of Global Health Heidelberg University Germany 10th International AIDS Economics Network Preconference Amsterdam 20 July 2018 Cost s and effects of alternative ID: 759878
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Slide1
Till Bärnighausen
Heidelberg Institute of Global Health, Heidelberg University, Germany10th International AIDS Economics Network PreconferenceAmsterdam 20 July 2018
Costs and effects of alternative service delivery models
Slide2Can alternative delivery models can contribute to sustainability?
Three
key
factors
Cost
Health
workers
Patient
convenience
and
satisfaction
I will
present
Evidence
from
5
randomized
controlled
health
systems
trials
Quasi-experimental
afterthoughts
Slide3ART = antiretroviral treatmentHontelez, Bor, Tanser, Pillay, Moshabela & Bärnighausen Health Affairs 2018
Individual
fixed effects
regression, controlling for calendar year and age; 6,505 observations in 2,252 individuals (2009-2013).
103
hospitalizations per 1,000 person-years.
ART supports sustainable
health systems
FIXED EFFECTS RESULTS
Slide4HIV treatment has strong SDG effects
Slide5Raifman, Patenaude, Chibmindi, Gareta, Tanser, Bärnighausen CROI 2015ART = antiretroviral treatment
Point estimate95% CIFirst stage: ART initiation0.2970.239-0.354Education: ITT0.3430.094-0.592Education: CACE1.1590.206-2.112N3,998
Regression discontinuity
with assignment as instrumental variable, controlling for youngest age at which the child reached the highest grade, adult CD4 count distance below the cutoff value of 200 cells per mm3, and adult CD4 count distance above the cutoff. Standard errors adjusted for clustering at the homestead level.ITT = intent-to-treat; CACE = complier average causal effect; CI = confidence interval
ART improves children’s education (SDG 4)
REGRESSION DISCONTINUITY RESULTS
Slide6Agenda: alternative delivery models
Universal test and treat:
MaxART
(
Eswatini
)
Home
delivery
: CHW for ART (
Tanzania
)
Continuous
qualit
y
improvement
: MONARCH (South
Africa
)
HIV
self-testing
: ZEST (Uganda)
General-population
PrEP
:
Sikomihle
(
Eswatini
)
Slide7Agenda: alternative delivery modalities
Universal test and treat:
MaxART
(
Eswatini
)
Home
delivery
: CHW for ART (
Tanzania
)
Continuous
qualit
y
improvement
: MONARCH (South
Africa
)
General-population
PrEP
:
Sikhomihle
(
Eswatini
)
HIV
self-testing
: ZEST (Uganda
)
Slide8Delivery model: universal test and treat (UTT)
Slide9Does UTT affect per-patient ART delivery costs?STEPPED-WEDGE RANDOMIZED CONTROLLED DESIGN
Steps (4 month periods)
Clinic
1
2
3
*4
5
6
**7
8
9
Total
1
67
58
34
14
20
20
13
15
4
245
2
81
27
23
10
8
18
13
13
7
200
3
27
13
17
6
14
12
13
12
8
122
4
37
12
56
14
19
16
8
5
5
172
5
27
13
10
13
14
9
15
5
1
107
6
50
27
33
34
25
23
17
11
6
226
7
20
5
6
10
4
8
4
5
14
76
8
163
87
83
116
109
78
43
57
62
798
9
93
45
30
17
22
18
6
19
22
272
10
64
28
29
29
18
35
15
16
7
241
11
59
23
30
34
30
27
24
21
10
258
12
54
16
34
20
9
26
23
16
13
211
13
16
18
18
22
12
7
17
6
4
120
14
112
63
36
27
34
33
24
10
18
357
Total
870
435
439
366
338
330
235
211
181
3405
Slide10UTT does not affect per-patient ART delivery costsSTEPPED-WEDGE RANDOMIZED CONTROLLED TRIAL RESULTS
Khan, Wong, Geldsetzer, Asmus,
How, Lejeune, Okello, Bärnighausen IAS 2018
Total
ARVs
Personnel
Labs
Slide11Khan, Wong, Geldsetzer, Asmus, How, Lejeune, Okello, Bärnighausen CROI 2018
B
ut ART deliver displays impressive economies of scaleMAXART COSTING STUDY RESULTS
Slide12Agenda: alternative delivery models
Universal test and treat:
MaxART
(
Eswatini
)
Home
delivery
: CHW for ART (
Tanzania
)
Continuous
qualit
y
improvement
: MONARCH (South
Africa
)
General-population
PrEP
:
Sikhomihle
(
Swaziland
)
HIV
self-testing
: ZEST (Uganda
)
Slide13Delivery model: community health workers (CHW) for ART home delivery
Slide14Geldsetzer, Francis, Ulenga, Sando, Lema, Mboggo, Vaikath, Koda, Lwezaula, Hu, Noor, Olofin, Larson, Fawzi, Bärnighausen BMC Health Services Research 2017
Intervention package:
Community delivery of HIV
treatment
Retention and adherence counseling
CHW
24 clinics
SoC
24 clinics
48 clinics
Are CHW as good as nurses in delivering ART?
