Costing guidelines for HIV/aids intervention stretegies - PDF document

ADB - UNAIDS Study Series : Tool IFor use in estimating Resource Needs,the Asia/Pacific region This document is a collaborative work of the Asian Development Bank, UNAIDS, Futures GroupInternational and Ease International and forms a part of the training material used to cost pre-vention and care activities at local, country and regional level. Contributors (in alphabetical or-Reddy, Swarup Sarkar and John Stover. The primary spreadsheet INPUT for Nepal was pro-duced by Anita Alban and Michael Hahn; the regional version was developed by Vidya Ganesh,DCS Reddy and Shyam Sundar, editing and review by Adriana Gomez, Michael Hahn, TonyLisle, Rebecca Moss, Lee-Nah Hsu, Rober Greenner and Swarup Sarkar. Views expressed inthis document do not necessarily reflect the official position of UNAIDS and Asian Development© Joint United Nations Programme on HIV/AIDS (UNAIDS) & Asian Development BankAll rights reserved. This document, which is not a formal publication of UNAIDS and ADB, maybe freely reviewed, quoted, reproduced or translated, in part or full, provided the source isacknowledged. The document may not be sold or used in conjunction with commercial pur-poses without prior written approval of UNAIDS or ADB (please contact the UNAIDS InformationCentre, UNAIDS, Geneva or ADB, Manila). The views expressed in documents by named au-thors are the sole responsibility of those authors.The designations employed and the presentation of the material in this work do not imply theexpression of any opinion whatsoever on the part of UNAIDS or ADB concerning the legal statusof any country, testimony, city or area or of its authorities, or concerning the delimitation of itsfrontiers and boundaries.The mention of specific organisations, companies or of certain manufacturerÕs products doesnot imply endorsement or recommendation by UNAIDS or ADB in preference to others of asimilar nature that are not mentioned. Errors and omissions excepted, the names of proprietaryproducts are distinguished by initial capital letters.UNAIDS Information Centre, 20 AvenueInternet: http://www.unaids.org 6 ADB Avennue, Mendaluyong Cityhttp://www.adb.org Over half of the worldÕs population live in Asia and the Pacific. With widespread evidence of riskbehaviors and of situations that increase their vulnerability to HIV/AIDS, the potential for a signifi-cant worsening of the epidemic in the region is unmistakable. Furthermore[O1], most of theinterventions have achieved very low coverage or have been limited to implementation at projectThe major barrier for scaling up is resources, both financial and human. Even when sufficientesources are available, they are not optimally used. This document provides guidelines for theprioritization and strategic allocation of resources as well as helping with developing local costestimates for appropriate activities that are of particular relevance to Asia-Pacific, Middle East-ern and North African countries. It provides simple tools for program managers, planners andproject directors to generate local costing figures based on local data.The document complements global tools developed by other groups, like Resources NeedModel and GOALS.[O2] This tool is a result of several years of work and is based on experi-ences from Bangladesh, India and Nepal and has been field tested in Indonesia. It builds uponthe hard work of NGOs, program managers, and health planners. The tool has been success-fully used for large-scale resource mobilization, to develop national strategic plans, and for fi-nancial guidelines and preparation of GFATM proposals. I believe the tool can assist in nationalstrategic planning and in particular for achieving key principles for the coordination of nationalAIDS responses - the 'Three Ones': One agreed HIV/AIDS framework, one national AIDS au-encourage countries to use this along with other tools. We would also appreciate feedbackto enable us to introduce further improvements, as required, and to develop other relevant toolsAssociate Director For use in estimating Resource Needs,the Asia/Pacific region Introduction......................................................................................................................1I.Prioritising the target population(s)..............................................................................4II.Setting population-based targets...............................................................................7III.Choosing and designing intervention packages..........................................................9IV.Computing the costs of interventions.......................................................................11Estimating the total resource needs based on the sizeof the population......................................................................................................21VI.Examining the impact of the planned intervention on the..........................................24prevalence and incidence of HIV; re-allocate and re-examineAnnex......................................................................................................................28Common abbreviations 1 Costing Guidelines for HIV/AIDS Intervention Strategies This booklet provides assistance and guidance to planners and programme mana-cused on the overall goals to halt and reverse the epidemic. It provides the schemefor Rapid Costing Assessments (RCAs) including a spreadsheet (INPUT) for genera-Most countries in the Asia/Pacific region have completed the initial stages of a stra-tegic planning process and have developed a plan for a number of years. The nextpopulation-linked targets and interventions. In order to mobilise resources and to re-prioritise targets and interventions, overall resource needs have to be estimated. Inorder to do this strategic and operational plans must be costed; only then can pro-gramme managers ensure that sufficient resources are available to reach a coveragenecessary to impact upon the epidemic. This often means re-prioritising interven-tions and/or re-thinking the efficacy and cost-effectiveness of such activities.These costing guidelines concentrate mainly on the process of developing unit costsdemic in order to prioritise sub-populations is introduced. Once the target popula-tion is decided upon and its size estimated, the coverage required can be assessed,and appropriate interventions for behaviour change and/or service delivery designed.These interventions are based on international best practice, which include cost-effectiveness. The overall costing fig ures can be arrived at using unit costs. A simplespreadsheet tool, INPUT, is introduced to assist programme managers in computinglocal unit costs for a given set of interventions. The process used to arrive at unitcosts is the RCA, which estimates resource needs for specific sub-populations basedon defined interventions and population size targets. It compares local costs withthose documented in international literature, and uses local costs when inputtingFor a given set of programme targets the overall impact on HIV prevalence can thenbe calculated using the GOALS model (http://www.futuresgroup.com/goals model).The current and future estimates of HIV projections with the estimated disease bur-den are used in this model. These inputs are directly imported from the SPECTRUMsoftware that conventionally generates the estimates. Specific interventions can thenbe chosen for different sub-populations with projected coverage and known unitprevalence among the adult population. In cases where the goal to halt and/or re-verse the epidemic is not achieved, interventions can be re-considered and re-en-tered in to the model until a decline in HIV prevalence is observed. 2 Costing Guidelines for HIV/AIDS Intervention Strategies However, for each intervention, realistic goals must be defined. Both the human andfinancial resources available should be considered. This booklet aims to assist in theestimation of overall financial resource needs for scaled-up, effective responses atlocal level to halt the spread of the HIV/AIDS epidemic[S3].These costing guidelines are aimed at programme managers and planners with orwithout a background of health economics or public health. The guidelines:¥ describe considerations for targeting appropriate population groups: the target population(s)¥ consider coverage issues for an effective large-scale response: targets for reaching a specific sub-populationeffective intervention packages and activities for the target population(s)¥ explain the use of spreadsheet(s) to ¥ use primary (local unit costs) and secondary data sources on costs (in absence ofestimating the total resource needs based¥ introduce different methods including use of the GOALS model for optimising thestrategic allocation of resources: on the prevalence and incidence of HIV; re-allocate and re-examine 3 Costing Guidelines for HIV/AIDS Intervention Strategies Figure 1. Step-by-step costing 4 Costing Guidelines for HIV/AIDS Intervention Strategies I. PRIORITISING THE TARGET POPULATION(S) In some countries local epidemics have been triggered by nosocomial infections and unsafe blood products. In low-prevalence countries the HIV epidemic is mostly limited to high-risk populationsThese groups are often hard to reach and/or criminalised due to socialstigma, factors which add to their vulnerability. The interventions required and thecomplexities of reaching the groups differ, as do the costs. As the epidemic ad-vances, it spreads to bridge populations (clients of SWs, partners of IDUs, migrant/mobile populations etc.) who continue its spread to the general population. As thevirus spreads from one group to another, the size and the composition of the popu-lation to be targeted for prevention and care changes, increasing the resources neededto address the epidemic effectively.Figure 2. Targeting the population Countries are classified into three epidemiological categories by the risk characteris-tics of predominantly-affected population groups and their HIV prevalence (Table 1).planners and programme managers to make strategic decisions. Table 1. Epidemiological categories 5 Costing Guidelines for HIV/AIDS Intervention Strategies Although sub-populations are focused on here, certain basic interventions (e.g. policy, safe blood supply, surveillance, raising of awarenessThe majority of countries in the Asia/Pacific region show low or concentrated levelsof the HIV epidemic on a national scale. Only Thailand and Cambodia are experienc-ing generalised epidemics. A national classification often masks the real picture atlocal level; an overall low-prevalence country may have concentrated and general-ised epidemics in certain locations that need to be addressed accordingly. The aimof planners and programme managers in countries with low - or concentrated epi-bring the prevalence below five percent in high-risk groups, andThe intent in countries already experiencing generalised epidemics is to halt andeverse the spread.Unfortunately, there is no standard answer to this much-debated question; a popu-lation is not a homogeneous group with uniform patterns of behaviour. It consists ofa number of small groups or sub-populations, each with its own culture, norms andbehavioural patterns. Accepting that in principle the whole population is at risk andthat there is no clear delineation between high-risk groups and the general popula-tion (e.g. SWs are part of the general population) the risk of being infected with HIVis higher for some sub-populations than for others. Due to limited resources, bothAs the HIV epidemic follows a predictable path - from high-risk/vulnerable groups(sub-groups with a higher risk of HIV infection) via bridge populations to the generalpopulation (the group with relatively lower risk of HIV infection) interventions andtargeted sub-populations will vary. Focusing interventions on recognised risk/vulner-able groups, before HIV gains a strong foothold, prevents and slows down the spreadInterventions should aim to cover all high-risk groups in order tocontain the spread to groups at relatively lower risk, i.e. the general population. Figure 3. Patterns of HIV showing low and concentrated epidemics in majority Asia/Pacific countriesSource: UNAIDS July 2002, Report of the Global HIV/AIDS epidemic 6 Costing Guidelines for HIV/AIDS Intervention Strategies able 2. Population sub-groups and programme goals Source: UNAIDS. 