion is common in Tanzania. Currently, postabortion care (PAC) is legally provided, but there is little information on the national cost. We estimated the health system costs of offering PAC in Tanzania in 2018, at existing levels of care and when hypothetically expanded to meet all need. METHODS: We employed a bottom-up costing methodology. Between October 2018 and February 2019, face-to-face interviews were conducted with facility administrators and PAC providers in a sample of 40 health facilities located across seven mainland regions and Zanzibar. We collected data on the direct and indirect cost of care, fees charged to patients, and costs incurred by patients for PAC supplies. Sensitivity analysis was used to explore the impact of uncertainty in the analysis. RESULTS: Overall, 3850 women received PAC at the study facilities in 2018. At the national level, 77,814 women received PAC, and the cost per patient was $58. The national health system cost for PAC provision at current levels totaled nearly $4.5 million. Meeting all need for PAC would increase costs to over $11 million. Public facilities bore the majority of PAC costs, and facilities recovered just 1% of costs through charges to patients. On average PAC patients incurred $7 in costs ($6.17 for fees plus $1.35 in supplies). CONCLUSIONS: Resources for health care are limited. While working to scale up access to PAC services to meet women's needs, Tanzanian policymakers should consider increasing access to contraception to prevent unintended pregnancies.

Linkage to Care Following an HIV Diagnosis in Three Public Sector Clinics in eThekwini (Durban), South Africa: Findings from a Prospective Cohort Study.

Linkage to care following an HIV diagnosis remains an important HIV care continuum milestone, even in the era of universal ART eligibility. In an 8-month prospective cohort study among 459 (309 women, 150 men) newly-diagnosed HIV-positive individuals in three public-sector clinics in Durban metropolitan region, South Africa, from 2010 to 2013, median time to return to clinic for CD4+ results (linkage) was 10.71 weeks (95% CI 8.52-12.91), with 54.1% 3-month cumulative incidence of linkage. At study completion (9.23 months median follow-up), 26.2% had not linked. Holding more positive outcome-beliefs about enrolling in care was associated with more rapid linkage [adjusted hazard ratio (AHR)each additional belief 1.31; 95% CI 1.05-1.64] and lower odds of never linking [adjusted odds ratio (AOR) 0.50; 95% CI 0.33-0.75]. Holding positive ARV beliefs was strongly protective against never linking to care. Age over 30 years (AHR 1.59; 95% CI 1.29-1.97) and disclosing one's HIV-positive status within 30 days of diagnosis (AHR 1.52; 95% CI 1.10-2.10) were associated with higher linkage rates and lower odds of never linking. Gender was not associated with linkage and did not alter the effect of other predictors. Although expanded access to ART has reduced some linkage barriers, these findings demonstrate that people's beliefs and social relations also matter. In addition to structural interventions, consistent ART education and disclosure support, and targeting younger individuals for linkage are high priorities.

Provider perspectives on contraceptive service delivery: findings from a qualitative study in Johannesburg, South Africa.

BACKGROUND: Healthcare providers' skills and attitudes are both barriers and facilitators of contraceptive uptake. In South Africa, migration of healthcare workers and the demands of the HIV epidemic have also contributed to inequitable access to sexual and reproductive health (SRH) care. Yet, the country has committed to achieving universal access to SRH services. We explored healthcare provider's opinions and attitudes on provision of contraceptive services in public facilities, their personal use of methods, and their thoughts on the recent integration of new contraceptive methods in their facilities. METHODS: We conducted a phenomenological, qualitative study in 2017 at an outpatient, public HIV treatment clinic and two primary healthcare clinics (PHCs) in Johannesburg, South Africa. We purposively selected providers who had worked at the facilities for at least six months and were seeing patients for HIV or SRH services. Trained study staff conducted semi-structured interviews. We conducted descriptive analyses for quantitative data, and used an iterative, thematic analysis approach for open-ended responses. RESULTS: We interviewed 14 healthcare providers (HIV clinic - 5; PHCs - 9). One respondent was a man; all were nurses. All respondents reported having ever personally used a contraceptive method; half (7/14) were currently using a method. Responses on service provision were conflicting. Respondents felt that their clinics currently met the contraceptive needs of their female patients through on-site services or referrals. However, they noted that staff shortages, lack of training, and a limited contraceptive offering meant that women did not always get the counselling or method they wanted. Respondents noted that the 'best' contraceptive methods for women were those that fit with a woman's lifestyle and medical needs; however, providers also felt strongly that injectables were best for all women. Recent introduction of the implant at one PHC and injectable contraceptives at the HIV clinic was not overly challenging, though there were concerns about staffing and demand creation for the new methods. CONCLUSIONS: Respondents' conflicting responses revealed challenges with current service delivery, particularly contraceptive counselling. Addressing staff workloads and providing refresher training on contraception would contribute to increased contraceptive service capacity and quality in this setting.

