Estimating the cost of HIV services for key populations provided by the LINKAGES program in Kenya and Malawi.

BACKGROUND: Data remain scarce on the costs of HIV services for key populations (KPs). The objective of this study was to bridge this gap in the literature by estimating the unit costs of HIV services delivered to KPs in the LINKAGES program in Kenya and Malawi. We estimated the mean total unit costs of seven clinical services: post-exposure prophylaxis (PEP), pre-exposure prophylaxis (PrEP), HIV testing services (HTS), antiretroviral therapy (ART), sexually transmitted infection (STI) services, sexual and reproductive health (SRH) services, and management of sexual violence (MSV). These costs take into account the costs of non-clinical services delivered alongside clinical services and the pre-service and above-service program management integral to the LINKAGES program. METHODS: Data were collected at all implementation levels of the LINKAGES program including 30 drop-in-centers (DICs) in Kenya and 15 in Malawi. This study was conducted from the provider's perspective. We estimated economic costs for FY 2019 and cost estimates include start-up costs. Start-up and capital costs were annualized using a discount rate of 3%. We used a combination of top-down and bottom-up costing approaches. Top-down methods were used to estimate the costs of headquarters, country offices, and implementing partners. Bottom-up micro-costing methods were used to measure the quantities and prices of inputs used to produce services in DICs. Volume-weighted mean unit costs were calculated for each clinical service. Costs are presented in 2019 United States dollars (US$). RESULTS: The mean total unit costs per service ranged from US$18 (95% CI: 16, 21) for STI services to US$635 (95% CI: 484, 785) for PrEP in Kenya and from US$41 (95% CI: 37, 44) for STI services to US$1,240 (95% CI 1156, 1324) for MSV in Malawi. Clinical costs accounted for between 21 and 59% of total mean unit costs in Kenya, and between 25 and 38% in Malawi. Indirect costs-including start-up activities, the costs of KP interventions implemented alongside clinical services, and program management and data monitoring-made up the remaining costs incurred. CONCLUSIONS: A better understanding of the cost of HIV services is highly relevant for budgeting and planning purposes and for optimizing HIV services. When considering all service delivery costs of a comprehensive HIV service package for KPs, costs of services can be significantly higher than when considering direct clinical service costs alone. These estimates can inform investment cases, strategic plans and other budgeting exercises.

The Cost of Providing Comprehensive HIV Services to Key Populations: An Analysis of the LINKAGES Program in Kenya and Malawi.

INTRODUCTION: Timely data on HIV service costs are critical for estimating resource needs and allocating funding, but few data exist on the cost of HIV services for key populations (KPs) at higher risk of HIV infection in low- and middle-income countries. We aimed to estimate the total and per contact annual cost of providing comprehensive HIV services to KPs to inform planning and budgeting decisions. METHODS: We collected cost data from the Linkages across the Continuum of HIV Services for Key Populations Affected by HIV (LINKAGES) program in Kenya and Malawi serving female and male sex workers, men who have sex with men, and transgender women. Data were collected prospectively for fiscal year (FY) 2019 and retrospectively for start-up activities conducted in FY2015 and FY2016. Data to estimate economic costs from the provider's perspective were collected from LINKAGES headquarters, country offices, implementing partners (IPs), and drop-in centers (DICs). We used top-down and bottom-up cost estimation approaches. RESULTS: Total economic costs for FY2019 were US$6,175,960 in Kenya and US$4,261,207 in Malawi. The proportion of costs incurred in IPs and DICs was 66% in Kenya and 42% in Malawi. The costliest program areas were clinical services, management, peer outreach, and monitoring and data use. Mean cost per contact was US$127 in Kenya and US$279 in Malawi, with a mean cost per contact in DICs and IPs of US$63 in Kenya and US$104 in Malawi. CONCLUSION: Actions undertaken above the service level in headquarters and country offices along with those conducted below the service level in communities, comprised important proportions of KP HIV service costs. The costs of pre-service population mapping and size estimation activities were not negligible. Costing studies that focus on the service level alone are likely to underestimate the costs of delivering HIV services to KPs.