2001. Based on "Effective prevention strategies in low HIV prevalence settings", Arlington: Family Health InterPrevalence inProgramme goals Affected populationaffected groups sub-groupsHalt progress of epidemic,groupsHalt and reverse progress,these groupsHalt and reverse progress, 7 Costing Guidelines for HIV/AIDS Intervention Strategies Setting targets for prevention coverageinfections) unless a critical mass of people change their behaviour. In other diseasesA wider population needs to be reached with effective behaviour change interven-tions, as not all of those targeted will change their behaviour. Unfortunately there isno standard ratio of people reached, to people who change their behaviour. Also,the effect of behaviour change intervention varies widely in intensity, effort and qual-Although the question of how many people need to change their behaviour before animpact on the epidemic is significant, for planning and costing purposes the reach ismore important. In order to trigger behaviour change, as many people as possibleneed to be reached in a specific population sub-group with quality interventions. There-fore, initially total coverage (reach) and behaviour change of an entire population willbe planned for. Later, when a more detailed picture is available as to the percentage ofthe sub-population reached actually changes their behaviour, the planning figures canbe adapted accordingly. When planners are faced with resource constraints (bothhuman resources as regards implementation capacity, and/or financial resources) pro-grammes should be phased in with increasing levels of coverage. For planning pur-percent of the sub-population in which behaviour change should occur.The normative approach, based on data shown in Fig. 4a (next page), is another prac-have used a 60 percentpurposes. This is based on historical data including Cambodia among others wherepre-intervention HIV prevalence among SWs was 42-57 percent. This figure started toSWs) exceeded 50 percent of the population. Still, for costing purposes the reach hadto be calculated, which was 10-20 percent higher than the behaviour change target.(target for coverage). Reliable historical data on coverage and incidence or preva-lence (if available) can be plotted to identify critical coverage levels. If prevalencedata are available the incidence can be estimated with SPECTRUM. Alternatively,these can be worked out using tools: e.g. HIV Tools developed by the London Schoolof Hygiene and Tropical Medicine (http://www.hivtools.lshtm.ac.uk). However it ispreferable to use local data in this model; if local data is not available, results fromIn Bangladesh it was found that HIV prevalence among SWs could be maintainedbelow five percent (from a baseline of less than one percent) if behaviour change(consistent condom use) was achieved among two thirds of the group.ting targets, planners and programme managers should remember that maintainingprevalence below five percent in high-risk groups is the overall goal of HIV/AIDSintervention programmes. World Bank.2000. The Project Appraisal Document for India. Washington DC: World Bank. Samsuddin A K M. 2000 Towards an expanded HIV/AIDS Response in Bangladesh-Protecting the Future. Presentation at NationalStrategic Planning Meeting. Dhaka by Dr. A.K.M. Shamsuddin, Programme Manager, National AIDS/STD Prog. Deputy Dir., PHC, Govt o II. SETTING POPULATION-BASED TARGETS 8 Costing Guidelines for HIV/AIDS Intervention Strategies Figure 4b. Modelling example showing HIV remaining (2/3rd coverage)Source: Dr. Samsuddin, National AIDS Programme Manager, Bangladesh 2000: Presentation at National Strategic Planning Meeting, D interventionSex worker afterinterventionClient withoutinterventionClient afterintervention Figure 4a. BSS and HIV sero-surveillance data, Cambodia demonstrating a clear correlationSource: Based on NCHADS. 2002. HIV Sentinel Surveillance: Presentation by Dr Tia Phalla at the disemmination meeting of HIV sur 010304050608090Year 1997199819992000 2001 9 Costing Guidelines for HIV/AIDS Intervention Strategies III. CHOOSING AND DESIGNING INTERVENTION PACKAGES When services or awareness campaigns are delivered and carried out outside institutional settings, such as clinics and educatiinstitutions, they are called ÔoutreachÕ activities. These activities need to be undertaken at beneficiariesÕ convenience. A Ôpfrom the same group or category as another; therefore, a sex worker (SW) may work as a ÔpeerÕ educator (PE) for SW-interventionstudent as a PE for another student. Peer norms and peer pressure are the most influential vehicles for behaviour change. In order to achieve specific outcomes, sets of activities need to be implemented. Inthese sets of activities are often either behaviour change, access to quality serviceslike sexually-transmitted disease (STD) treatment and voluntary counseling and test-ing (VCT), or raising awareness to a certain level, e.g. correct knowledge about HIV/AIDS. These packages can be designed for different sub-populations and/or out-This approach allows for the design and costing of prevention intervention packagesple) or delivering care services like ART or PMTCT etc. Usually, the activities in aspecific intervention package can be grouped around five main elements:1.Behaviour change communication (including outreach and peer-outreach ac-2.Delivery of tools (commodities) and services for prevention (needles and sy-and treatment of STDs for specific sub-populations) and care (testing,counseling, ART, treatment of OIs)3.Creation of an enabling environment at project level4.Programme management5.Monitoring and evaluation at project levelExamples of activities for each of these elements are presented in detail in Table 3,p12. A specific outcome often requires different intervention packages for a numberof sub-populations, and as the costs of activities vary, the costs of a specific out-come often vary for different groups; e.g. the costs of facility-based STD services forthe general population may be completely different to the costs of delivering STDSWs and the MSM population are marginalised, they may not attend clinics for theneeds. Therefore, when assessing the resource needs in prevention and care inter-ventions, cost considerations relevant to the target populations should be taken intoAn alternative approach is to cost the activities directly, irrespective of the sub-popu-lation they are targeted at. Costs pertaining to population-specific additional inputs(e.g. costs accruing on account of multiple visits by a peer-educator [PE] to educateat the beneficiaryÕs convenience) are overlooked when this approach is used. A list ofdirectly costed activities used in the Resource Needs model and the GOALS modelis given on page 21. Interventions can be identified and adopted from this list forcosting sub-population-specific programmes, with due corrections for sub-popula- 10 Costing Guidelines for HIV/AIDS Intervention Strategies VCT and PMTCT are undoubtedly effective prevention interventions. However, in this document, these are discussed under care beboth need finally referral to care and support systems. Although TB is an OI, it is listed as a separate item because it is the most common OI in the Asia/Pacific region. Interventions are discussed for prevention of HIV/AIDS among the following- Needle/syringe programmes¥ Young people (life skills and awareness programmes)Interventions related to care are discussed for the following:¥ Voluntary counseling and testing (VCT)¥ Mother-to-child transmission (MTCT)¥ Care and Support (includes the following)¥ Palliative care¥ Opportunistic infection (OI) treatment¥ TB treatment¥ OI prophylaxis¥ HAART, including laboratory monitoringered when costing. A list of sub-activities for each intervention is provided in theAnnex, p25-37. Interventions to alleviate impact like programs for orphans are nottions (policy, blood safety, military and police, mass media) is captured in a work-book named 'other interventions' in the INPUT spreadsheet. 11 Costing Guidelines for HIV/AIDS Intervention Strategies IV. COMPUTING THE COSTS OF INTERVENTIONS These are not fixed guidelines or normative packages. In each country the necessary interventions and the INPUT spreadsheet ardeveloped to fit local needs and resources. INPUT can be modified to local needs easily without the need for IT specialists. This is simple provided some general principles are applied. The following para-Unit costs are the total costs divided by the output measure. For example if US$100,000 are spent in one year on SW-interventions and 1,000 SWs are reachedwith these interventions, the unit costs are US $100 (per SW, per year). The outputmeasures can be the number of people reached, condoms distributed, patientstreated etc. Unit costing tries to estimate the costs needed per intervention and is forplanning purposes only. Unit costs are average figures, including assumptions ofcoverage and cannot replace a project budget; but for resource need estimation andallocation purposes they are accurate and easy to compute.Economic costing vs. programme costingEconomic costing tries to cover all cost elements including the costs of free items.Programme costing covers only those costs that are met by the programme. Ineconomic terms free items do not exist, as everything has a price; e.g. in economiccostings, the full price for condoms would be included, even if the condoms areprovided free to the programme because somebody pays for them. Airtime costswould also be included in full economic costings. Although in actual terms the air-time may be provided free, it still has a price. This is especially important whencomparing unit costs of specific interventions; be careful not to compare full eco-nomic unit costs with programme costs. Unfortunately the method often used forcosting is not part of the information on unit costs, which makes the two very difficultto compare. The method used here and in the following models is economic cost-Normally, single activities do not exist. Even a straightforward activity like handingout a leaflet in the street, is composed of a set of activities and cost elements (sala-ries, printing, transport etc.). More complex interventions like delivery of HAART re-quire a larger sub-set of activities to be carried out as well as essential resources inorder to achieve behaviour change (e.g. training, supervision, salaries, addressingstigma and discrimination) and quality of services (e.g. ensuring proper adherenceto drug regimens, and necessary support systems). Planners and programme man-e.g. peer-educators (PEs) for outreach, supervisors, condoms, STI services, an ena-bling environment at local level, training materials, programme management etc.pages list examples of such packages that have been used in different countries inthe Asia/Pacific region, and a simple spreadsheet for calculating unit costs. 