IMPLEMENTATION RCT, DAR ES SALAAM
Sample size:
2,082 adult ART patients
Follow-up period:
12 months
Outcome assessment:
Viral load
Funders:
3ie and Bill & Melinda Gates Foundation
Slide15Geldsetzer, Francis,
Sando
,
Asmus
, Lema, Mboggo, Koda, Lwezaula, Ambikapathi, Fawzi, Ulenga, Bärnighausen IAS 2018
CHW are as good as nurses in delivering ART
IMPLEMENTATION RCT, DAR ES SALAAM
Slide16Policy and practice can generate quasi-random intervention assignmentRD DESIGN
Epidemiology
2014Epidemiology 2015Journal of Clinical Epidemiology 2015Current Epidemiology Reports 2016Journal of Clinical Epidemiology 2017PLOS ONE 2017PLOS Medicine 2017Social Science and Medicine 2017American Journal of Epidemiology 2017
David
Sackett
Price 2017 for Ellen Moscoe
Slide17Bor, Fox, Rosen, Atheenar, Tanser, Pillay, Bärnighausen PLOS Medicine 2017
ART
thresholds reduce retention
RD RESULTS
Slide18Adult did not eat
Adult cut size of meal
Child cut size of meal
Δ
probability (pp)
Δ
probability (pp)
Years on ART
N
= 1662-2300 for “adult did not eat” and “child cut size of meal
”,
N
= 1662-2297 for “adult cut size of meal”
ITT
CACE
Patenaude, Chimbindi, Pillay, Bärnighausen Social Science & Medicine 2018ITT = intent to treat, CACE = complier average casual effect, pp = percentage points, ART = antiretroviral treatment
ART
reduces food security (SDG 2)
RD RESULTS
Slide19Chimbindi,
Bor, Newell, Tanser, Baltussen, Hontelez, de Vlas, Lurie, Pillay, Bärnighausen JAIDS 2015ART = antiretroviral treatment
Patient exit
interviewsN = 400 for ART and TB; N = 300 for pre-ART. Self-care includes expenditures for traditional medicines, items to fight disease bought at spaza shops, and special foods.
ART
patient costs are substantial (SDG
3
)
PATIENT EXIT INTERVIEWS
Slide20Bor, Tanser, Newell, Bärnighausen Health Affairs 2012ART = antiretroviral treatment
Individual fixed effects
regressions,
linear probability model, controlling for sex, age, education, calendar year, month and day of survey. N = 32,316 persons with 138,020 observations.