When donor funding leaves: an interrupted time-series analysis of the impact of integrating direct HIV care and treatment into public health services in a region of Johannesburg.

BACKGROUND: Early in South Africa's HIV response, donor-funded organizations directly provided HIV treatment through Comprehensive HIV Care, Management and Treatment sites (CCMTs), using their own and government staff. From 2012 to 2014 the donor-funded CCMT model was phased out, leaving nurses in South Africa's public clinics responsible for delivery of antiretroviral treatment (ART) services. We aimed to examine the impact on resources, staff workloads, and service delivery throughout this period of integration of HIV treatment into primary health clinics. METHODS: We conducted an Interrupted Time-Series Analysis (ITSA) using data from three public clinics, including one former CCMT site, in one administrative region of Johannesburg. The ITSA was complemented by visual inspection of the data in Excel. We compared trends in expenditure, clinical staffing levels, patient headcounts, and services rendered at the clinics during four periods: pre-CCMT (2004-2007), CCMT operational (2007-2012), CCMT closure (2012-2014), and post-CCMT (2014-2016). Data were drawn from the country's District Health Information System, a national HIV treatment database, local budget and expenditure reports, National Health Laboratory Service charge records, and staff records. RESULTS: Closure of the CCMT differentially impacted the study clinics. As expected, ART services decreased at Clinic 1, where the CCMT was co-located, and increased at Clinics 2 and 3 possibly reflecting redistribution of patients. Despite a reduction in patient headcounts post-CCMT, Clinic 1 experienced a decrease in staff and a large increase in patients seen per clinical staff member per month. In contrast, Clinics 2 and 3 increased or maintained stable workforces, and staff workloads post closure were similar to pre-closure levels. Other primary care services-contraception and immunisations-seemed largely unaffected at Clinics 1 and 2. At Clinic 3, service delivery reduced, but this was accompanied by lowered patient headcounts generally, likely due to clinic renovations. CONCLUSIONS: In this study, integration of HIV treatment into primary healthcare services did not result in large-scale reductions in overall service delivery. One facility did experience increased staff workloads, but we were unable to assess service quality. To mitigate potential problems, monitoring systems should be introduced in advance and acknowledge the disparate and decentralised management of various data sources.

Women's costs for accessing comprehensive sexual and reproductive health services: findings from an observational study in Johannesburg, South Africa.

BACKGROUND: Evaluating progress towards the Sustainable Development Goal of universal access to sexual and reproductive (SRH) services requires an understanding of the health needs of individuals and what constitutes access to services. We explored women's costs of accessing SRH services in Johannesburg, South Africa and contextualized costs based on estimates of household income. METHODS: We conducted an observational study of women aged 18-49 at a public HIV treatment site and two public primary health care facilities from June 2015 to August 2016. Interviews assessed women's SRH needs (for contraception, fertility problems, menstrual problems, menopause symptoms, sexually transmitted infections (STI), experiences of intimate-partner violence (IPV), and cervical and breast cancer screening) and associated costs. We calculated average and total costs (including out-of-pocket spending, lost income, and estimated value of time spent) for women who incurred costs. We also estimated the total and average costs of meeting all SRH needs in a hypothetical "full needs met" year. Finally, we contextualize SRH spending against a measure of catastrophic expenditure (> 10% of household income). RESULTS: Among the 385 women who participated, 94.8% had at least one SRH need in the prior 12 months; 79.7% incurred costs for accessing care. On average, women spent $28.34 on SRH needs during the prior year. Excluding one HIV-negative woman who spent 112% of her annual income on infertility treatment, HIV-positive women spent more on average annually for SRH care than HIV-negative women. Sixty percent of women reported at least one unmet SRH need. If all participants sought care for all reported needs, their average annual cost would rise to $52.65 per woman. Only two women reported catastrophic expenditure - for managing infertility. CONCLUSIONS: SRH needs are constants throughout women's lives. Small annual costs can become large costs when considered cumulatively over time. As South Africa and other countries grapple with increasing access to SRH services under the rubric of universal access, it is important to remember that individuals incur costs despite free care at the point of service. Policies that address geographic proximity and service quality would be important for reducing costs and ensuring full access to SRH services. Literature on women's financial and economic costs for accessing comprehensive sexual and reproductive health care in low- and middle-income countries is extremely limited, and existing literature often overlooks out-of-pocket costs associated with travel, child care, and time spent accessing services. Using data from a survey of 385 women from a public HIV treatment site and two public primary health care facilities in Johannesburg, we found nearly all women reported at least on sexual and reproductive health need and more than 75% of women incurred costs related to those needs. Furthermore, more than half of women surveyed reported not accessing services for their sexual and reproductive health needs, suggesting a total annual cost of more than $50 USD, on average, to access services for all reported needs. While few women spent more than 10% of their total household income on sexual and reproductive health services in the prior year, needs are constant and costs incur throughout a woman's life suggesting accessing services to meet these needs might still result in financial burden. As South Africa grapples with increasing access to sexual and reproductive health services under the rubric of universal access, it is important to remember that individuals incur costs despite free care at the point of service. Policies that address geographic proximity and service quality would be important for reducing costs and ensuring full access to services.