12 Costing Guidelines for HIV/AIDS Intervention Strategies Using the INPUT spreadsheet to estimate unit costsThe INPUT spreadsheet calculates unit costs for common HIV/AIDS interventions,using the prevailing local costs in a particular country. Its purpose is to generateelevant and realistic unit costs for use in costing national plans. It is based on coun-try-level experiences in the Asia/Pacific region and has been successfully used incosting HIV/AIDS plans by a number of countries in the region. INPUT is a workbookwith several worksheets: the first three sheets contain information on local currencyand its US dollar equivalent; converge target and summary of resource needs; theemaining nine sheets are designed to calculate unit costs for each individual inter-ventions. They deal with both prevention and care and support .Under the section on prevention there are six intervention modules covering SWs,MSM, IDUs (harm reduction and oral substitution), migrant and mobile populationsand young people (including life skills development and awareness generation). Mostmunication (BCC), prevention tools and supplies, enabling environment, programmeBehaviour change interventions are based on peer-outreach strategies. The under-lying assumption is that behaviour change is more than mere awareness and re-quires reinforcement of a message by repeated interaction through peer-outreachnetworks, group education (IEC/events), availability of prevention tools (commodi-ties) and easy access to services. If availability of prevention tools (e.g. condoms,lubricants, needles and syringes) or access to services (e.g. treatment of STDs for allrisk populations) and substitution therapy (e.g. methadone and Buprenophine forIDUs) is poor, awareness rarely leads to behaviour change.In the absence of a supportive environment, the target population may not acceptthe services offered. Also local people may be hostile to the target population (e.g.needle use or outreach programmes) that promote these activities. Therefore, con-making at each stage of project implementation are essential.Project activities also include management costs of employing and capacity-build-ing of NGO staff. Establishment of service facilities through these networks is neces-sary because often public services do not exist or are rarely accessed by high-riskgroups, mobile populations and young people. Lastly, monitoring at project level isessential for making revisions as and when necessary and for the project as a whole.tions, which form the basis for the INPUT spreadsheet, are summarised in Table 3below. Intervention programmes for young people in most of the Asia/Pacific countries are based on raising awareness only. Life skillprogrammes are limited. Youth-friendly services are still not in place and therefore could no be costed. 13 Costing Guidelines for HIV/AIDS Intervention Strategies Major activities Sub-activityFrequency/qualityProvision of servicesCreation of enablingenvironment (mainly atproject site)Project management andOutreach activitiesCommunity reinforcement ofIDUs (methadone, Buprenorphine)Delivery of prevention toolsProvision of needles/syringes (IDUs)strengthen and support commu-egarding HIV/AIDS programmes.(addressing needs, involvement indecision-making of all project activities)Elements: recruitment, recurringcosts, and recruitment of staff,setting up of project office,Continued measurement ofstaff and PEs for regular revisionof programmeBi-weekly Once every three monthsfrequency of education (should be high ifthe group is marginalised, hidden or hardto reach) IEC (group education)- once aMainstream services are not user-friendlyand therefore specialist STD services (STDphysicians/nurses) or drug treatmentcentres are planned (ongoing) Local dataneedle and syringe programmes (preva-of clients/day, and number of injections ofIDUs are usually used)Identification of local power structures,and order personnel, advocacy: localleaders, power holders and law/orderpersonnel at regular intervals (once aand group formation, addressing com-depreciated over timemid-term and three-yearly evaluations able 3. INPUT activities and principles The mode of delivery of these services varies according to the type of population; the more marginalised andillegal its practices a population is, the more limited mass education and group education becomes. To com-pensate for this peer education and its frequency increases. Instead of mainstream service delivery for STDs,special clinics are often required. Depending on the settings most marginalised sub-populations are SWs,IDUs and MSMs; young people are the least marginalised and migrant and mobile populations are usuallyHow the table above translates into spreadsheets to calculate unit costs is demonstrated below using the exam-ple of sex workers. The spreadsheet was developed for and tested in Nepal in August 2002 and revised inJanuary 2004. The tool is flexible and can be applied to other settings in the region. In this example NRs indicateNepalee Rupees as the local cuurency which can be changed to the respective currency of each country in theINPUT spreadsheet. 14 Costing Guidelines for HIV/AIDS Intervention Strategies Spreadsheet structureThe spreadsheets contain simple calculation modules for the different essential ele-ments of each intervention. They refer to BCC (e.g. training, remuneration of PE,etc.) commodities and services, enabling environments, programme managementcosts of individual elements e.g. training, condom supplies, STI services, or staff costs.A change in one of the input fields automatically re-calculates the overall costing;elatively minor changes in peer educator remuneration for example will show anProgramme elementsThe essential package of SW-intervention consists of peer-education, supervisiondistribution, creation of enabling environments, programme management, and moni-ApproachAs shown in Table 3 above, each intervention has a number of activities. For exam-ple, activities directed at behaviour change usually comprise IEC activities, PE (in-cluding training) and outreach activities. The planning and costing of each has toconsider various issues such as the number of PEs required, their training/re-trainingconditions and the price and salary structures in a country or region. It is this hetero-geneity that underscores the need for computing local cost inputs to arrive at moreealistic estimations of resource needs.Figure 6. INPUT spreadsheet (sex workers) Cost componentNRsUSD%Training of PE122,8001,5744PE/SW ratioPE/dayPE neededTotal PEUS$PE renumeration520,0006,66717155067520,0006,667Outreach worker/SV720,0009,23123 Each PE is expected to spend 3days/week to interact with peer s Outreach/DIC150,0001,9235ParticipantsTrainersDays/yearParticipants/courseIEC/events15,0001920672220Commodities&ServicesTraining Coursepp/dTraining/yearTotal yearUS$$/pp/courseCondoms748,8009,60024food/refreshments20027,467122,8001,57424STI Services186,2502,3886material20013,333Enabling environment77,0009872trainer per day1,00013,333Programme Management400,0005,12813 y 25068,667 s Investments28,0003591OWRenum/monthOW/PE ratiototal OWUS$M+E (5%)146,9931,8855Staff512,00013720,0009,231TOTAL3,114,84339,934NRsUS$UNIT3,11540 r 150,0001,923UNIT w/o condoms2,36 6 3 0 NRsUS$ r 15,000192clients/dworking dayscond use %ex. suppl. %cost/c $Condoms needed400,0005080200.02Excess suppl y 80,000NRsUS$Condoms total480,000748,8009,600StaffUnitsSalary/monthtot/monthdoctor135,000NRsUS$nurse118,00077,000987assistant10NRsUS$Time/patient (minutes)30400,0005,128drugs per treatment300US$Deprec.YearsInvest/yearUS$ A ssumed STI prev. %20140,0001,795528,000359Assumed STI/SW/year2STI treatments/year400NRsUS$4666186,2502,388 cost per year (Larger version on next page) 15 Costing Guidelines for HIV/AIDS Intervention Strategies Cost componentNRsUSD%Training of PE122,8001,5744PE/SW ratioPE/dayPE neededTotal PEUS$PE renumeration520,0006,66717155067520,0006,667Outreach worker/SV720,0009,23123 Each PE is expected to spend 3days/week to interact with peer s Outreach/DIC150,0001,9235ParticipantsTrainersDays/yearParticipants/courseIEC/events15,0001920672220Commodities&ServicesTraining Coursepp/dTraining/yearTotal yearUS$$/pp/courseCondoms748,8009,60024food/refreshments20027,467122,8001,57424STI Services186,2502,3886material20013,333Enabling environment77,0009872trainer per day1,00013,333Programme Management400,0005,12813 y 25068,667 s Investments28,0003591OWRenum/monthOW/PE ratiototal OWUS$M+E (5%)146,9931,8855Staff512,00013720,0009,231TOTAL3,114,84339,934NRsUS$UNIT3,11540 r 150,0001,923UNIT w/o condoms2,36 6 3 0 NRsUS$ r 15,000192clients/dworking dayscond use %ex. suppl. %cost/c $Condoms needed400,0005080200.02Excess suppl y 80,000NRsUS$Condoms total480,000748,8009,600StaffUnitsSalary/monthtot/monthdoctor135,000NRsUS$nurse118,00077,000987assistant10NRsUS$Time/patient (minutes)30400,0005,128drugs per treatment300US$Deprec.YearsInvest/yearUS$ A ssumed STI prev. %20140,0001,795528,000359Assumed STI/SW/year2STI treatments/year400NRsUS$4666186,2502,388 cost per year Figure 6. (Enlarged) INPUT spr 16 Costing Guidelines for HIV/AIDS Intervention Strategies Figure 7. Input for BCCariables to be entered:1. Targeted SWs(columnn A, row 3): It is not necessary to input an exact number to calculate unitaverage unit costs. Smaller numbers would increase i.e. programme management,training and supervision costs, higher numbers would under-estimate the cost oftraining, investments and management. It may be worthwhile to calculate smallereach for certain project sites, and a higher number for others. In this way a range ofunit costs can be established which can then be applied accordingly. Most impor-tant point, however, is to adjust the number of peer educators required for reachingthe target sex worker population on a regular basis. PE to SW ratio (columnn B, row 6): Define the PE to SW ratio, which dependswould be responsible for peer education and behaviour change communica-tion (BCC) of ten or 20 SWs on a