ART
increases employment, but slowly (SDG
1
)
FE ANALYSIS
Slide21Agenda: alternative delivery models
Universal test and treat:
MaxART
(
Eswatini
)
Home
delivery
:
CHW for ART (
Tanzania
)
Continuous
qualit
y
improvement
:
MONARCH (South
Africa
)
General-population
PrEP
:
Sikhomihle
(
Eswatini
)
HIV
self-testing
: ZEST (Uganda)
Slide22Delivery model: continuous quality improvement (CQI)
Slide23Can CQI improve critical HIV-related tests in ANC?IMPLEMENTATION RCT MOTIVATION AND DESIGN
Chetty, Yapa, Herbst, Geldsetzer, Naidu, De Neve, Herbst, Matthews, Pillay, Wyke, Bärnighausen BMC Health Services Research 2018
Stepped-wedge cluster RCTCQI mentors Pre-registered primary endpoints:Second HIV test in HIV-VL in HIV+
Step/clinic123456789101 2 3 4 5 6+7
Pre-QI
QI implementation
QI maintenance
PMTCT failures
Undetected incident HIV infection
Undetected treatment failure
Slide24CQI
can increase critical HIV-related testing in ANCIMPLEMENTATION RCT RESULTS
Yapa, Chetty, Herbst, Geldsetzer, Naidu, De Neve, Herbst, Matthews, Pillay, Wyke, Bärnighausen CROI 2018
VL testing
Repeated
HIV
testing
Slide25Agenda: alternative delivery models
Universal test and treat:
MaxART
(
Eswatini
)
Home
delivery
: CHW for ART (
Tanzania
)
Continuous
quality
improvement
: MONARCH (South
Africa
)
General-population
PrEP
:
Sikhomihle
(
Eswatini
)
HIV
self-testing
: ZEST (Uganda
)
Slide26Delivery model: general-population PrEP
100%
94%
78%
63%
87%
93%
97%
59%
600
500
400
300
200
100
0
Engaged
Eligible
Initiated
Retained
at
o
ne
month
Nu
m
ber
of
clients
Screened
for
risk
At
risk
Interested
Screened
for
eligibility
Hughey, Hettema, McMahon,
Lejeune
, Matse, Bärnighausen
I
AS
2018
Slide27Desirability is key to intervention effectiveness
ANRS 12249 TRIAL RESULTS
Motivation
Can a policy to test an entire population frequently and initiate HIV treatment immediately reduce population HIV incidence?
Trial
Treat all HIV+ individuals
Treat according to South African guidelines
22 clusters in rural KwaZulu-Natal randomized
Results
Person-years
10.646 (intervention arm)
11,787 (control arm)
ART coverage
45% (intervention arm)
43% (control arm)
Iwuji
, Orne-
Gliemann
,
Larmarange
,
Balestre
,
Thiebaut
,
Tanser
,
Okesola
,
Makowa
,
Dreyer, Bärnighausen
,
Boyer
,
De
Oliveira,
Rekacewicz
,
Bazin
,
Newell
,
Pillay,
Dabis
Lancet HIV
2017
Slide28Design research can increase desirability, feasibility and viability
Ideation
Finding
themes
Creating
insight
statements
Creating
frameworks
‘
How
might
we‘ questionsBundling ideasIdentifying design principles…
InspirationSecondary researchClient interviewsExpert interviewsGroup interviewsGuided tourProcess mapping …
ImplementationLive prototypingRoadmapResource assessmentPilotEvaluationIteration…
IDEO 2015
Slide29Design research identified dimensions of desirabilityCLIENT INTERVIEWS, THEMES AND INSIGHTS DURING STUDY BASELINE
Bärnighausen, Matse, Kennedy, Lejeune, Hughey, Hettema, Bärnighausen, McMahon
AIDS (forthcoming)
“What has made me come [for PrEP] now is that I found out that my husband is having relationships with people who are on ARVs, and he has children with some of them. Now, I am dealing with the problem and taking the pills because I am in love with him. He does not want to use the condom, sometimes he would put it on and say it broke and sometimes he would not use it at all. So I decided to take the pills so I can continue with life.” – PrEP client, age 29
Control
