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 FindingsRouth, 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 FindingsWHO 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 benefitsPrice, 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 FindingsMarseille, 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 CostsFP $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