regular basis. This will automatically generatethe number of PEs needed (columnn D, row 6) by dividing the target SWsPE/day (columnn C, row 6): Input the proposed daily remuneration for a PE asthey are usually part-time workers (one principle is to compensate for loss ofearnings during time spent on the project if they would have worked) PE/SW ratioPE/dayPE neededTotal PEUS$155067520,0006,667 Each PE is expected to spend 3days/week to interact with peer s ParticipantsTrainersDays/yearParticipants/course672220Training Coursepp/dTraining/yearTotal yearUS$$/pp/cours e food/refreshments20027,467122,8001,57424material20013,333trainer per day1,00013,333 y 25068,667 s OWRenum/monthOW/PE ratiototal OWUS$Staff512,00013720,0009,231NRsUS$ r 150,0001,923NRsUS$ r 15,000192 17 Costing Guidelines for HIV/AIDS Intervention Strategies PE days/week (column C, row 7): Input the number of days a PE is expectedto "work" per week. This is essential for calculating the total remuneration forPEs (see column E, row 6 for local currency, and column F, row 6 for US$). Determine the number of trainers required to organise a training course forone batch of PEs and enter in column D, row 9.Determine the number of days required to complete one course of PE trainingon the basis of the curriculum and contents and enter in column D, row 9 (ifefresher trainings are planned, add up the total number of days per year andDetermine the number of PEs that can be accommodated in a group depend-ing on the local circumstances (column E, row 9). It is appropriate to organisetraining programmes for small groups to ensure effective communication, usu-Enter training-related costs (column B, row 11 to 14): food and refreshmentper participant/day, training materials per participant/course, fee of trainer perday, and daily allowance paid to participants. Cost of accommodation perin local currency, in column E, row 11 in US$, and costs per participant percourse in US$ in column F, row 11. It is assumed that OWs are NGO staff and supervise and guide the work of peer-educators. They support PEs in planning daily peer outreach work, help in recordkeeping, ensure PE safety, negotiate and advocate with local power structuresand standardise the peer education content and methods of communication.Enter the number of OWs required in column B, row 16. (a OW/PE ratio iscalculated in column D, row 16 for reference. Usually a OW can supervise/Enter the monthly salaries of OWs (column C, row 16). (The total resourceneeds for OW per year are calculated in local currency (column E, row 16),and in US$ (column F, row 16) each work and/or dr op-in centr Enter (column B, row 18) either the transport costs per year, or the runningcosts of a drop-in centre per year (excluding the staff costs), or both which-ever is relevant. PEs do not usually incur transport costs as they are usuallyfrom the same place of peer education activity; NGO outreach workers doincur transport costs. Drop-in centres (DICs) are safe places for the targetpopulation: they can gather and talk among themselves without fear. DICscan be used for group education, peer education or both and sometimes also 18 Costing Guidelines for HIV/AIDS Intervention Strategies (v) Enter (column B, row 20) the costs for the entire year of IEC material and/orEvents include participation in World AIDS Day, International WomenÕs Day and other clients/dworking dayscond use %ex. suppl. %cost/c $Condoms needed400,0005080200.02Excess suppl y 80,000NRsUS$Condoms total480,000748,8009,600StaffUnitsSalary/monthtot/monthdoctor135,000NRsUS$nurse118,00077,000987assistant10NRsUS$Time/patient (minutes)30400,0005,128drugs per treatment300US$Deprec.YearsInvest/yearUS$ A ssumed STI prev. %20140,0001,795528,000359Assumed STI/SW/year2STI treatments/year400NRsUS$4666186,2502,388 cost per year Figure 8: Input for commodities and services, enabling environment, program management and3. Preventive tools and services Enter the average number of clients per SW/day in column B, row 23. Thisfigure should be obtained from local studies.per year in column C, row 23. This figure should be obtained from local stud-ies. If this is not available use the default value given on the spreadsheet.Enter the percentage of SWs using condoms consistently (column D, row 23).This information should be taken from research or programme data availablein the country. If this is not available use a Enter the buffer stocks of condoms you would like to procure as a percentageof the total assessed requirement for the year (column E, row 23).Enter the cost per condom in US dollars (column F, row 23).The total requirements are calculated for the number of condoms needed, excesssupply, the total number of condoms and the respective costs generated in columnsG to J, and rows 22 to 24. Enter the number of each category of staff, such as doctors, nurses, laboratorytechnicians etc. required to deliver STI services in column B, row 26 to 28).Enter the monthly salaries for each category of staff in column C, row 26 to 28.Enter the average time needed (in minutes) to examine and treat a patient(column B, row 29)Enter the average cost of drugs for managing one STI episode, preferablybased on syndromic management (column B, row 30). 19 Costing Guidelines for HIV/AIDS Intervention Strategies clients/dworking dayscond use %ex. suppl. %cost/c $Condoms needed400,0005080200.02Excess suppl y 80,000NRsUS$Condoms total480,000748,8009,600StaffUnitsSalary/monthtot/monthdoctor135,000NRsUS$nurse118,00077,000987assistant10NRsUS$Time/patient (minutes)30400,0005,128drugs per treatment300US$Deprec.YearsInvest/yearUS$ A ssumed STI prev. %20140,0001,795528,000359Assumed STI/SW/year2STI treatments/year400NRsUS$4666186,2502,388 cost per year Enter the STI prevalence among the target group(column B, row 31). Enter local figures if availableyear (column B, row 32), or use an average ofCalculated fields show the expected number of STI treat-ments per year (column B, row 33), costs per treat-ment (column C, D, and row 34), and total costs perumn C and D, row 35).4. Enter the costs of creating an enablingenvironment as a total for one year(column I, row 27). The costs of this intervention coverstwo types of activities: The first group of activities isdirected towards the power groups and community andincludes mapping the local power structures, conduct-ing key informant interviews, baseline surveys and regu-and people in power. This includes regular meetingswith such people individually and in groups for advo-cacy, trouble shooting with law and order officials etc.The second group of activities is directed at the targetdren and families, education, etc.5. Enter the costs for programme management(such as core staff, running costs of office etc.) for oneyear (column I, row 29).6. If investments are needed(goods that last more than one year) enter the total (col-umn G, row 31), and the number of years for deprecia-tion (normally five) in column I, row 31. Calculated incolumn J and K, row 31 is the amount of the total in-one year.Figure 8: (Enlarged) Input for commodities and services, enabling environment, program management and investment 20 Costing Guidelines for HIV/AIDS Intervention Strategies Costing here is done as economic costs. Costs taken from elsewhere (e.g. con-doms, drugs for STI treatment) should not be included when calculating programmecosts. In order to compare, the full economic costs should be calculated first, andonly when these have been arrived at should the programme costs be calculated.STI treatment is provided as syndromic case management. A referral rate of 10percent is assumed for further testing and treatment, but not costed in the SW pack-percent of the overall activity costs but this can be changed according to local needs.Figure 9. Summary of unit costs Cost componentNRsUSD%Training of PE122,8001,5744PE renumeration520,0006,66717Outreach worker/SV720,0009,23123Outreach/DIC150,0001,9235IEC/events15,0001920Condoms748,8009,60024STI Services186,2502,3886Enabling environment77,0009872Programme Management400,0005,12813Investments28,0003591M+E (5%)146,9931,8855TOTAL3,114,84339,934UNIT3,11540 The unit costs derived from this approach can be compared with global references,as well those obtained from other spreadsheets such as the RNM.In this example, 23 percent ofOW staff, 17 percent forpercent on condoms and sixpercent on STIs. Projectcosts are approximately 13percent and five percentespectively. 21 Costing Guidelines for HIV/AIDS Intervention Strategies ESTIMATING THE TOTAL RESOURCE NEEDS BASED ON SIZE OF POPULATIONBelow is an estimation of total resource needs based on coverage targets fixed fordifferent sub-populations, and unit costs derived from the INPUT spreadsheet. Thisexample is taken from Indonesia. The percentages of (sub-) populations to be tar-geted were decided upon first; these percentages were then translated into num-bers based on the sizes of sub-populations from previous studies. The unit costswere then multiplied by the number of the population to be targeted in order to arriveat the final figures. In an early stage of the epidemic, Indonesia targeted 80 percentof the high-risk population. Local unit costs (prevention) were based on the five ele- Prisoners10020406080100MTCT801020405080OIs802050607080RVs802050607080Other care802050607080 or activityFinal Yr2345SWs802050607080IDUs802050607080802050607080PopulationYear PopulationTotal pop. SWs100,00020,00050,00060,00070,00080,000IDUs100,00020,00050,00060,00070,00080,000MSM 12,0002,4006,0007,2008,4009,600Prisoners 74,00014,80029,60044,40059,20074,000MTCT2,984902244976811,492OIs19,1001001,0003,0005,00010,000ARVs19,1001001,0003,0005,00010,000Other care19,1001001,0003,0005,00010,000 Prisoners MTCTOIsARVsOther care90.10143.0090.106.8035.00300.00600.0075.001,801,9502,852,131216,234100,0003,13930,00060,0007,5004,504,8747,130,327540,585200,0007,843300,0006,000,00075,0005,405,8498,556,392648,702300,00017,384900,0001,800,000225,0006,306,8249,982,458756,819400,00023,8521,500,0003,000,000375,0007,207,79911,408,523864,936500,00052,2193,0006,000,000750,00025,227,29639,929,8313,027,2751,500,000104,4385,730,00011,460,0001,432,500 Cost/yr perperson ($)Population/ActivityYear of Programming5 Figures 9a. Steps of computation of cost for major activities in Indonesia, 2003Figures 9b. Steps of computation of cost for major activities in Indonesia, 2003Figures 9c. Steps of computation of cost for major activities in Indonesia, 2003 22 Costing Guidelines for HIV/AIDS Intervention Strategies Figure 10. Distribution of costs according to intervention: Final year,For IndonesiaÕs population of 240 million, 30 million US dollars was calculated as theannual programme requirement (32 percent for care; 68 percent for prevention) cov-ering 80 percent of the high-risk population and 50 percent of those eligible for ARV.This figure does not include the costs of policy, surveillance, management, bloodsafety, youth interventions or awareness programmes.Currently, population sizes of different risk groups are used to estimate the numberof HIV and AIDS cases in a particular country. Country-specific data is available