"I did not see a need to get tested before, everything was going well with my health": a qualitative study of HIV-testing decision-making in KwaZulu-Natal, South Africa.

Few studies have examined HIV-testing decision-making since the South African national HIV counseling and testing campaign in 2010-2011 and subsequent expansion in antiretroviral therapy (ART) eligibility in 2012. We describe HIV-testing decision-making and pathways to testing among participants in Pathways to Care, a cohort study of newly-diagnosed HIV-positive adults in KwaZulu-Natal. Our analysis is embedded within a theoretical framework informed by Arthur Kleinman's work on pluralistic healthcare systems, and the concept of diagnostic itineraries (i.e., the route taken to HIV testing). We conducted 26 semi-structured interviews in 2012, within one month of participants' diagnosis. Most (n = 22) deferred testing until they had developed symptoms, and then often sought recourse in non-biomedical settings. Of the eleven symptomatic participants who accessed professional medical services prior to testing, only three reported that a healthcare professional had offered or recommended an HIV test. Although ART emerged as an important motivator, offering hope of health and normalcy, fear of death and HIV-related stigma remained key barriers. Despite national policy changes in testing and treatment, health system and individual factors contributed to ongoing high levels of late diagnosis of HIV in this study population. Encouraging local health systems to direct clients toward HIV testing, and continuing to raise awareness of the benefits of routine testing remain important strategies to reduce delayed diagnoses.

Characterizing breast conditions at an open-access breast clinic in South Africa: a model that is more than cancer care for a resource-limited setting.

BACKGROUND: While most breast-related research focuses on cancer, presentation of symptomatic persons in non-screened environments requires understanding the spectrum of breast diseases so as to plan services in resource-constrained settings. This study presents the variety of breast disease managed at a government, open-access breast clinic in South Africa. METHODS: We performed a retrospective file review using a systematic random sample of patients 18 years and above presenting for breast care over a 14-month period. We collected demographics, clinical characteristics, management and final diagnoses from the first visit and twelve subsequent months. RESULTS: The final sample contained 365 individuals (97 · 5% women). Most were black, unmarried and South African citizens with a median age of 43 years (IQR 31-55) . Of those reporting their status (24 · 1%) 38 · 6% were HIV-positive. A mass (57 · 0%) and/or pain (28 · 5%) were the most common symptoms. Imaging and breast biopsies were required in 78 and 25% of individuals, respectively. Nearly half of biopsies identified breast cancer (44 · 1% of women ≤40 and 57 · 3% for women >40). Benign conditions (47 · 7%) and no abnormality (18 · 2%) were common final classifications among women. There was no difference between the final classifications of patients who self-referred versus those who were formally referred from another health care provider. Nearly half of the participants (46 · 6%) travelled 20 km or more to attend the clinic. CONCLUSIONS: Benign breast conditions far outweighed cancer diagnoses. As breast cancer awareness increases in resource-limited countries, facilities offering breast care require administrative and clinical preparation to manage a range of non-cancer related conditions.

Contraceptive Use among Women in Accra, Ghana: 2003 and 2008.

