Costs and cost drivers of comprehensive sexual reproductive health services to female sex workers in Kenya.

BACKGROUND: Comprehensive sexual reproductive health (SRH) programs for female sex workers (FSW) offering clinical, behavioural, and structural interventions have contributed to declining rates of HIV in this population. However, data on costs and cost drivers is needed to support programs and their donors to better allocate resources, make an investment case for continued funding, and to identify areas of improvement in program design and implementation. We aimed to estimate the annual per-FSW costs of comprehensive services for a standalone FSW program in Kenya. METHODS: We implemented a top-bottom and activity-based costing study of comprehensive FSW services at two drop-in centres (DICs), Mtwapa and Kilifi town, in Kilifi County, Kenya. Service costs were obtained from routinely collected patient data during FSW scheduled and unscheduled visits using Kenyan Ministry of Health records. Costing data were from the program and organization's expenditure reports, cross checked against bank documents and supported by information from in-depth interviews. Data were collected retrospectively for the fiscal year 2019. We obtained approval from the AMREF Research Ethics Committee (AMREF-ESRC P862/2020). RESULTS: In 2019, the unit cost of comprehensive services was 105.93 USD per FSW per year, roughly equivalent to 10,593 Kenya shillings. Costs were higher at Mtwapa DICs compared to Kilifi town DIC; 121.90 USD and 89.90 USD respectively. HIV counselling and testing cost 63.90 USD per person, PrEP was 34.20 USD and family planning was 9.93 USD. Of the total costs, staff salaries accounted for about 60%. Adjusted for inflation, costs in 2024 would be approximately 146.60. CONCLUSION: Programs should strive to maximize the number of FSW served to benefit from economies of scale. Given that personnel costs contribute most to the unit costs, programs should consider alternative designs which reduce personnel and other costs.

Differences in condom access and use and associated factors between persons with and without disabilities receiving social cash transfers in Luapula province, Zambia-A cross-sectional study.

Persons with disabilities are disadvantaged in accessing sexual and reproductive health services, including condoms. In this study, we investigated whether condom access and use and their associated factors differed between persons with and without disabilities. We used data from adults in households receiving the Government of Zambia social cash transfers (SCT) in four districts of Luapula province. Condom access and use was the outcome. Disability, defined by the Washington Group Short Set Questions on Disability, was the main predictor. We performed logistic regression analyses to determine the associations between condom access and use and disability. In multivariable analyses, we controlled for covariates including age, sex, marital status, poverty status, HIV testing, and receiving the SCT. The sample comprised 1,143 people aged 16-49, with a median age of 21 years (interquartile range 18-28); 57.4% (n = 656) were female, 86.5% (n = 989) accessed and used condoms, and 17.9% (n = 205) were disabled, rating themselves with a 3 or a 4 on a scale of 1 = "not limited" to 4 = "cannot at all" in performing any of the six daily functions (seeing, hearing, walking, cognition, self-care, or communicating). Nearly sixty percent(58.5% (n = 120)) of persons with disabilities were female, 79.5% (n = 163) reported being very poor, 87.8% (n = 180) reported receiving SCT, and 86.3% (n = 177) reported accessing and using condoms. Condom access and use did not differ between persons with and without disabilities (adjusted odds ratio: 1.09; 95% confidence interval [CI]: 0.60-1.98]). We found no differences between persons with and without disabilities in condom access and use. We established that individual-level factors such as age, sex, marital status, and knowledge of being HIV positive might play a more important role in condom access and use than disability. Condom promotion interventions should account for these factors.

Cost-Effectiveness and Budget Impact Analysis of the Implementation of Differentiated Service Delivery Models for HIV Treatment in Mozambique: a Modelling Study.