fromthe national experts involved in projection.While INPUT provides a tool for developing local costs and estimating resource needsfor major HIV/AIDS prevention and care of a country, it does not cover all the aspectsof a comprehensive response of a national strategic plan, which should include policy,capacity-building, advocacy, mass awareness programmes, blood safety, nationalused to provide additional data in order to compare country data with other coun-tries of the region, as well as figures generated globally using the RNM.UNAIDS.2003.EPP spreadsheets. Geneva: UNAIDS (unpublished data) Source: Ministry of Health, GOI 2003: costing for GFATM, 3rd round. (unpublished data). Other Care 2%SW 24%IDU 36%OI 10%MTCT 0%VCT 3%Prisoner 2%MSM 3% 23 Costing Guidelines for HIV/AIDS Intervention Strategies Harm reduction programmesImproving STI managementPublic and commercialsector condom provisionPrevention of mother-to-Care and treatment modelsPalliative careDiagnostic HIV-testingOI prophylaxis inHAART and its associatedOrphanage care There are three RNM worksheets: coverage targets, key inputs and unit costs, which should all be compared withdata generated from INPUT. The major RNM intervention activities are given in the left-hand columnn of Table 5.It is useful to compare the costs of these with locally calculated figures which are provided as defaults in the RNMUnit costCoverage targetsTotal costPrevention modelsAsia (RNM)NationalUNGASSNational 24 Costing Guidelines for HIV/AIDS Intervention Strategies The impact of the planned activities in terms of incidence and prevalence of HIV canbe examined by using the GOALS model. The GOALS model requires the allocatedbudget for different interventions to be entered into a spreadsheet. It then calculatescoverage based on unit costs and resource allocation automatically. This coverageis translated into impact in terms of prevalence and reduction of incidence, if any.VI. EXAMINING IMPACT AND OPTIMISING RESOURCE ALLOCATION GoalsModel for HIV/AIDS Resource Allocation : Relating expenditures to goals for prevention and careBudgetCoverageCapacity BuildingSupportive policy environmentPolicy$%Human rights$%Political supportStigma$%obilization$%mmunity involvementMass media$%Behavior changeHigh riskMedium riskLow riskMSMIDUBehavior changeuseSTI treatmentNumber artnersAge at first sexUnsafe injectionsVCT$%Social marketing$%Vulnerable populationsCSW$%MSM$%IDU$%outh: in-school$%34330.3outh: out-of-school$%34330.3Service deliveryBlood safety$%ondoms$%STI treatment$%1422place programs$%PMTCT$%Care and treatmentPalliative care$%eatment of OIs$%Prophylaxis of OIs$%AART$%uberculosis$%Mitigationphanage care$%Community support for OVC$%School support for orphans$%Program supportManagement and coordination$%Monitoring and evaluation$%Research$ Coverage0%20%40%60%80%100%HAARTProphylaxis of OIsTreatment of OIslliative careSTI treatmentBloodPMTCT HIV Prevalence : 15-49 Year Olds10%12%14%199520002005 anNo change If the results do not meet the expected reduction in incidence and prevalence, differ-ent combinations of resource allocation should be attempted (re-prioritisation). Ad-ditionally, the GOALS model also allows areas to be identified in which a resourceeduction does not influence the desired reduction in prevalence and incidence. Figure 11. The GOALS model for HIV/AIDS resource allocation: relating expenditures to impact 25 Costing Guidelines for HIV/AIDS Intervention Strategies UNAIDS. 2000. Best Practice Collection Module 4, Guide to the strategic planning process for a national response to HIV/AIDS. UNAIDS. Available at http:// www. unaids.org /publications /documents/responses/national/una0021e.pdf Creese A, Floyd K, Alban A, Guinness L 2002. Cost effectiveness of HIV/AIDS interventions in Africa: a review of the evidenceLancet, Vol. 305:1635-1642. Kumaranayake L, Watts C, Vickerman P et al UNAIDS 2000: The cost-effectiveness of HIV preventive measures among injecting drug Guinness L, Watts C, Azim T et al. 2003:Modelling the impact and cost effectiveness of CARE SHAKTI : an HIV intervention progrInjecting drug users and sex workers in Bangladesh. London: Watts C , LSHTM. (Personal communication). Stover J, Garnett G P, Seitz S, Forsythe S. 2002. The epidemiological impact of an HIV/AIDS vaccine in developing countries. WDC: World Bank. As already stated, resources are invariably limited in most countries. If programmedemands exceed resources, making the right decisions about the population to betargeted and the interventions to be implemented, in order to make the best use ofthe available resources, becomes an issue for strategic planners. Several simple tocomplex criteria are available for making these decisions. Commonly used criteriaEpidemiological approaches that consider the stage of the epidemic and thegradient of spread of HIV.Cost-effectiveness-based approaches such as infections averted (DALY saved)Rights- (or absence of rights-) based approaches.Epidemiological approachesPrioritisation based on epidemiological analysis is possibly the simplest of the threeapproaches. As discussed previously, the stage of the epidemic in combination withterventions can then be identified that are likely to have maximum impact on theepidemic. Another approach is to use simple arguments like the gradient of spreadof infection in different population sub-groups, or different geographical areas. Forexample, the urban-rural gradient of spread of HIV leads to programmes that favoururban areasCost-effectivenessCost-effective analyses identify the relative efficiency of alternative activities by com-paring costs with results or outputs. If adequate and locally relevant information isavailable, this is the preferred method for programme managers and planners whenmaking choices about resource allocation. Focusing on the cost-effectiveness orefficiency of an intervention also involves continuously assessing the costs involvedin a specific activity or group of activities in the programme, and what is achievedwith that money.able 6 below shows the relative cost-effectiveness of a range of interventions rel-evant to the Asia/Pacific region. However, most studies are from Africastudy of IDU interventions is from Belarus in Eastern Europe.ecently and one set of data is available from a vaccine model.able 6 shows that the most cost-effective interventions a country can invest in arethose for high-risk populations with a high probability of infecting others - irrespec- 26 Costing Guidelines for HIV/AIDS Intervention Strategies Standard vaccine programmes reach 65 percent of adults after five years with 50 percentefficacy, 10 years protection and no behavioural reversals.**1998 prices.***Single dose nevirapine, targeted.The applicability of information from Africa and Eastern Europe for setting prioritiesin the Asia/Pacific region is always a subject for debate. The relative cost-effective-ness can be adapted to an Asian setting - provided that the approach taken and thecoverage achieved are similar.how different coverage levels of interventions might yield a variable impact on theepidemic (national unit costs can be fed directly in to the GOALS model). UNAIDStools can be used to assess the impact of individual interventions for high-risk groups(http://www.unaids.org/publications/documents/economics/costmodel).activities need to be identified quickly. For rapid scaling-up, the potential to use theexisting infrastructure to achieve widespread coverage must be maximised.12 below presents a scheme of prioritisation based on the phase of the epidemic.The decision on preparatory activity to saturation may also be based on capacity,esources or political and social acceptance of a programme in a country.able 6. Cost-effectiveness of selected HIV/AIDS interventions HIV/AIDS activities Cost/case averted Cost per DALY US $2000 US $2000 African Development Forum. 2001.Costs of scaling-up HIV Program Activities to a National Level in Sub-Saharan Africa, Methods Estimates .Addis Ababa: Economic Commission for Africa. Available at http://www.uneca.org/adf2002/costs Commercial SWs, PE (1, 3)79-160, 8134-7,30IDUs (2, 3)54-128**4.7MTCT prevention (1)20-341***1-12STI treatment (1)27112VCT (1)393-48218-22AIDS vaccine, standard* (4)210-1410NAHAART, Senegal and Ivory Coast (1)NA1100TB, DOTS treatment (1)NA2-4Community-based careNA77 27 Costing Guidelines for HIV/AIDS Intervention Strategies Figure 12. Prioritising interventions by phase of epidemicImplicitly or explicitly, rights or privileges of certain populations are used to prioritiseinterventions in almost all countries. A rights-based approach in HIV/AIDS program-ming leads to substantial reduction in incidence, although the impact may or maynot be visible in a shorter timespan. For example, access to care and support andeduced stigma leads to higher acceptance and compliance to the prevention pro-grammes. A good blood safety programme often raises awareness of HIV pro-grammes among politicians and medical professionals.It is argued that unborn children have rights even if the infection is dead-end (nofurther spread). Conversely, the SW-epidemic cannot be prioritised in some coun-Re-examination and re-allocation of resourcesOnce re-allocation has taken place the impact should be re-examined. This processshould be repeated until the desired mix of interventions, as well as the resultantimpact, are envisaged. Educated EliteReligious Leaders HIGH RISKPOPULATION OutreachSTD Treat. / Condom Condom Soc MktChild / Adolescent IEC RURAL ACTIVITIES HIV% AMONG 15-49 YRS WOMEN 1-5%�5% EARLYEPIDEMICENDEMIC Enabling Context 28 Costing Guidelines for HIV/AIDS Intervention Strategies The MSM spreadsheet is very similar to the SW calculation, except that a cost fieldfor lubricants is added (column F, row 25). The assumption is that the same numberof lubricant units and condoms are provided. If no lubricants are available throughthe programme, the cost should be set to 0.frequencies. Ideally, unit costs for MSM population with higher sex frequencies likeExplanations of the INPUT spreadsheets for intervention modules for SWs have beengiven in the main text. Modules other than SW-intervention are provided below. Inorder to avoid repetition. this section will focus on, and explain the differences be-tween the sex worker spreadsheet and the intervention being discussed. MEN WHO HAVE SEX WITH MENUNIT COSTCost componentNRsUSD%Training of PE122,8001,5744PE/MSM ratioPE/dayPE neededTotal PEUS$PE renumeration520,0006,66717155067520,0006,667Outreach worker/SV720,0009,23123 Each PE is expected to spend 3days/week to interact with peer s Outreach/DIC150,0001,9235ParticipantsTrainersDays/yearParticipants/courseIEC/events15,0001920672220Commodities&ServicesTraining Coursepp/dTraining/yearTotal yearUS$$/pp/courseCondoms748,8009,60024food/refreshments20027,467122,8001,57424Lubricants00material20013,333STI Services186,2502,3886trainer per day1,00013,333Enabling environment77,0009872 y 25068,667 s Programme Management400,0005,12813OWRenum/monthOW/PE ratiototal OWUS$Investments28,0003591Staff512,00013720,0009,231M+E (5%)146,9931,8855NRsUS$TOTAL3,114,84339,934 r 