Despite a relatively low fertility rate, maternal mortality in Ghana still remains high. According to the Ghana Demographic and Health Surveys, about 22% of Ghanaian women of reproductive age currently use contraception. We analyzed contraceptive use among a representative sample of women in Accra, Ghana, to better understand contraceptive use patterns. We used data from two cross-sectional surveys of a representative cohort of women in Accra. In 2003, 28.9% of sexually active women used a contraceptive method. In 2008, 31.5% of sexually active women used a contraceptive method. Additionally, we observed high rates of discontinuation-from 64.1% among those using longer-acting methods to 82.1% among those using traditional methods-between years. Further research on women's contraceptive decision-making is needed to explain these patterns and to ensure that family planning interventions meet the needs of women in Ghana.

Cost-effectiveness of using the Cervex-Brush (broom) compared to the elongated spatula for collection of conventional cervical cytology samples within a high-burden HIV setting: a model-based analysis.

BACKGROUND: From 2010 to 2014, approximately 2 million Pap smears from HIV-infected women were submitted to the South African National Health Laboratory Services (NHLS) through the national cervical cancer screening programme. The objective of this analysis was to determine whether using the plastic Cervex brush ("broom") would be a cost-effective approach to improve cytology specimen quality as compared to the wooden spatula used currently. METHODS: A decision analysis model was built using the expected adequacy rates for samples collected with the spatula (<$0.02) and broom ($0.23) and the probability of detecting cervical dysplasia. NHLS data was used for testing volumes and rates of HIV-positivity, suitability of specimens, and presence of endocervical cells. Expected positivity of Pap smears in HIV-infected women (73 %), odds ratios of the effectiveness of the broom (OR: 1.57), and improved sensitivity when endocervical cells present (OR: 1.89) are from literature. NHLS costs were used for the collection devices and conventional cytology ($4.89). Cost of clinic visit is from WHO CHOICE ($8.36). RESULTS: In 2010, 80 % of specimens submitted to NHLS were adequate for evaluation; in 2014, only 54 % met the same criteria. For HIV-infected women, according to the guidelines model, using the wooden spatula costs $6.25 million per year, $16.79 per woman tested. Under intended practice, for each additional HSIL case detected among HIV-infected women, the South African cervical cancer screening programme could save $13.64 (95 % CI: $13.52 to $13.76) by using the broom as its standard of care collection device through increased collection of endocervical cells and consequent reduction in repeat Pap smears. CONCLUSION: Under a wide range of parameters tested using a simulation model, the more expensive plastic broom could save the South African cervical cancer screening programme money and increase detection of high-grade cervical dysplasia in HIV-infected women compared to the current wooden spatula.

Accessing Sexual and Reproductive Health Information and Services: A Mixed Methods Study of Young Women's Needs and Experiences in Soweto, South Africa.

Young women and girls in South Africa are at high risk of unintended pregnancy and HIV. Previous studies have reported barriers to contraceptive and other sexual and reproductive health (SRH) services among young women in this context. We aimed to assess young women's SRH knowledge and experiences and to determine how they get SRH information and services in Soweto, South Africa using quantitative and qualitative methods. Young women, aged 18-24, recruited from primary health clinics and a shopping mall, reported that they have access to SRH information and know where to obtain services. However there are challenges to accessing and utilizing information and services including providers' unsupportive attitudes, uneven power dynamics in relationships and communication issues with parents and community members. There is a need to assist young women in understanding the significance of SRH information. They need access to age-appropriate, youth-friendly services in order to have healthy sexual experiences.

Setting Health Targets Using Information from Probabilistic Projections: A Research Brief on an Application to Contraceptive Coverage.

Broad and aspirational targets to meet health service needs are useful for advocacy, but setting measurable, time-defined targets for accelerated yet feasible progress is necessary for national monitoring and planning purposes. Information from probabilistic projections of health outcomes and service coverage can be used to set country-specific targets that reflect different starting points and rates of change. We show the utility of this approach in an application to contraceptive coverage in 131 low- and middle-income countries (LMICs) and the related cost and impact of different coverage scenarios. We use the sustainable development goal (SDG) indicator of the proportion of women who have their need for family planning satisfied with modern contraception. The results show that accelerated progress targets would collectively result in 83% of the need satisfied in 2030 for LMICs, which is 5% points higher than the projected level based on the current pace of progress. This translated into 41 million fewer women with an unmet need for modern methods and 14 million fewer unintended pregnancies. Annual direct costs would be $480 million more in 2030 to support contraceptive services compared with costs in 2030 based on the current pace of progress. As governments plan and budget for expanded health service coverage, information from probabilistic projections can guide them in setting measurable, ambitious yet realistic targets that are relevant to their particular contexts. Supplementary Information: The online version contains supplementary material available at 10.1007/s11113-023-09766-2.