INTRODUCTION: In 2018, the Mozambique Ministry of Health launched guidelines for implementing differentiated service delivery models (DSDMs) to optimize HIV service delivery, improve retention in care, and ultimately reduce HIV-associated mortality. The models were fast-track, 3-month antiretrovirals dispensing, community antiretroviral therapy groups, adherence clubs, family approach and three one-stop shop models: adolescent-friendly health services, maternal and child health, and tuberculosis. We conducted a cost-effectiveness analysis and budget impact analysis to compare these models to conventional services. METHODS: We constructed a decision tree model based on the percentage of enrolment in each model and the probability of the outcome (12-month retention in treatment) for each year of the study period-three for the cost-effectiveness analysis (2019-2021) and three for the budget impact analysis (2022-2024). Costs for these analyses were primarily estimated per client-year from the health system perspective. A secondary cost-effectiveness analysis was conducted from the societal perspective. Budget impact analysis costs included antiretrovirals, laboratory tests and service provision interactions. Cost-effectiveness analysis additionally included start-up, training and clients' opportunity costs. Effectiveness was estimated using an uncontrolled interrupted time series analysis comparing the outcome before and after the implementation of the differentiated models. A one-way sensitivity analysis was conducted to identify drivers of uncertainty. RESULTS: After implementation of the DSDMs, there was a mean increase of 14.9 percentage points (95% CI: 12.2, 17.8) in 12-month retention, from 47.6% (95% CI, 44.9-50.2) to 62.5% (95% CI, 60.9-64.1). The mean cost difference comparing DSDMs and conventional care was US$ -6 million (173,391,277 vs. 179,461,668) and -32.5 million (394,705,618 vs. 433,232,289) from the health system and the societal perspective, respectively. Therefore, DSDMs dominated conventional care. Results were most sensitive to conventional care interaction costs in the one-way sensitivity analysis. For a population of 1.5 million, the base-case 3-year financial costs associated with the DSDMs was US$550 million, compared with US$564 million for conventional care. CONCLUSIONS: DSDMs were less expensive and more effective in retaining clients 12 months after antiretroviral therapy initiation and were estimated to save approximately US$14 million for the health system from 2022 to 2024.

Economic outcomes among microfinance group members receiving community-based chronic disease care: Cluster randomized trial evidence from Kenya.

BACKGROUND: Poverty can be a robust barrier to HIV care engagement. We assessed the extent to which delivering care for HIV, diabetes and hypertension within community-based microfinance groups increased savings and reduced loan defaults among microfinance members living with HIV. METHODS: We analyzed cluster randomized trial data ascertained during November 2020-May 2023 from 57 self-formed microfinance groups in western Kenya. Groups were randomized 1:1 to receive care for HIV and non-communicable diseases in the community during regular microfinance meetings (intervention) or at a health facility during routine appointments (standard care). Community and facility care provided clinical evaluations, medications, and point-of-care testing. The trial enrolled 900 microfinance members, with data collected quarterly for 18-months. We used a two-part model to estimate intervention effects on microfinance shares purchased, and a negative binomial regression model to estimate differences in loan default rates between trial arms. We estimated effects overall and by participant characteristics. RESULTS: Participants' median age and distance from a health facility was 52 years and 5.6 km, respectively, and 50% reported earning less than $50 per month. The probability of saving any amount (>$0) through purchasing microfinance shares was 2.7 percentage points higher among microfinance group members receiving community vs. facility care. Community care recipients and facility care patients saved $44.90 and $25.24 over 18-months, respectively, and the additional amount saved by community care recipients was statistically significant (p = 0.036). Overall and in stratified analyses, loan defaults rates were not statistically significantly different between community and facility care patients. CONCLUSIONS: Receiving integrated care in the community was significantly associated with modest increases in savings. We did not find any significant association between community-delivered care and reductions in loan defaults among HIV-positive microfinance group members. Longer follow up examination and formal mediation analyses are warranted.

Costing of a Combination Intervention (Kyaterekera) Addressing Sexual Risk-Taking Behaviors among Vulnerable Women in Southern Uganda.