There are some questions you may not ask in a clinic: providing contraception information to young people in Kenya using SMS.

OBJECTIVE: To evaluate the acceptability, information access, and potential behavioral impact of providing contraception information via text message on mobile phones to young people in Kenya. METHODS: Three methods of data collection were implemented during the 17-month pilot period for the Mobile for Reproductive Health (m4RH) program in Kenya: automatic logging of all queries to the m4RH system; demographic and behavior change questions sent via short message service protocol (SMS) to everyone who used m4RH during the pilot period; and telephone interviews with a subset of m4RH users. RESULTS: During the pilot period, 4817 unique users accessed m4RH in Kenya. Of these, 82% were 29 years of age and younger, and 36% were male. Condom and natural family-planning information was accessed most frequently, although users queried all methods. One in 5 used the m4RH system to locate nearby clinics. Respondents liked the simple language and confidentiality of receiving health information via mobile phone, and reported increased contraceptive knowledge and use after using m4RH. CONCLUSION: Providing contraception information via mobile phone is an effective strategy for reaching young people. More research is needed to learn how to link young people to youth-friendly services effectively.

"A cup of tea with our CBD agent ": community provision of injectable contraceptives in Kenya is safe and feasible.

BACKGROUND: In rural areas of Kenya, where the majority of Kenya's population lives, contraceptive use remains low compared with that in urban areas (37% vs. 47%). Inadequate access to family planning services in rural areas is partly due to fewer health facilities and the shortage of health care workers. Community-based access to injectable contraceptives can improve access for rural populations and expand the range of contraceptive methods available. Our pilot project sought to generate local evidence on safety, feasibility, and acceptability of the provision of injectable depot medroxyprogesterone acetate (DMPA) by community health workers (CHWs). DESIGN: We trained 31 CHWs in Tharaka District to provide injectable DMPA in addition to pills and condoms. Data were collected on family planning clients served by CHWs in Tharaka District as well as those who received services from health facilities from August 2009 to September 2010. Service statistics were collected from 3 pilot health facilities in the CHW service catchment area. RESULTS: In the 12-month study period, CHWs reached 1,210 women with family planning services including referrals for long-acting and permanent methods. Family planning use in the pilot sites for all methods increased an estimated fivefold, from 9% in facilities to 46% when facilities and CHWs were combined (32% for CHWs and 14% for facilities). The majority (69%) of clients served by CHWs chose DMPA. No client reported any signs of infection at the injection site nor did any CHW report needlestick injuries or other adverse events. The re-injection rate was 68% at the third visit, which compares favorably with other DMPA continuation studies. Two main reasons given for discontinuing were change of residence and temporary separation from spouse. CONCLUSION: Community-based provision of DMPA along with other contraceptive methods increased the use of family planning and improved method choice during the study period. Injectable contraception provided by trained CHWs is a safe, acceptable, and feasible service delivery option in Kenya.

Preventing unintended pregnancy among young women in Kenya: prospective cohort study to offer contraceptive implants.

BACKGROUND: Subdermal contraceptive implants have low discontinuation rates but are underused among young women in Africa. This study aimed to isolate the role initial contraceptive method has on preventing unintended pregnancy. STUDY DESIGN: We recruited 399 Kenyan women aged 18-24 years into a prospective cohort study if they wanted short-acting hormonal methods (injectable or oral contraceptives). We offered an implant and formed two study groups: implant and short-acting. For contraceptive discontinuation/pregnancy, we used log-rank tests and proportional hazards models. We applied intent-to-treat principles to evaluate the role of initial method choice on future pregnancy. RESULTS: Twenty-four percent opted for an implant (n=97), and the remainder opted for a short-acting method (n=299). The 18-month discontinuation probability was 21 per 100 for implant users and 43 per 100 for the short-acting method group (p=.001). Twenty-two unintended pregnancies occurred; all were among the short-acting group. The adjusted relative risk of pregnancy among the short-acting group vs. implant group was 7.4 (95% confidence interval: 1.6-34.5). CONCLUSIONS: Many young Kenyan women found implants to be a reasonable alternative to short-acting methods. Having choice is essential, and starting on implants provides substantial and clear protection from unintended pregnancy relative to short-acting methods.