Predictors of antiretroviral therapy initiation in eThekwini (Durban), South Africa: Findings from a prospective cohort study.

Despite expanded antiretroviral therapy (ART) eligibility in South Africa, many people diagnosed with HIV do not initiate ART promptly, yet understanding of the reasons is limited. Using data from an 8-month prospective cohort interview study of women and men newly-diagnosed with HIV in three public-sector primary care clinics in the eThekwini (Durban) region, South Africa, 2010-2014, we examined if theoretically-relevant social-structural, social-cognitive, psychosocial, and health status indicators were associated with time to ART initiation. Of 459 diagnosed, 350 returned to the clinic for their CD4+ test results (linkage); 153 (33.3%) were ART-eligible according to treatment criteria at the time; 115 (75.2% of those eligible) initiated ART (median = 12.86 weeks [95% CI: 9.75, 15.97] after linkage). In adjusted Cox proportional hazard models, internalized stigma was associated with a 65% decrease in the rate of ART initiation (Adjusted hazard ratio [AHR] 0.35, 95% CI: 0.19-0.80) during the period less than four weeks after linkage to care, but not four or more weeks after linkage to care, suggesting that stigma-reduction interventions implemented shortly after diagnosis may accelerate ART uptake. As reported by others, older age was associated with more rapid ART initiation (AHR for 1-year age increase: 1.04, 95% CI: 1.01-1.07) and higher CD4+ cell count (≥300µL vs. <150µL) was associated with a lower rate of initiation (AHR 0.38, 95% CI: 0.19-0.80). Several other factors that were assessed prior to diagnosis, including stronger belief in traditional medicine, higher endorsement of stigma toward people living with HIV, food insecurity, and higher psychological distress, were found to be in the expected direction of association with ART initiation, but confidence intervals were wide and could not exclude a null finding.

Budgeting for comprehensive sexual and reproductive health and rights under universal health coverage.

Achieving universal health coverage (UHC) for sexual and reproductive health (SRH) requires informed budgeting that is aligned with UHC objectives. We draw data from Adding It Up 2019 (AIU-2019) to provide critical new country-level and regional, intervention-specific costs for the provision of SRH services. AIU-2019 is a cost-outcomes analysis, undertaken from the health system perspective, which estimates the costs and impacts of offering SRH care in low- and middle-income countries. We present direct cost estimates for 109 SRH interventions and find that human resources comprise the largest category of direct SRH service costs and that the most expensive services in the model are largely preventable. We use scenario analysis to explore the synergistic costs and impacts of providing SRH interventions in clusters, focussing on chlamydia and gonorrhoea treatment, provision of safe abortion and post-abortion care services, and safe childbirth services. When costs are considered for the preventive and impacted services in these three clusters, there are cost savings for some of the impacted services in the packages and for the abortion-related package overall. The direct cost estimates from our analysis can be used to guide UHC budgeting and planning efforts. Having these cost estimates and understanding the potential for cost savings when providing comprehensive SRH services are critical for efforts to fulfil the rights and needs of all individuals, including the most marginalised, to access this essential care.

The Health System Costs of Postabortion Care in Senegal.

CONTEXT: Unsafe abortion is common in Senegal, but postabortion care (PAC) is not accessible to some women who need it, and the cost to the health care system of providing PAC is unknown. METHODS: The cost to Senegal's health system of providing PAC in 2016-at existing service levels and if access were hypothetically expanded-was estimated using the Post-Abortion Care Costing Methodology, a bottom-up, ingredients-based approach. From September 2016 to January 2017, face-to-face interviews were conducted with PAC providers and facility administrators at a national sample of 41 health facilities to collect data on the direct and indirect costs of care provision, as well as the fees charged to patients. A sensitivity analysis was conducted to examine the precision of the results. RESULTS: In total, 1,642 women received PAC at study facilities in 2016, which translates to 18,806 women receiving PAC nationally. Public facilities provided nearly all services. The average cost per patient at study facilities was US$26.68; nationally, the estimated cost was US$24.72. The estimated total national cost of providing PAC at existing levels was US$464,928; direct costs accounted for more than three-quarters of the cost. Charges to PAC patients amounted to 20% of all incurred costs. If service provision had been expanded to meet all PAC needs, estimated total costs to the health system would have been US$804,518. CONCLUSION: The annual costs of PAC are substantial in Senegal. Greater investment in ensuring access to contraceptives could lower these costs by reducing the number of unintended pregnancies that often lead to unsafe abortion.