“My husband has two wives. We are two and unfortunately they contracted the virus. They are both taking ARVs. My sister wife told me that they are living with HIV but when I came to test I found that I hadn’t acquired the virus. I can tell them I have PrEP. I can tell them we are all safe”. – PrEP client, age 36
Safety
“You can stop taking PrEP when you wish to or when you feel the risk has been minimized, you go to the clinic and tell them, they then give you pills for 28 days then you can stop and you can restart PrEP again when you want. There is no problem.” – PrEP client, age 23
F
lexibility
Slide30A design study on PrEP revealed five opportunities for improvement of ‘form’FACILITATORS AND BARRIERS OF PrEP, EXPERT AND CLIENT INTERVIEWS
PrEP is discreet mechanism to prevent HIV transmission"Finally there is something I can offer to women who don’t know their husbands whereabouts and cannot insist on a condom" – Nurse
Emphasized in Enhanced Nurse and Counsellor Training and (i) PrEP Video, (ii) PrEP Counselling Flip Chart, and (iii) Comprehensive Client Booklet
PrEP-related processes take too long“Of course I’m not initiating (Client A) on PrEP. Look at that line of women waiting. …?” – Nurse
(iv) Streamlined PrEP process for nurses(v) HIV Risk Self-Assessment (instead of nurse-led risk assessment)
Misunderstanding“Why are you giving me 30 pills? I thought I take one pill, each day, for 7 days and then I’m set for life?” – Male client
Improved communication about PrEP effects in (i) PrEP Video, (ii) PrEP Counselling Flip Chart, and (iii) Comprehensive Client Booklet
Concerns about side effects“Tell me exactly what all of this means. Am I hurting my baby?” – Female client (showing PrEP bottle’s drug warning to a provider)
Improved communication about side effects in (i) PrEP Video, (ii) PrEP Counselling Flip Chart, and (iii) Comprehensive Client Booklet
Bärnighausen,
Matse
, Kennedy, Lejeune, Hughey, Hettema, Bärnighausen, McMahon
Submitted
2018
Slide31Agenda: alternative delivery models
Universal test and treat:
MaxART
(
Eswatini
)
Home
delivery
: CHW for ART (
Tanzania
)
Continuous
qualit
y
improvement
: MONARCH (South
Africa
)
General-population
PrEP
:
Sikomihle
(
Eswatini
)
HIV
self-testing
: ZEST (Uganda)
Slide32Delivery model: HIV self-testing for FSW
Slide33Does HIV self-testing for FSWs work?
INNOVATION RCT, STUDY DESIGN
Ortblad, Kibuuka Musoke, Ngabirano, Nakitende, Magoola, Kayiira,Taasi, Barresi, Haberer, McConnell, Oldenburg, Bärnighausen PLOS Medicine 2017FSWs = female sex workers
Slide34Bor
, Fox, Rosen, Atheenar, Tanser, Pillay, Bärnighausen PLOS Medicine 2017 (forthcoming)
Ortblad, Kibuuka Musoke, Ngabirano, Nakitende, Magoola, Kayiira, Taasi, Barresi, Haberer, McConnell, Oldenburg, Bärnighausen PLOS Medicine 2017
P
eer provision vs. standard of care
Facility collection vs. standard of carePeer provision vs. facility collection
HIV self-test kits increase testing ratesINNOVATION RCT RESULTS – ALL HIV TESTING
Slide35… but
crowd out facility-based testingINNOVATION RCT RESULTS – FACILITY-BASED HIV TESTING
Slide36Unit costs can change dramatically and quickly
Slide37Our capacity to scale up alternative delivery models will determine the sustainability of HIV interventions
Shifting from nurses to CHW
Shifting from CHW to clients
Public-
sector
cost
effects
vs.
c
lient
cost
and
economic
effects
Client
behavioral
responses
Desirability
Slide38Thank you
ParticipantsColleaguesFundersAlexander von Humboldt FoundationNIH R01-AI124389R01-HD084233R01-AG041710P01-AG041710D43-TW009775Wellcome Trust European UnionInternational Initiative for Impact Evaluation (3ie)World Health OrganizationClinton Health Access InitiativeBill and Melinda Gates Foundation