150,0001,923UNIT3,11540NRsUS$UNIT w/o condoms2,36630 r 15,000192condoms/daydays/yearcond use %ex. suppl. %cost/c $Condoms needed400,0005080200.02Excess suppl y 80,000NRsUS$cost/lub $Condoms total480,000748,8009,600StaffUnitsSalary/monthtot/month0.00Lubricant total480,00000doctor135,00035,000NRsUS$nurse118,00018,00077,000987assistant100NRsUS$Time/patient (minutes)30400,0005,128drugs per treatment300 D eprec.Year s Invest/yearUS$ A ssumed STI prev. %20140,0001,795528,000359Assumed STI/SW/year2STI treatments/year400NRsUS$4666186,2502,388 cost per year Figure 13. Men who have Sex with Men 29 Costing Guidelines for HIV/AIDS Intervention Strategies ENUNIT COSTCost componentNRsUSD%Training of PE122,8001,5744PE/MSM ratioPE/dayPE neededTotal PEUS$PE renumeration520,0006,66717155067520,0006,667Outreach worker/SV720,0009,23123 Each PE is expected to spend 3days/week to interact with peer s Outreach/DIC150,0001,9235ParticipantsTrainersDays/yearParticipants/courseIEC/events15,0001920672220Commodities&ServicesTraining Coursepp/dTraining/yearTotal yearUS$$/pp/courseCondoms748,8009,60024food/refreshments20027,467122,8001,57424Lubricants00material20013,333STI Services186,2502,3886trainer per day1,00013,333Enabling environment77,0009872 y 25068,667 s Programme Management400,0005,12813OWRenum/monthOW/PE ratiototal OWUS$Investments28,0003591Staff512,00013720,0009,231M+E (5%)146,9931,8855NRsUS$TOTAL3,114,84339,934 r 150,0001,923UNIT3,11540NRsUS$UNIT w/o condoms2,36630 r 15,000192condoms/daydays/yearcond use %ex. suppl. %cost/c $Condoms needed400,0005080200.02Excess suppl y 80,000NRsUS$cost/lub $Condoms total480,000748,8009,600StaffUnitsSalary/monthtot/month0.00Lubricant total480,00000doctor135,00035,000NRsUS$nurse118,00018,00077,000987assistant100NRsUS$Time/patient (minutes)30400,0005,128drugs per treatment300 D eprec.Year s Invest/yearUS$ A ssumed STI prev. %20140,0001,795528,000359Assumed STI/SW/year2STI treatments/year400NRsUS$4666186,2502,388 cost per year Figure 13. (Enlarged) Men who have Sex with Men 30 Costing Guidelines for HIV/AIDS Intervention Strategies It can be seen that the structure of the IDU spreadsheet and the SW spreadsheet(see p14-17) are identical except for the provision of needles and syringes and theintroduction of primary health care. Therefore, peer education, outreach/DIC, OWsand IEC/events under behavior change communication are not repeated here. Thecost of other activities like enabling environment, programme management and in-vestment also remain same. Pr exchange per day or per week) as per the national programme policy. Optionsare distribution and/or exchange; needs are calculated based on the possiblenumber of needles used per IDU per week and the possible return rate ofPercentage of excess supply of needles: enter the buffer stocks of needlesand syringes to be procured as a percentage of the total assessed require-ment for the year. Enter the number of condoms each IDU receives per month and the cost ofone condom in US dollars. The number of condoms required by an averageIDU will be less than that a SW. PHC (Primary Health Car IDUs need treatment for skin conditions, management of abscesses, etc. whichare not strictly linked to HIV. For operational reasons these primary health careinterventions are clustered under services (methadone or buprenorphine fororal substitution are costed in the oral substitution worksheet).Figure 14. Injecting drug users: INJECTING DRUG USERS - NEEDLE EXCHANGEUNIT COSTCost componentNRsUSD%PE (incl. Training)649,6678,32914PE/client ratioPE/dayPE neededtotal PEUS$Outreach/DIC150,0001,9233155067520,0006,667Outreach worker/SV780,00010,00017 Each PE is expected to spend 3days/week to interact with peersIEC/events78,0001,0002ParticipantsTrainersDays/yearParticipants/courseCommodities&Services672220Syringes/Needles1,639,87221,02436pp/dTraining/yearTotal/yearUS$ $ /pp/cours e Condoms280,8003,6006food/refreshments25034,333129,6671,66225PHC17,5002240material20013,333Enabling environment78,0001,0002trainer per day1,00013,333Programme Management700,0008,97415DA/day25068,667Investments20,0002560NRsUS$M+E (5%)218,6922,8045Costs transport/DIC/y150,0001,923TOTAL4,612,53159,135OWRenumerationOW/PE ratiototal OWUS$UNIT4613593,00013780,00010,000Cost per N/s delivered11 r NRsUS$ r 78,0001,000per contactcontactsreturn rateex. suppl. %cost USSyringes Needles438,000NRsUS$36560200.04Excess supply87,6001,639,87221,024Syringes Needles total525,600no. condoms/client/month15cost/condom US$0.02NRsUS$NRsUS$78,0001,000cost/client3504NRsUS$700,0008,974% in need5US$Deprec. Years n vestm/ye a 100,0001,282520,000256 r cost per yea r (Larger version on next page) 31 Costing Guidelines for HIV/AIDS Intervention Strategies Cost componentNRsUSD%PE (incl. Training)649,6678,32914PE/client ratioPE/dayPE neededtotal PEUS$Outreach/DIC150,0001,9233155067520,0006,667Outreach worker/SV780,00010,00017 Each PE is expected to spend 3days/week to interact with peersIEC/events78,0001,0002ParticipantsTrainersDays/yearParticipants/courseCommodities&Services672220Syringes/Needles1,639,87221,02436pp/dTraining/yearTotal/yearUS$ $ /pp/cours e Condoms280,8003,6006food/refreshments25034,333129,6671,66225PHC17,5002240material20013,333Enabling environment78,0001,0002trainer per day1,00013,333Programme Management700,0008,97415DA/day25068,667Investments20,0002560NRsUS$M+E (5%)218,6922,8045Costs transport/DIC/y150,0001,923TOTAL4,612,53159,135OWRenumerationOW/PE ratiototal OWUS$UNIT461359513,00013780,00010,000Cost per N/s delivered11 r NRsUS$ r 78,0001,000per contactcontactsreturn rateex. suppl. %cost USSyringes Needles438,000NRsUS$36560200.04Excess supply87,6001,639,87221,024Syringes Needles total525,600no. condoms/client/month15cost/condom US$0.02NRsUS$NRsUS$78,0001,000cost/client3504NRsUS$700,0008,974% in need5US$Deprec. Years n vestm/ye a 100,0001,282520,000256 r cost per yea r Figure 14. Injecting drug users (Enlarged) : 32 Costing Guidelines for HIV/AIDS Intervention Strategies ariables that impact most on unit costs are:The number of PEs required and their remunerationOWs: are they only needed for supervision, or are they active in exchange?Needles and syringes (if bleach and water are also provided, the return rateBecause of operational issues oral substitution is discussed seperately.The assumptions are based on a total of 500 clients on the programme enrolled atone oral substitution site. Inputs required are the number of staff in each differentcategory (and their respective salaries) needed to cater for 500 clients (including theequired support services like house visits, counseling, etc.). Other components arestaff training costs, running costs of the programme and IEC costs. The single mostdone or buprenorphine can vary up to 2,000 percent, depending on the source ofpurchase and the type of packaging used; this has a direct impact on unit costs. Inthis example, plastic cups are used as the methadone purchased comes in a pow-dered form (the cheapest international form).Usually, the majority of the IDU population who use methadone will not be usingneedles and therefore should not be counted when costing needle and syringe pro-grammes and vice versa. The percentage of drug users likely to use substitution, ortheir ratio to the number of IDUs using needle and syringe programmes are notknown but can be established over a period of time. Obviously, there is a hugevariation from country to country depending on the existing legal requirements foregistering treatment, the nature of drug use, etc. INJECTING DRUG USERS - ORAL SUBSTITUTIONUNIT COSCost componentNRsUSD%Staff1,360,00017,43635 f Unitssalary/yearTotalUS$Training209,4002,6855Doctors1.5300,000450,0005,769Running costs140,0001,7954Nurses+Counseling3.0150,000450,0005,769IEC/events79,0001,0132Counselors2.0150,000300,0003,846Commodities&ServicesWatchmen/peon2.080,000160,0002,051Drugs1,170,00015,00030ParticipantsTrainersDays/yearUsables2,340300staff/counselors7220Condoms140,4001,8004pp/dtraining/yearTotalUS$Enabling environment78,0001,0002food/refreshments40072,000209,4002,685Programme Management500,0006,41013material2001,400Investments76,0009742trainer per day2,500100,000NRsUS$M+E183,9572,3585DA/day20036,00029,914384 3,939,09750,501NRsUS$Total/year140,0001,795UNIT7878101 r NRsUS$ r 79,0001,013NRsUS$78,0001,000Commodities & ServicesProgramme ManagementNRsUS$client/yearTotalUS$500,0006,410US$3015,0002,340US$Deprec. Year s nvestm/ye a cost/cupNRs380,0004,872576,000974Plastic cups (1 client/day)1.00182,5005% no. condoms/client/month15cost/condom US$0.02 cost per year Figure 15. Oral Substitution 33 Costing Guidelines for HIV/AIDS Intervention Strategies TIONUNIT COSCost componentNRsUSD%Staff1,360,00017,43635 f Unitssalary/yearTotalUS$Training209,4002,6855Doctors1.5300,000450,0005,769Running costs140,0001,7954Nurses+Counseling3.0150,000450,0005,769IEC/events79,0001,0132Counselors2.0150,000300,0003,846Commodities&ServicesWatchmen/peon2.080,000160,0002,051Drugs1,170,00015,00030ParticipantsTrainersDays/yearUsables2,340300staff/counselors7220Condoms140,4001,8004pp/dtraining/yearTotalUS$Enabling environment78,0001,0002food/refreshments40072,000209,4002,685Programme Management500,0006,41013material2001,400Investments76,0009742trainer per day2,500100,000NRsUS$M+E183,9572,3585DA/day20036,00029,914384 L 3,939,09750,501NRsUS$Total/year140,0001,795UNIT7878101 r NRsUS$ r 79,0001,013NRsUS$78,0001,000Commodities & ServicesProgramme ManagementNRsUS$client/yearTotalUS$500,0006,410US$3015,0002,340US$Deprec. Year s nvestm/ye a cost/cupNRs380,0004,872576,000974Plastic cups (1 client/day)1.00182,5005% no. condoms/client/month15cost/condom US$0.02 cost per year Figure 15. Oral Substitution (Enlarged) 34 Costing Guidelines for HIV/AIDS Intervention Strategies Approachraining of counselors, integration of services or free-standing counseling units. Regularsupervision/coaching. Programme assumptions: one counselor can counsel five clientsper day (includes pre-/post-test counseling, records, etc.). The minimum staff require-ment for one centre is two trained counselors. The maximum number of participants on1.Start to cost a full training course (maximum 15)2.Input the number of trainers/course, days of training, (if refresher trainings are3.Enter training-related costs (food/refreshment per participant/day, training mate-rial per participant/course, fee of trainer/day, and daily allowance (daily allowance4.Decide on the number of counselors/unit, the capacity used' (as a percentage)and a monthly salary. The capacity characterises the percentage of their respec-tive working time counselors will spend counseling on the programme. Thespreadsheet then calculates the maximum number of clients based on capacity(the number of counselors and percentage of their worktime).5.Enter the number of supervisors, their renumeration and the number of supervi-6.Condoms: enter the number of condoms a client is supplied with after counseling.7.If a separate unit is used for counseling, input investments (e.g. furniture, repairs,8.Testing: the cost of testkits needed is based on the maximum number of clients/year and the average sero-prevalence (to calculate confirmatory tests). Enter