In Uganda, women engaged in sex work (WESW) are a marginalized population at the intersection of multiple vulnerabilities. The Kyaterekera intervention is targeted at WESW in Rakai and the greater Masaka regions in Uganda and combines a traditional HIV risk-reduction approach with a savings-led economic empowerment intervention and financial literacy training. We estimated the economic costs of the Kyaterekera intervention from a program provider perspective using a prospective activity-based micro-costing method. All program activities and resource uses were measured and valued across the control arm receiving a traditional HIV risk-reduction intervention and the treatment arm receiving a matched individual development savings account and financial literacy training on top of HIV risk reduction. The total per-participant cost by arm was adjusted for inflation and discounted at an annual rate of 3% and presented in 2019 US dollars. The total per-participant costs of the control and intervention arms were estimated at $323 and $1,435, respectively, using the per-protocol sample. When calculated based on the intent-to-treat sample, the per-participant costs were reduced to $183 and $588, respectively. The key cost drivers were the capital invested in individual development accounts and personnel and transportation costs for program operations, linked to WESW's higher mobility and the dispersed pattern of hot spot locations. The findings provide evidence of the economic costs of implementing a targeted intervention for this marginalized population in resource-constrained settings and shed light on the scale of potential investment needed to better achieve the health equity goal of HIV prevention strategies.

Analysis of Health-Related Quality of Life and Incurred Costs Among Human Immunodeficiency Virus, Tuberculosis, and Tuberculosis/HIV Coinfected Outpatients in Indonesia.

OBJECTIVES: A growing interest in healthcare costs and patients' health-related quality of life (HRQoL) exists in the context of the increasing importance of health technology assessment in countries with high numbers of the HIV and tuberculosis (TB) patient populations, such as Indonesia. This study aimed to analyze the HRQoL and out-of-pocket (OOP) costs of HIV, TB, and TB/HIV coinfected participants in a city in Indonesia with a high prevalence of HIV and TB. METHODS: A cross-sectional survey was conducted in the voluntary counseling and testing and lung clinics of Bekasi City Public Hospital (Indonesia) from January to March 2018. Patients' HRQoL was measured using the EQ-5D-5L questionnaire, whereas OOP costs were extracted from a semistructured questionnaire. RESULTS: Of the 460 eligible participants, 82% resided in the city, 48% of them were married, and their median age was 34 years. Less than half were insured, and more than half had no source of income. The median values of health utilities for participants with HIV, TB, and TB/HIV were perceived as potentially high (1.0, 0.9, and 0.8, respectively). The TB/HIV coinfected outpatients had the highest OOP costs (US$94.5), with the largest contribution coming from direct medical OOP expenditures. Taking loans from family members was adopted as a financial strategy to overcome inadequate household incomes and high treatment costs. CONCLUSION: This study suggests that TB/HIV coinfection potentially lowers HRQoL and increases healthcare costs and the need for economic analysis to underpin cost-effective treatment in such patients.

Dynamic Linkages among HIV/AIDS, Health Expenditures, Environmental Degradation, Life Expectancy, and Economic Growth: A Case of Eastern Africa Countries.

BACKGROUND: Eastern African countries are among the countries with a very high HIV/AIDS prevalence rate. High HIV/AIDS prevalence is a problem that has a detrimental effect on the economic development of these countries. Previous studies have generally examined the relationship of HIV/AIDS with life expectancy or economic growth. In this study, three different models have been established and the relationship of HIV/AIDS with economic growth, health expenditures, and life expectancy has been analyzed, and current econometric methods and policy recommendations have been developed according to the results. OBJECTIVE: The aim of this study was to investigate the relationship between health expenditure, environmental degradation, life expectancy, HIV/AIDS, and economic growth. METHOD: Annual data from 9 Eastern African countries for the period of 2000-2019 were used. Panel ARDL/PMG and Dumitrescu-Hurlin methods were used. RESULTS: HIV/AIDS negatively affects economic growth and life expectancy, and positively affects health expenditures. According to the causality results, HIV/AIDS is the cause of economic growth. In addition, a bidirectional causal relationship has been found between HIV/AIDS and life expectancy. CONCLUSION: The main conclusion of the study is that HIV/AIDS plays a negative role in economic growth and life expectancy. Further steps must be taken to prevent the further spread of HIV/AIDS, which causes these factors to affect the well-being of the countries.