Factors associated with uptake of subdermal contraceptive implants in a young Kenyan population.

BACKGROUND: Subdermal contraceptive implants may be a reasonable option for young women in sub-Saharan Africa; little is known about factors associated with method uptake in this subpopulation. STUDY DESIGN: Four hundred women aged 18-24 years who sought short-acting hormonal contraception were offered an opportunity to use an implant instead. Cross-tabulations and logistic regression analysis were used to examine participant characteristics and other factors associated with choosing an implant. RESULTS: Twenty-four percent of participants chose the implant. Participants with greater than 4 years of contraceptive need were over three times more likely to choose an implant [odds ratio (OR), 3.4; 95% confidence interval (CI), 1.6-6.9]. Women with health concerns over short-acting hormonal methods (OR, 2.2; 95% CI, 1.3-3.6) and those who expressed some difficulty returning to a clinic (OR, 1.9; 95% CI, 1.1-3.1) were about twice as likely to choose an implant. Product attributes such as long-acting protection and convenience were cited reasons for choosing an implant. CONCLUSIONS: The implant appears to be an attractive option for a fairly large proportion of young women in Kenya. Within this age group of implant users, homogeneity of demographic characteristics relative to short-acting users suggests that the product has broad appeal.

The promise of affordable implants: is cost recovery possible in Kenya?

BACKGROUND: Contraceptive implants are one of the most effective methods of family planning but remain underutilized due to their relatively high upfront cost. The increasing availability of a low-cost implant may reduce financial barriers and increase uptake of implants. The commodity cost of Sino-implant (II) is approximately 60% less than two other widely available implants, and a direct service delivery cost of approximately US$12 makes it one of the most cost-effective methods available. This study was conducted to assess whether implant clients in Kenya are paying as much or more than the direct service delivery cost of Sino-implant (II). STUDY DESIGN: A study was conducted in 22 facilities throughout Kenya, including public (n=8), private for-profit (n=6) and private not-for-profit facilities (n=8). Interviews were conducted with a convenience sample of 293 current and returning implant clients after at least 6 months of product use. RESULTS: The median price for implant insertion paid by clients in the public, private for-profit and private not-for-profit sectors was US$1.30, US$13.30 and US$20.00, respectively. CONCLUSION: Patient fees in both private sectors allow for 100% recovery of the direct cost of providing Sino-implant (II). Currently in Kenya, all sectors can receive donated commodities free of charge; Sino-implant (II) has the potential to reduce reliance on donor-supplied implants and thereby improve contraceptive security.

Reaching providers is not enough to increase IUD use: a factorial experiment of 'academic detailing' in Kenya.

Although the IUD is an extremely effective and low-cost contraceptive method, its use has declined sharply in Kenya in the past 20 years. A study tested the effectiveness of an outreach intervention to family planning providers and community-based distribution (CBD) agents in promoting use of the IUD in western Kenya. Forty-five public health clinics were randomized to receive the intervention for providers only, for CBD agents only, for both providers and CBD agents, or no detailing at all. The intervention is based on pharmaceutical companies' "detailing" models and included education/motivation visits to providers and CBD programmes, as well as provision of educational and promotional materials. District health supervisors were given updates on contraceptives, including the IUD, and were trained in communication and message development prior to making their detailing visits. Detailing only modestly increased the provision of IUDs, and only when both providers and CBD agents were targeted. The two detailing visits do not appear sufficient to sustain the effect of the intervention or to address poor provider attitudes and lack of technical skills. The cost per 3.5 years of pregnancy protection was US$49.57 for the detailing intervention including the cost of the IUD, compared with US$15.19 for the commodity costs of the current standard of care--provision of the injectable contraceptive depot-medroxyprogesterone acetate (DMPA). The effectiveness of provider-based activities is amplified when concurrent demand creation activities are carried out. However, the cost of the detailing in comparison to the small number of IUDs inserted indicates that this intervention is not cost-effective.