theaverage sero-prevalence rate as a percentage.9.Programme management is set by default to 15 percent, and monitoring andevaluation to 10 percent of the overall activity costs. You can change the respec- LUNTARY COUNSELING AND TESTINGCost/clientNRsUSD%Staff360,0004,61549No. staff/unit2NRsUS$Running costs units84,0001,07711Salary/staff/month15,000360,0004,615Training51,6006627Counseling Capacity used %75Commodities&ServicesMax. no. of clients counselled750Testing62,6258039total yearUS$/yearCondoms11,70015027,00084,0001,077Programme Management70,00089710Investments60,0007698ParticipantsTrainersDays/yearM+E34,9964495Counsellors10220TOTAL734,9219,422pp/dtraining/yearTotalUS$food/refreshments40096,000258,0003,308UNIT98013material2002,000Costs pp /yeartrainer per day2,500100,000NRsUS$DA/day25060,00025,800331NRsUS$Per year70,000897300,000NRsUS$ A ssumed HIV prevalence (%)5Depreciation - years560,000769NRsUS$Monitoring & Evaluation5% ofsingle test761confirmation test1502Total cost single test57,000731Total cost confirmation5,62572Total testing62,625803cond/clientcondom US$100.02Condoms total7,500150 of operational costs Figure 16. Voluntary Counseling and Testing 35 Costing Guidelines for HIV/AIDS Intervention Strategies ND TESTINGCost/clientNRsUSD%Staff360,0004,61549No. staff/unit2NRsUS$Running costs units84,0001,07711Salary/staff/month15,000360,0004,615Training51,6006627Counseling Capacity used %75Commodities&ServicesMax. no. of clients counselled750Testing62,6258039total yearUS$/yearCondoms11,70015027,00084,0001,077Programme Management70,00089710Investments60,0007698ParticipantsTrainersDays/yearM+E34,9964495Counsellors10220TOTAL734,9219,422pp/dtraining/yearTotalUS$food/refreshments40096,000258,0003,308UNIT98013material2002,000Costs pp /yeartrainer per day2,500100,000NRsUS$DA/day25060,00025,800331NRsUS$Per year70,000897300,000NRsUS$ A ssumed HIV prevalence (%)5Depreciation - years560,000769NRsUS$Monitoring & Evaluation5% ofsingle test761confirmation test1502Total cost single test57,000731Total cost confirmation5,62572Total testing62,625803cond/clientcondom US$100.02Condoms total7,500150 of operational costs Figure 16. Voluntary Counseling and T 36 Costing Guidelines for HIV/AIDS Intervention Strategies A. This module simply calculates the costs for testing and treatment of known positive women. To calculate screening costs, thmodule can be used. In low prevalence settings, the costs for screening are higher (because only relatively few positive casesdetected ) than the costs for counselling and treatment of those who are found to be HIV+. B. In this module the cost of formula to substitute breastfeeding is not included, but could be easily added. Especially in the beginning, demand for services will be low (therefore unit costs willbe very high). A balance has to be struck between the free capacity of existing VCTCounselors (number, renumeration)'Free-standing units' or integration with existing structures participantsTrainersDays/year2022person/daytraining/yearTotal/yearUS$food/refreshments2008,80018,800241material1002,000Costs pp /yeartrainer per day1,0004,000NRsUS$ A 1004,00094012Women - Children treatedstaff salary/mstaffhours/treatmentstaffcost/treatment10015,000194 y No:US $/test 1.00 NRsUSDStaff time9,375120Training18,800241Drugs31,200400Tests15,600200M+E (5%)3,74948TOTAL78,72 UNIT78710 Figure 17. Prevention of Mother to Child TransmissionApproachPrevention of MTCT is a facility-based intervention integrated with antenatal serv-ices. The resources required include staff training, provision of test kits and ARVsupply for prophylaxis. Although behaviour change communication is also an essen-tial element, it is delivered as a part of youth-focused intervention and is therefore1. Training costsDetermine the number of trainers required to organise a training course (aminimum of two trainers should be present).Determine the number of days required to complete a course on the basis ofthe curriculum and contents and enter (if refresher trainings are planned, addDetermine the number of participants that can be accommodated in a groupdepending on the local circumstances. It is appropriate to organise trainingprogrammes for small groups to ensure effective communication, usually not 37 Costing Guidelines for HIV/AIDS Intervention Strategies Enter training-related costs: food and refreshment per participant/day, train-ing materials per participant/course, fee of trainer per day, and daily allow-The total costs of training in local currency and per capita costs in US dollars will beautomatically generated in the grey cells on the spreadsheet.2. Staff remunerationEnter the estimated number of antenatal mothers who will require counselingand treatment in a year per site.Enter the salary for one staff member based on country salary structure.otal and per patient costs accruing on account of staff salaries per patient appear inadjoining grey-coloured cells on the spreadsheet.Enter the costs of drugs administered per mother and child pair as per coun-try protocol (this varies according to the PMTCT protocol used).Enter the number of tests required per mother and child pair (this depends onthe protocol used; if none enter 0).Figure 18. Young people (Life Skills) Target groupPE/pupils ratioPE neededRenumeration/PE/dayPE days/yearPE TotalLIFE-SKILLSNRsUSD500153301040Training235,3333,017ParticipantsTrainersDays/yearPE renumeration00 y 10Supervision42,000538pp/dayTraining/yearTotal/yearUS$US $/pIEC/events5,00064food/refreshments20080,667235,3333,01779Transport/DA24,000308material1003,833Programme Manag.7,800100trainer per day2,50050,000M+E (5%)15,707201 A 250100,833 L 329,8404,229No. SVSV per monthSVdays/location/yea r No. visits/yea r UNIT659.688.46Supervisor115,0002412Transport/location1,500Supervision staff cost18,000 A 250Transport costs18,000 A 6,000IEC/events/yea r 5,000Total/location42,000 r NRsUS$7,800100 Programme approach: Life skillswareness-raising is one of the essential elements of behaviour change and doesnot lead to behaviour change unless behaviour change services are provided andthe environment is supportive. A life skills programme on the other hand provides afull behaviour change package with inclusion of non HIV-essential issues communi-cation. Where services cannot directly be arranged referral to services (e.g. VCT andyouth-friendly services) must be offered. 38 Costing Guidelines for HIV/AIDS Intervention Strategies Behaviour change communication: training, peer-educationovision of services: referral, supervisioneating of enabling environment1.Define the size of the target group (e.g. 500 in a school setting).2.Define the PE to young person ratio (depends on location, but normally around3.Enter the number of PEs required, their remuneration and the number of daysa PE is expected to work per year. It is assumed that the PEs would noteceive any remuneration. These cells can be used if this is used for collegestudents and some allowance or souvenirs are given.4.Input the number of people who will be trained beside PEs (e.g. teachers,community members, parents), the number of trainers required for each course,the number of PE-training days required and the maximum number of partici-pants on each training course (if refresher trainings are planned, add up the5.Enter training-related costs: food and refreshment per participant/day, train-ing material per participant/course, fee of trainer per day, and daily allowance.6.Enter the number of supervisors required, their remuneration, the number ofto that location per year.7.Enter the average transport costs per trip, and the daily allowance for thesupervisor.8.Input the cost of IEC materials for one person for one year. This input can alsotion on referrals. Events may include debates, quizzes, essays, WorldAIDS Day, visits to hospices, meeting HIV-positive people and PWA groups9.Creation of enabling environments includes mobilising teachers, local authori-ties and opinion leaders, and parents and communities in order to create moretrust in young people, endorse sex education, peer education and referral10.Monitoring and evaluation includes collection of baseline data, monitor-ing of activities and outcome, including monitoring of supportive environments.11. Programme management is set to 15 percent by default, and monitoring andevaluation to 10 percent of overall activity costs. The respective parametersPE remuneration 39 Costing Guidelines for HIV/AIDS Intervention Strategies Programme approach: AwarenessThe youth awareness programme trains teachers, parents, community members,pupils etc. in a specific location to give three to four orientations (to young people) ayear. IEC events during the year include competitions, small theatre performanceswareness sessions, IEC and training for the same1.Enter the number of people to be trained, the number of trainers and the2.Enter training-related costs: food and refreshment per participant/day, train-ing material per participant/course, fee of trainer per day, and daily allowance.3.Enter the number of people to be oriented (e.g. 500 in a school) and the4.Enter the remuneration per person for each orientation.5.Input the total costs of IEC materials for each person per year.6.Enter the programme management costs as a percentage of overall activity7.If supervision is included, enter the number of supervisors, the number ofsupervision visits per year, the transport costs per visit, the daily allowance8.Enter the number of cycles per year i.e. how often the specified target group HIV/AWARENES(Objective: Correct knowledge)AWARENES S NRsUSDNRsUS$for orientation atper yea r 750096Orientation22,500288location500Training4,70060NRsUS$IEC material/events7,50096per session50per yea r 3,00038Programme Managemen t 3,00038Fee orienter perNRsM+E (5%)1,88524session750 L 39,585508Training "orienters"SupervisionUnit w/o supervision791.02Participants5Supervisors115,000Unit supervised981.26Days2supervision visits (1d)2 R Trainers1SV/day750Participant/dayTransport/visit1,699food/refreshments100DA250material per participant100Travel days to/fro2trainer fee per day1,000Supervision/yearNRsUS$DATransport3,39844Transport Trainer1,000Staff costs4,50058NRsUS$DA1,50019Training total4,70060Total/Yea r 9,398120Cost per participant940 12 Figure 19. Young People (HIV Awareness) 40 Costing Guidelines for HIV/AIDS Intervention Strategies Unit cost/clientNRsUS$VCT/STI clients/day/team3097212Total days in field30Tot. clients/team/field days900 f Salary/month incl. FringeUnitscost for field daysDoctors70,0002140,000Nurses36,000272,000Laboratory staff36,000272,000Counsellors25,000250,000Peer Educators15,000575,000Porters60074,200Transport/person4,000DA40013156,000Tests105,300105,300Drugs (general+STI)150,000150,000 s 50,54450,544IEC per person105050US$TOTAL875,09 4 no.:900no.:costs US$full test US$590450single test US$1900900Prevalence (%)10Total costsno. condoms/client30cost/condom US$0.02NRsUS$Excess supply %2050,544648 Condoms Total Figure 20. Mobile VCT/STI Services:Programme Approach:These interventions are designed for labour migrants (before they leave, and afterthey return to their communities), and their families.Different INPUT modules can be used to compose packages; e.g. awareness andlife-skills from the youth package, VCT, or a SW/IDU model of a peer education-based approach and delivery of condoms.The following model costs a mobile VCT/STI camp for migrants returning home andtheir families. It is based in a rural setting with hardly any other infrastructure and1.Enter the estimated number of people that VCT/STI services can accommo-date per day.2.Input the total number of days that staff will spend in the field.3.Enter the number of staff required and their monthly salaries.4.Enter the estimated cost of drugs required (STIs as well as general drugs) for5.Input IEC materials as expenditure per person per month.6.Enter the prevalence and cost of test-kits to calculate total test costs.7.Input condom variables to estimate the cost of condoms. 