RESUMEN Contexto: El aborto inseguro es una práctica común en Senegal, pero la atención postaborto (APA) no es accesible para algunas mujeres que la necesitan y se desconoce el costo de proveer APA para el sistema de atención a la salud. Métodos: Se estimó el costo de proveer APA para el sistema de salud de Senegal en 2016 ­a los niveles de servicio existentes y si, hipotéticamente, el acceso se expandiera­mediante el uso de la Metodología de Costeo de la Atención Postaborto, un enfoque ascendente basado en componentes. De septiembre de 2016 a enero de 2017 se condujeron entrevistas personales con proveedores de APA y administradores de instituciones de salud en una muestra nacional de 41 instituciones de salud, con el fin de recolectar datos sobre los costos directos e indirectos de la provisión de atención, así como sobre las cuotas que se cobran a las pacientes. Se llevó a cabo un análisis de sensibilidad para examinar la precisión de los resultados. Resultados: En total, 1,642 mujeres recibieron APA en las instituciones de salud del estudio en 2016, lo que se traduce en 18,806 mujeres que recibieron APA a nivel nacional. Las instituciones de salud pública proveen casi la totalidad de los servicios. El costo promedio por paciente en las instituciones del estudio fue de US$26.68; a nivel nacional, el costo estimado fue de US$24.72. El costo total estimado a nivel nacional de proveer APA a los niveles existentes fue de US$464,928; los costos directos representaron más de las tres cuartas partes del costo. Los cargos cobrados a las pacientes de APA ascendieron al 20% del total de costos incurridos. Si la provisión del servicio se hubiera expandido para satisfacer todas las necesidades de APA, los costos estimados para el sistema de salud habrían sido de US$804,518. Conclusión: Los costos anuales de la APA son cuantiosos en Senegal. Una mayor inversión para garantizar el acceso a anticonceptivos podría disminuir estos costos al reducir el número de embarazos no planeados que, con frecuencia, conducen al aborto inseguro.

RÉSUMÉ Contexte: L'avortement non médicalisé est courant au Sénégal, mais les soins après avortement (SAA) ne sont pas accessibles à certaines femmes qui en ont besoin et le coût de la prestation de ces soins, au niveau du système de santé, est inconnu. Méthodes: Le coût pour le système sanitaire sénégalais de la prestation de SAA en 2016 ­ aux niveaux existants et si l'accès était hypothétiquement élargi ­ a été estimé selon l'approche ascendante par élément PACCM (Post-Abortion Care Costing Methodology). De septembre 2016 à janvier 2017, des entretiens en personne ont été menés avec des prestataires de SAA et des administrateurs d'établissement dans un échantillon national de 41 structures de santé, dans le but de collecter des données sur les coûts directs et indirects de la prestation de soins, ainsi que sur les frais imposés aux femmes. La précision des résultats a été examinée par analyse de sensibilité. Résultats: Au total, 1 642 femmes avaient reçu des SAA dans les structures soumises à l'étude en 2016, ce qui équivaudrait à 18 806 femmes à l'échelle nationale. Presque tous les services étaient fournis dans des structures publiques. Le coût moyen par patiente dans les structures de l'étude était de 26,68 dollars américains. À l'échelle nationale, ce coût était estimé à 24,72 dollars. Le coût national total estimé de la prestation de SAA aux niveaux existants a été calculé à 464 928 dollars. Les coûts directs représentent plus de trois quarts de ce montant. Les frais imposés aux patientes de SAA s'élevaient à 20% de la totalité des coûts encourus. Si la prestation de services avait été étendue pour satisfaire à la totalité des besoins de SAA, les coûts totaux estimés, pour le système de santé, auraient atteint 804 518 dollars. Conclusion: Les coûts annuels des SAA sont considérables au Sénégal. Un investissement accru dans l'assurance de l'accès à la contraception permettrait de faire baisser ces coûts par réduction du nombre de grossesses non planifiées qui mènent souvent à un avortement non médicalisé.