Evolución temporal de la terapia antirretroviral (2017-2021): análisis de la modificación del tratamiento y su impacto económico / Temporal evolution of antiretroviral therapy (2017-2021): analysis of treatment change and its economic impact

Objetivos. Analizar las modificaciones de la terapia antirre troviral (TAR) y su impacto económico en la práctica clínica diaria. Material y métodos. Estudio observacional, retrospectivo de los pacientes que iniciaron TAR entre 01/2017-12/2021 (se guimiento hasta 12/2022). Variables recogidas: TAR, duración, motivo del cambio y costes del tratamiento. Resultados. 280 pacientes iniciaron TAR. La mediana de durabilidad de la 1ª línea fue: 19,9 meses en 2017 (IC95% 13,9-25,9), 12,2 meses en 2018 (IC95% 4,7-19,7), 27,4 meses en 2019 (IC95% 6,8-48,1) y no se alcanzó la mediana para los años 2020 y 2021 (p p<0,001). De un total de 541 líneas prescri tas, la triple terapia con inhibidores de la proteasa se modificó en el 63,8% (81/127), seguido de los inhibidores de la integrasa 52,1% (159/305), mientras que, la terapia dual (DTG/3TC) solo en el 8,3% (7/84). De un total de 261 modificaciones, la simpli ficación/optimización 47,5% (124/261) fue el principal motivo, seguido de efectos adversos 21,8% (57/261), siendo el 2017 el único año donde ambos motivos se encontraban al mismo nivel. El impacto económico de los cambios supusieron una re ducción del coste medio de 34,0€ [-391,4 a +431,4] al mes/ paciente. El año 2019 es el único año donde estos cambios se asociaron con un incremento del coste adicional medio (23,4€ [-358,3 a +431,4]). Conclusiones. Dejando atrás el fracaso virológico, la sim plificación a regímenes de un solo comprimido y de mayor tolerancia han marcado la nueva la era TAR. Con un impacto económico que, a pesar del punto de inflexión del 2019, refleja una reducción progresiva de costes mantenida en el tiempo (AU)

Objectives. To analyze the modifications of antiretrovi ral therapy (ART) and their economic impact on daily clinical practice. Material and methods. Observational, retrospective study of patients who started ART between 01/2017-12/2021 (follow-up until 12/2022). Variables collected: prescribed ART, duration, the reason for the change, and treatment costs. Results. A total of 280 patients initiated ART therapy. The median durability of 1st line was: 19.9 months in 2017 (95%CI 13.9-25.9), 12.2 months in 2018 (95%CI 4.7-19.7), 27.4 months in 2019 (95%CI 6.8-48.1) and the median was not reached for the years 2020 and 2021 (p<0.001). Triple therapy with protease inhibitors was changed in 63.8% (81/127) of cases, followed by integrase inhibitors 52.1% (159/305), while dual therapy (DTG/3TC) only in 8.3% (7/84). The main cause of dis continuation was simplification/optimization 47.5% (124/261), followed by adverse effects 21.8% (57/261), with 2017 being the only year where simplification/optimization was at the same level as adverse effects. The economic impact of ART changes resulted in an average cost reduction of 34.0€ [-391.4 to +431.4] per month per patient. The year 2019 stands out as the only year where these changes were associated with an increase in mean additional cost (23.4€ [-358.3 to +431.4]). Conclusions. Optimization/simplification accounts for almost half of the reasons for TAR change, with an econom ic impact that, despite the inflection point of 2019, each year manages to exceed the previous one, achieving a progressive cost reduction maintained over time (AU)

PEPFAR Reauthorization by Congress Urgent for Global Health.

This Viewpoint discusses the importance of the US Congress reauthorizing funding for the President's Emergency Plan for AIDS Relief, a program developed in 2003 that has played a critical role in fighting HIV/AIDS worldwide as well as other emerging infections and noncommunicable diseases.

"If I don't take my treatment, I will die and who will take care of my child?": An investigation into an inclusive community-led approach to addressing the barriers to HIV treatment adherence by postpartum women living with HIV.