41 Costing Guidelines for HIV/AIDS Intervention Strategies Unit cost/clientNRsUS$VCT/STI clients/day/team3097212Total days in field30Tot. clients/team/field days900 f Salary/month incl. FringeUnitscost for field daysDoctors70,0002140,000Nurses36,000272,000Laboratory staff36,000272,000Counsellors25,000250,000Peer Educators15,000575,000Porters60074,200Transport/person4,000DA40013156,000Tests105,300105,300Drugs (general+STI)150,000150,000 s 50,54450,544IEC per person105050US$TOTAL875,09 4 no.:900no.:costs US$full test US$590450single test US$1900900Prevalence (%)10Total costsno. condoms/client30cost/condom US$0.02NRsUS$Excess supply %2050,544648 Condoms Total Figure 20. Mobile VCT/STI Services (Enlarged) : 42 Costing Guidelines for HIV/AIDS Intervention Strategies Figure 21. Care and SupportImproved care for PLWHA isImproved access to care for allcaretreatment ComponentNRsUS$Each PLWHA will spend30days in hospital in his last 2 yearsInpatient day 117015Each PLWHA will visit8times an outpatient departmentOutpatient visit781Each PLWHA will visit10times a pharmac y Spending per Pharmacy visi t 100.13 s Total inpatient costs35,100450Cost per lifetime (last 2 years) Total outpatient costs6248NRs5,772Pharmacy costs1001US$74Community based care5,77274Total41,596533Estimated Adult Deaths2001200220032004200520062,0902,5083,0103,6124,3435,3006,500Estimated people in their last 2 lifeyears5,0586,0707,2898,79910,722Burden of Disease NRs210,392,568252,487,720303,172,446366,003,204445,971,5141,578,027,452Total C+SUS$2,697,3413,237,0223,886,8264,692,3495,717,58420,231,121ComponentUS$NRs $ YearSourcePallative care, life time002000GlobalOI treatment, life time002000GlobalOI prophylaxis, life time001995Uganda (DOTS)HBC/CBC/life time745,7722000GlobalTB treatment/year002000GlobalDrugs HAART 1st line/year40831,824Drug HAART, 2nd line/year1,00078,000% on 1st line treatment907,020% on 2nd line treatment107802000GlobalLab.monitoring, HAART/year15011,7002000/2002Tanzania, 2 yearsassumed treatment years5 a l Life Time Costs excl. HAAR T 745,772 * 63249,296 *cost average includes proportional 1st and 2nd line drugs Assessing the cost of care:Costing of care in the National Strategic Plan poses an extraordinary challenge sincelimited data is available in the Asia/Pacific region, and many countries such as Nepalhave few known HIV/AIDS cases. The lack of an infrastructure for providing basiccare for people with HIV/AIDS-related diseases is adding to the problem when de-ciding how many PLWHA will actually be able to utilise care services. The approachto assessing the cost of care consequently relies on reference studies from otheregions and/or models based on expected consumption of health care services (withlocal costs) preferably taking into account the infrastructure in the individual country.Burden of Disease:The Burden of Disease (BoD) tries to calculate the costs arising in the last two yearsof life of PLWHA. This is not a planning figure, but can be used for advocacy pur-poses and to alert the health system of costs related to HIV/AIDS. The upper leftmodule needs inputs of cost per inpatient day, cost per outpatient visit, and averageThe upper right module is an estimation of 1) how many days a PLWHA will spend invisited and c) how often a pharmacy visit will be necessary.If costs are available for home/community-based care, they should be entered aslifetime costs in the next module of the spreadsheet. These costs usually includecosts for terminal care and drug kits (or other supplies) provided to the families ofPLWHA. The next two modules are an estimation of people living in their last twoyears for a given year. The first needs inputs of estimated adult deaths for a specificyear (these estimates can be taken from estimation models). The second then calcu-Finally, the total BoD is calculated by multiplying the number of people in their last 43 Costing Guidelines for HIV/AIDS Intervention Strategies ComponentNRsUS$30days in hospital in his last 2 yearsInpatient day 117015Each PLWHA will visit8times an outpatient departmentOutpatient visit781Each PLWHA will visit10times a pharmac y Spending per Pharmacy visi t 100.13 s Total inpatient costs35,100450Cost per lifetime (last 2 years) Total outpatient costs6248NRs5,772Pharmacy costs1001US$74Community based care5,77274Total41,596533Estimated Adult Deaths2001200220032004200520062,0902,5083,0103,6124,3435,3006,500Estimated people in their last 2 lifeyears5,0586,0707,2898,79910,722Burden of Disease NRs210,392,568252,487,720303,172,446366,003,204445,971,5141,578,027,452Total C+SUS$2,697,3413,237,0223,886,8264,692,3495,717,58420,231,121ComponentUS$NRs $ YearSourcePallative care, life time002000GlobalOI treatment, life time002000GlobalOI prophylaxis, life time001995Uganda (DOTS)HBC/CBC/life time745,7722000GlobalTB treatment/year002000GlobalDrugs HAART 1st line/year40831,824Drug HAART, 2nd line/year1,00078,000% on 1st line treatment907,020% on 2nd line treatment107802000GlobalLab.monitoring, HAART/year15011,7002000/2002Tanzania, 2 yearsassumed treatment years5 a l Life Time Costs excl. HAAR T 745,772 * 63249,296 *cost average includes proportional 1st and 2nd line drugs Figure 21. Care and Support (Enlarged) 44 Costing Guidelines for HIV/AIDS Intervention Strategies Care and Support - Treatment:This is a relatively simple spreadsheet to calculate the total lifetime costs for care andtreatment excluding anti-retroviral therapy (HAART), and a per/year cost for treat-ment including HAART. Please note that for this module inputs are required in USdollars (as many countries have US dollar costs for the required fields).Inputs needed: costs for palliative care (lifetime), costs for treatment of opportunisticinfections (OI) and OI prophylaxis respectively. Home/community-based costs aretaken from the BoD calculation, and costs for TB treatment per year.The next five input fields are on HAART. The cost of drugs (person/year) are definedas the 'first-line treatment' in respective national protocols. The next are the cost ofdrugs which will be given if the first-line treatment is either not tolerated, or ineffec-tive. These 'second-line drugs' are much more expensive, and the module asks foran estimated percentage of people who will be on first-line and second-line drugsespectively. The last field on HAART is an estimated cost of clinical and laboratorymonitoring as cost/patient/year. These costs may vary widely depending on whichlaboratory methods are used, but countries will have some clinical monitoring stepsdefined in their treatment protocols.Approaches to assess the cost of care available for the countries include:Empirical cost data studies (difficult to undertake if the epidemic has startedModels of treatment packages (from essential services to HAART)Burdens of disease study based on estimated utilisation of existing servicesEmpirical data from Thailand540 and 386 million baht on medical services respectively. It is unlikely that any othercountry in the Asia/Pacific region would be able to obtain such detailed cost infor-since it demands knowledge of the local profile of HIV-related opportunistic diseases(incidence and cost of treatment) and an estimate of coverage. The WHO has pro-posed that care packages are developed to match the country resources and costsand HAART.The GOALS model has also been used to estimate the costs of the three care pack-ages proposed by UNAIDS/WHO:In order to adapt the figures to national circumstances, some knowledge of the localinfrastructure is necessary including the behaviour pattern for those seeking healthcareand access to healthcare. Futures Group International. 2004. http://www.futuresgroup.com/Goalsmodel 45 Costing Guidelines for HIV/AIDS Intervention Strategies The GOALS model provides a more sophisticated method for the provision of HAART.Here it is assumed that of PLWHA accepting HAART, 76 percent will have a goodesult in the first year. For the others the first regimen will fail due to side-effects andesistance. When a certain regimen fails, an alternative regimen is tried. A certainproportion of patients will have a good result for each regimen. For others it will failand they will need to switch to another regimen.Note for other interventionsStandard package tools (spreadsheets) include HIV/AIDS interventions from the NepalStrategic Plan. The interventions are broken down into relevant cost componentsfollowing the cost principle adapted. Some activities may not be relevant to othercountries, however, they can be used as a checklist (not exhaustive) and hopefullywill assist in clarifying Best Practice programme interventions. When available, unitcosts from international studies have been included with the Nepal figures as refer-ence values which could prove beneficial for comparative purposes when local costfigures are developed. 46 Costing Guidelines for HIV/AIDS Intervention Strategies ADBAsian Development BankAIDSAcquired Immune deficiency syndromeANCantenatal casesARTAntiretroviral therapyARVAnti-retroviral drugsAZTZidovudineBCCBehavior Change CommunicationBCIBehaviour Change InterventionBehaviour Change CommBehaviour Change CommunicationCondCondomCSWCommercial sex workerDepDepreciationDFIDDepartment of International DevelopmentDICDrop In CenterELISAEnzyme Linked Immunosorbent AssayEnvEnvironmentGFATMGlobal Fund to Fight AIDS, Tuberculosis andGTZGerman Technical CooperationHAARTHighly Active Anti-Retroviral TreatmentHBCHome based careHIVHuman immunodeficiency virusNGONon-governmental organizationIECInformation Education and CommunicationLCLocal currencyM&EMonitoring and evaluationM+EMonitoring and EvaluationMgmtManagementMSMMen having sex with menNRNepalese Rupee (Local Currency)OIHIV-related opportunistic infectionOWOutreach workerPEPeer EducatorPLWHAPeople Living with HIV/AIDSProgProgrammeSTISexually-transmitted infectionSWSex WorkerTBTuberculosisTrgTVCTVoluntary Counseling and TestingRNMResource Needs ModelCommon abbreviations 47 Costing Guidelines for HIV/AIDS Intervention Strategies Notes: 48 Costing Guidelines for HIV/AIDS Intervention Strategies Notes: Joint United Nations Programme on HIV/AIDSUNAIDS Third Floor, United Nations BuildingRajadamnern Nok Avenue, Bangkok 10200, Thailandinternet: www.unaids.org6 ADB Avennue, Mendaluyong Cityhttp://www.adb.org