Voices from the front lines: A qualitative study of integration of HIV, tuberculosis, and primary healthcare services in Johannesburg, South Africa.

INTRODUCTION: In South Africa, in 2013-2014, provision of antiretroviral treatment (ART) shifted in some areas from NGOs to public facilities. Tuberculosis (TB) management has also been integrated into public services. We aimed to explore the opinions and experiences of service managers and healthcare providers regarding integration of HIV and TB services into primary healthcare services. METHODS: The study sites included three clinics in one peri-urban/urban administrative region of Johannesburg. From March 2015 to August 2016, trained interviewers conducted semi-structured interviews with purposively selected participants. Participants were eligible if they were city/regional managers, clinic managers, or healthcare providers responsible for HIV, TB, non-communicable diseases, or sexual and reproductive health at the three study sites. We used a grounded theory approach for iterative, qualitative analysis, and produced descriptive statistics for quantitative data. RESULTS: We interviewed 19 individuals (nine city/regional managers, three clinic managers, and seven nurses). Theoretical definitions of integration varied, as did actual practice. Integration of HIV treatment had been anticipated, but only occurred when required due to shifts in funding for ART. The change was rapid, and some clinics felt unprepared. That said, nearly all respondents were in favor of integrated care. Perceived benefits included comprehensive case management, better client-nurse interactions, and reduced stigma. Barriers to integration included staff shortages, insufficient training and experience, and outdated clinic infrastructure. There were also concerns about the impact of integration on staff workloads and waiting times. Finally, there were concerns about TB integration due to infection control issues. DISCUSSION: Integration is multi-faceted and often contingent on local, if not site-specific, factors. In the future in South Africa and in other settings contending with health service reorganization, staff consultations prior to and throughout phase-in of services changes could contribute to improved understanding of operational requirements, including staff needs, and improved patient outcomes.

Correction: Costs and cost-effectiveness of LEEP versus cryotherapy for treating cervical dysplasia among HIV-positive women in Johannesburg, South Africa.

[This corrects the article DOI: 10.1371/journal.pone.0203921.].

Doing more for less: identifying opportunities to expand public sector access to safe abortion in South Africa through budget impact analysis.

OBJECTIVE(S): To estimate the costs of public-sector abortion provision in South Africa and to explore the potential for expanding access at reduced cost by changing the mix of technologies used. STUDY DESIGN: We conducted a budget impact analysis using public sector abortion statistics and published cost data. We estimated the total costs to the public health service over 10 years, starting in South Africa's financial year 2016/17, given four scenarios: (1) holding service provision constant, (2) expanding public sector provision, (3) changing the abortion technologies used (i.e. the method mix), and (4) expansion plus changing the method mix. RESULTS: The public sector performed an estimated 20% of the expected total number of abortions in 2016/17; 26% and 54% of all abortions were performed illegally or in the private sector respectively. Costs were lowest in scenarios where method mix shifting occurred. Holding the proportion of abortions performed in the public-sector constant, shifting to more cost-effective service provision (more first-trimester services with more medication abortion and using the combined regimen for medical induction in the second trimester) could result in savings of $28.1 million in the public health service over the 10-year period. Expanding public sector provision through elimination of unsafe abortions would require an additional $192.5 million. CONCLUSIONS: South Africa can provide more safe abortions for less money in the public sector through shifting the methods provided. More research is needed to understand whether the cost of expanding access could be offset by savings from averting costs of managing unsafe abortions. IMPLICATIONS: South Africa can provide more safe abortions for less money in the public sector through shifting to more first-trimester methods, including more medication abortion, and shifting to a combined mifepristone plus misoprostol regimen for second trimester medical induction. Expanding access in addition to method mix changes would require additional funds.

Costs and cost-effectiveness of LEEP versus cryotherapy for treating cervical dysplasia among HIV-positive women in Johannesburg, South Africa.