INTRODUCTION: Initiatives to support adherence to HIV treatment in South Africa are often centred on service delivery thereby avoiding key challenges to adherence: stigma and poverty. In contrast, this study aims to demonstrate the strength of an inclusive research and programme approach to improving the lives of people living with HIV and simultaneously ARV adherence. METHODS: Participatory Action Research combined with a visual participatory method (Photovoice) was used by postpartum women to share their experience of taking ARVs. The research was analysed from an interpretative and critical paradigm where both the women and a non-governmental organisation collaborated in the data collection, analysis and interpretation of the findings. Together, they then disseminated the findings and used a community-led approach to create a programme addressing these barriers effectively. FINDINGS: Two main barriers to ARV adherence emerged: the anticipated stigma associated with issues of disclosure and poverty epitomized by alcohol abuse, gender-based violence and hunger. The women and the NGO staff successfully presented their findings at conferences and collaborated to develop a programme of support for all women living with HIV in the area. The programme addresses each of the issues raised by the co-researchers and is run via a community-led process where the participants lead on design, implementation, and monitoring and ultimately will revise the programme as needed. DISCUSSION: The inclusive approach of this study enabled these postpartum women to portray the intersectional nature of both HIV stigma and poverty that affects their lives. By working with the local NGO to develop a programme based on these insights, they were able to tailor specific interventions to the issues women living with HIV face in their area. In doing so, they aim to improve the lives of people living with HIV by demonstrating a more sustainable way to impact ARV adherence. CONCLUSION: Currently, health service insistence on measuring ARV adherence does not address the core barriers to taking ARVs and misses the opportunity to focus on the long term health and well-being of people living with HIV. In contrast, locally targeted participatory research and programme development based on inclusivity, collaboration and ownership do address the fundamental challenges of people living with HIV. In doing so, it can have a greater impact on their long term well-being.

Impact of COVID-19 on HIV Prevention Access: A Multi-platform Social Media Infodemiology Study.

This study seeks to identify and characterize key barriers associated with PrEP therapy as self-reported by users on social media platforms. We used data mining and unsupervised machine learning approaches to collect and analyze COVID-19 and PrEP-related posts from three social media platforms including Twitter, Reddit, and Instagram. Predominant themes detected by unsupervised machine learning and manual annotation included users expressing uncertainty about PrEP treatment adherence due to COVID-19, challenges related to accessibility of clinics, concerns about PrEP costs and insurance coverage, perceived lower HIV risk leading to lack of adherence, and misinformation about PrEP use for COVID-19 prevention.

Impact and cost-effectiveness of non-governmental organizations on the HIV epidemic in Ukraine among MSM.

OBJECTIVE: Non-governmental organizations (NGOs) in Ukraine have provided HIV testing, treatment, and condom distribution for MSM. HIV prevalence among MSM in Ukraine is 5.6%. We estimated the impact and cost-effectiveness of MSM-targeted NGO activities in Ukraine. DESIGN: A mathematical model of HIV transmission among MSM was calibrated to data from Ukraine (2011-2018). METHODS: The model, designed before the 2022 Russian invasion of Ukraine, evaluated the impact of 2018 status quo coverage levels of 28% of MSM being NGO clients over 2016-2020 and 2021-2030 compared with no NGO activities over these time periods. Impact was measured in HIV incidence and infections averted. We compared the costs and disability adjusted life years (DALYs) for the status quo and a counterfactual scenario (no NGOs 2016-2020, but with NGOs thereafter) until 2030 to estimate the mean incremental cost-effectiveness ratio (cost per DALY averted). RESULTS: Without NGO activity over 2016-2020, the HIV incidence in 2021 would have been 44% (95% credibility interval: 36-59%) higher than with status quo levels of NGO activity, with 25% (21-30%) more incident infections occurring over 2016-2020. Continuing with status quo NGO coverage levels will decrease HIV incidence by 41% over 2021-2030, whereas it will increase by 79% (60-120%) with no NGOs over this period and 37% (30-51%) more HIV infections will occur. Compared with if NGO activities had ceased over 2016-2020 (but continued thereafter), the status quo scenario averts 14 918 DALYs over 2016-2030 with a mean incremental cost-effectiveness ratio of US$600.15 per DALY averted. CONCLUSION: MSM-targeted NGOs in Ukraine have prevented considerable HIV infections and are highly cost-effective compared with a willingness-to-pay threshold of 50% of Ukraine's 2018 GDP (US$1548).

