COST EFFECTIVENESS ANALYSIS &
INFECTIONS AVERTED OF PMTCT SERVICES
BY COMMUNITY AND FACILITY
STRENGTHENING IN MASHONALAND
CENTRAL PROVINCE, ZIMBABWE
Ravikanthi Rapiti¹, Angela Mushavi2 , Ann Levine3, Julie Pulerwitz1 & Ibou Thior 3
1Population
Council, 2Zimbabwe Ministry of Health, 3 PATH
International AIDS Economic Network
19 July 2014
Melbourne, Australia
PMTCT in Zimbabwe
• In 2009
– Pregnant women attended ANC—54%1
– ANC HIV prevalence—16% (20% in Mashonaland
Central)
– MTCT rate—30%2
• Roll out of 2010 WHO Option A guidelines in 2011
• Health facilities required significant training and
mentoring to provide these newer, more complicated
regimens
• To increase uptake, communities, families and males
also needed to be engaged
1World
Health Organization. Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: towards
universal access. Available at: http://www.who.int/hiv/pub/mtct/antiretroviral2010/en/index.html Accessed 29 April 2013.
2UNAIDS
Global AIDS Response Progress Report, 2012: Zimbabwe Country Report. Available at:
http://www.unaids.org/en/dataanalysis/knowyourresponse/countryprogressreports/2012countries/ce_ZW_Narrative_Repo
rt.pdf. Accessed 29 April 2013.
Objectives
• Evaluation of the Arise PMTCT project implemented
in 21 sites in Mashonaland Province, Zimbabwe that
sought to address whether a strengthened PMTCT
package could improve:
– PMTCT coverage
– Outcomes
– Cost and cost effectiveness
• Could a paediatric infection be averted in <500USD
per infection?
Arise study sites
Project timeline (45 months)
Project
start up
Sept 2010
ARISE intervention
concludes
Baseline survey
Aug-Sept 2011
Sept
Aug-Sept
2010
2011
March 2014
2012
2013
April
2014
May
2014
ARISE intervention
initiated
End line
survey
Project
closure
Dec 2011
April 2014
May 2014
Components of intervention
• Facility level
–
–
–
–
Provision of point-of-care CD4 machines
Training & mentoring of providers
Strengthening completion of routine PMTCT registers
Strengthening links with central laboratory
• Community level
– Awareness campaigns, dramas
– Follow up with clients who missed scheduled visits in the
PMTCT cascade
– Sensitizing community leader & faith healers
– Establishing support groups
– Outreach and targeting of men
– Strengthening community and health facility linkages
Data sources for the evaluation
• Financial reports on expenditures for costing
• An activity-based costing approach
• Costing templates were developed
• Types of costs were defined
• Infections averted were calculated
• Sensitivity analysis was conducted
• Costing was determined
How many HIV infections were
averted over the intervention
period?
Estimating infant HIV infections averted
• Modeled estimates of infant HIV infections.
– Estimated number of HIV-exposed infants were
derived from the HIV prevalence rate times the
estimated number of live births per year in the
project catchment area.
– Validated data from routinely completed PMTCT
facility registers
Estimated number of infections averted
Lower Limit
Upper Limit
15,968
20,508
HIV prevalence in pregnant women (as proportion)
16%
20%
Total number of HIV+ pregnant women delivering
per year
2,554.9
4,101.6
# deliveries per year
Year 1
Year 2
Year 3
Year 4
(Quarter 1)
Total
Lower Limit
361
626
649
187
1,822
Upper Limit
580
1,005
1,041
300
2,925
What were the costs per infection
averted?
Describing costs
Type of cost
Cost category/cost items
Start up
Financial
(programmatic
costs defined as
DFATD funded
financial
expenditure used to
deliver the services
to beneficiaries)
Micro-planning,
developing
materials, training
& mentoring,
sensitization
Economic
(financial costs plus
the value of shared
project costs and
the value of all
donated goods and
services)
Start-up financial
costs value of all
donated goods
and services, and
of resources
already financed
to provide
comprehensive
care and
treatment
Recurrent
Health commodities &
storage/transport,
personnel, capital
(annualized), transport
& travel, office
facilities, admin, &
meetings
Data sources
Indirect
programmatic
costs
Cell phone &
communication
costs for nondirect staff, rent
& office bills,
office repairs &
upkeep
Project
expense
reports
(ZAPP, CHAI
& PC);
Facility data;
Ministry of
Finance;
Recurrent economic
Financial indirect MoH
costs and other shared programmatic
costs including HCW
costs plus that
costs and the
were shared with
laboratory and ARV
other programs,
health commodity costs including rent for
the CHAI office
Costing Period (2011–2013)
Cost category
DFATD upfront
financial
Start-up
233,555
Recurrent
363, 986
Indirect programmatic costs
58,014
Total costs (no indirect programmatic
costs)
867,120
Total costs (with indirect programmatic
costs)
655,555
Costing Period (2013-2014)
Cost category
DFATD upfront
financial
Start-up
34,500
Recurrent
235,079
Capital costs
21,443
Indirect programmatic costs
58,014
Total costs (no indirect programmatic costs)
291,022
Total costs (with indirect programmatic
costs)
349,036
Final Costing
• The front line costs for 2011–2013 included
both the facility and the community
intervention.
• The community intervention continued until
the end of the project (February 2014).
• The cost of infections averted during 2013–
2014 is a range between $ 537.81 and $
335.30 when the prevalence is varied
between 16 percent and 20 percent
respectively.
Conclusions
• This project demonstrated that a combined
community and health facility approach has
the potential to improve access and
retention across the PMTCT cascade.
• Community strategies on retention and male
involvement as well as cost data will be
important contributions as Zimbabwe now
moves to Option B+.
Conclusions (con’t)
• Use of routine real world programmatic data
for estimating infections averted is a
strength of this study.
• Even though a more efficacious PMTCT
program, Option A, costs more than previous
regimens, the cost of averting infections are
lower compared to lifetime treatment costs.
Considerations
• Lack of control facilities.
• Contributions of other stakeholders and
other donors to national and provincial level
efforts.
• Investments in infrastructure and human
capacity development will remain.
Acknowledgements
This presentation was produced under Arise—Enhancing HIV Prevention
Programs for At-Risk Populations, through financial support provided by the
Canadian Government through Foreign Affairs, Trade and Development
Canada, and via financial and technical support provided by PATH. Arise
implements innovative HIV prevention initiatives for vulnerable
communities, with a focus on determining cost-effectiveness through
rigorous evaluations.