BACKGROUND: Cervical cancer incidence is significant in countries, such as South Africa, with high burdens of both HIV and human papillomavirus (HPV). Cervical cancer is largely preventable if dysplasia is diagnosed and treated early, but there is debate regarding the best approaches for screening and treatment, especially for low-resource settings. Currently South Africa provides Pap smears followed by colposcopic biopsy and LEEP if needed in its public health facilities. We estimated the costs and cost-effectiveness of two approaches for treating cervical intraepithelial neoplasia grade 2 or higher (CIN2+) among HIV-infected women, most of whom were taking antiretroviral treatment, at a public HIV treatment facility in Johannesburg, South Africa. METHODS: Method effectiveness was derived from an intention-to-treat analysis of data gathered in a clinical trial completed previously at the study facility. In the trial, women who were diagnosed with CIN2+ and eligible for cryotherapy were randomized to cryotherapy or LEEP. If women were CIN2+ at six months as determined via Pap smear and colposcopic biopsy, all women-regardless of their original treatment assignment-received LEEP. "Cure" was then defined as the absence of disease at 12 months based on Pap smear and colposcopic biopsy. Health service costs were estimated using micro-costing between June 2013 and April 2014. Capital costs were annualized using a discount rate of 3%. Two different service volume scenarios were considered, and results from an as-treated analysis were considered in sensitivity analysis. RESULTS: In total, 166 women with CIN2+ were enrolled (86 had LEEP; 80 had cryotherapy). At 12 months, cumulative loss to follow-up was 12.8% (11/86) for the LEEP group and 13.8% (11/80) for cryotherapy. Based on the unadjusted intention-to-treat analysis conducted for this economic evaluation, there was no significant difference in efficacy. At 12 months, 83.8% (95% CI 73.8-91.1) of women with CIN2+ at baseline and randomized to cryotherapy were free of CIN2+ disease. In contrast, 76.7% (95% CI 66.4-85.2) of women assigned to LEEP were free from disease. On average, women initially treated with cryotherapy were less costly per patient randomized at US$ 118.00 (113.91-122.10), and per case "cured" at US$ 140.90 (136.01-145.79). Women in the LEEP group cost US$ 162.56 (157.90-167.22) per patient randomized and US$ 205.59 (199.70-211.49) per case cured. In the as-treated analysis, which was based on trial data, LEEP was more efficacious than cryotherapy; however, the difference was not significant. Cryotherapy remained more cost-effective than LEEP in all sensitivity and scenario analyses. CONCLUSIONS: For this cost-effectiveness analysis, using an intention-to-treat approach and taking into consideration uncertainty in the clinical and cost outcomes, a strategy involving cryotherapy plus LEEP if needed at six months was dominant to LEEP plus LEEP again at six months if needed for retreatment. However, compared to other studies comparing LEEP and cryotherapy, the efficacy results were low in both treatment groups-possibly due to the HIV-positivity of the participants. Further research is needed, but at present choosing the "right" treatment option may be less important than ensuring access to treatment and providing careful monitoring of treatment outcomes.

The costs and cost effectiveness of providing second-trimester medical and surgical safe abortion services in Western Cape Province, South Africa.

BACKGROUND: In South Africa, access to second-trimester abortion services, which are generally performed using medical induction with misoprostol alone, is challenging for many women. We aimed to estimate the costs and cost effectiveness of providing three safe second-trimester abortion services (dilation and evacuation (D&E)), medical induction with mifepristone and misoprostol (MI-combined), or medical induction with misoprostol alone (MI-misoprostol)) in Western Cape Province, South Africa to aid policymakers with planning for service provision in South Africa and similar settings. METHODS: We derived clinical outcomes data for this economic evaluation from two previously conducted clinical studies. In 2013-2014, we collected cost data from three public hospitals where the studies took place. We collected cost data from the health service perspective through micro-costing activities, including discussions with site staff. We used decision tree analysis to estimate average costs per patient interaction (e.g. first visit, procedure visit, etc.), the total average cost per procedure, and cost-effectiveness in terms of the cost per complete abortion. We discounted equipment costs at 3%, and present the results in 2015 US dollars. RESULTS: D&E services were the least costly and the most cost-effective at $91.17 per complete abortion. MI-combined was also less costly and more cost-effective (at $298.03 per complete abortion) than MI-misoprostol (at $375.31 per complete abortion), in part due to a shortened inpatient stay. However, an overlap in the plausible cost ranges for the two medical procedures suggests that the two may have equivalent costs in some circumstances. CONCLUSION: D&E was most cost-effective in this analysis. However, due to resistance from health care providers and other barriers, these services are not widely available and scale-up is challenging. Given South Africa's reliance on medical induction, switching to the combined regimen could result in greater access to second-trimester services due to shorter inpatient stays without increasing costs.