Optimizing HIV Prevention Efforts to Achieve EHE Incidence Targets.

BACKGROUND: A goal of the US Department of Health and Human Services' Ending the HIV Epidemic (EHE) in the United States initiative is to reduce the annual number of incident HIV infections in the United States by 75% within 5 years and by 90% within 10 years. We developed a resource allocation analysis to understand how these goals might be met. METHODS: We estimated the current annual societal funding [$2.8 billion (B)/yr] for 14 interventions to prevent HIV and facilitate treatment of infected persons. These interventions included HIV testing for different transmission groups, HIV care continuum interventions, pre-exposure prophylaxis, and syringe services programs. We developed scenarios optimizing or reallocating this funding to minimize new infections, and we analyzed the impact of additional EHE funding over the period 2021-2030. RESULTS: With constant current annual societal funding of $2.8 B/yr for 10 years starting in 2021, we estimated the annual incidence of 36,000 new cases in 2030. When we added annual EHE funding of $500 million (M)/yr for 2021-2022, $1.5 B/yr for 2023-2025, and $2.5 B/yr for 2026-2030, the annual incidence of infections decreased to 7600 cases (no optimization), 2900 cases (optimization beginning in 2026), and 2200 cases (optimization beginning in 2023) in 2030. CONCLUSIONS: Even without optimization, significant increases in resources could lead to an 80% decrease in the annual HIV incidence in 10 years. However, to reach both EHE targets, optimization of prevention funding early in the EHE period is necessary. Implementing these efficient allocations would require flexibility of funding across agencies, which might be difficult to achieve.

The worldwide burden of HIV in transgender individuals: An updated systematic review and meta-analysis.

INTRODUCTION: Transgender individuals are at risk for HIV. HIV risks are dynamic and there have been substantial changes in HIV prevention (e.g., pre-exposure prophylaxis [PrEP]). It is thus time to revisit HIV prevalence and burden among transgender individuals. The objective of this systematic review and meta-analysis was thus to examine worldwide prevalence and burden of HIV over the course of the epidemic among trans feminine and trans masculine individuals. METHODS: We conducted an updated systematic review by searching PsycINFO, PubMed, Web of Science, and Google Scholar, for studies of any research design published in in a peer-reviewed journal in any language that reported HIV prevalence among transgender individuals published between January 2000 and January 2019. Two independent reviewers extracted the data and assessed methodological quality. We then conducted a meta-analysis, using random-effects modelling, to ascertain standardized prevalence and the relative burden of HIV carried by transgender individuals by country and year of data collection, and then by geographic region. We additionally explored the impact of sampling methods and pre-exposure prophylaxis (PrEP). RESULTS: Based on 98 studies, overall standardized HIV prevalence over the course of the epidemic, based on weights from each country by year, was 19.9% (95% CI 14.7% - 25.1%) for trans feminine individuals (n = 48,604) and 2.56% (95% CI 0.0% - 5.9%) for trans masculine individuals (n = 6460). Overall OR for HIV infection, compared with individuals over age 15, was 66.0 (95% CI 51.4-84.8) for trans feminine individuals and 6.8 (95% CI 3.6-13.1) for trans masculine individuals. Prevalence varied by geographic region (13.5% - 29.9%) and sampling method (5.4% - 37.8%). Lastly, PrEP effects on prevalence could not be established. CONCLUSION: Trans feminine and trans masculine individuals are disproportionately burdened by HIV. Their unique prevention and care needs should be comprehensively addressed. Future research should further investigate the impact of sampling methods on HIV prevalence, and monitor the potential impact of PrEP.