amp Infections averted of PMTCT Services by Community and Facility Strengthening in Mashonaland Central Province Zimbabwe Ravikanthi Rapiti¹ Angela Mushavi 2 Ann Levine 3 Julie Pulerwitz ID: 132436
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Cost Effectiveness Analysis & Infections averted of PMTCT Services by Community and Facility Strengthening in Mashonaland Central Province, Zimbabwe
Ravikanthi Rapiti¹, Angela Mushavi2 , Ann Levine3, Julie Pulerwitz1 & Ibou Thior 31Population Council, 2Zimbabwe Ministry of Health, 3 PATHInternational AIDS Economic Network19 July 2014Melbourne, AustraliaSlide2
PMTCT in ZimbabweIn 2009 Pregnant women attended ANC—54%1
ANC HIV prevalence—16% (20% in Mashonaland Central) MTCT rate—30%2 Roll out of 2010 WHO Option A guidelines in 2011Health facilities required significant training and mentoring to provide these newer, more complicated regimensTo increase uptake, communities, families and males also needed to be engaged1World Health Organization. Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: towards universal access. Available at: http://www.who.int/hiv/pub/mtct/antiretroviral2010/en/index.html Accessed 29 April 2013.2UNAIDS Global AIDS Response Progress Report, 2012: Zimbabwe Country Report. Available at: http://www.unaids.org/en/dataanalysis/knowyourresponse/countryprogressreports/2012countries/ce_ZW_Narrative_Report.pdf. Accessed 29 April 2013.Slide3
ObjectivesEvaluation of the Arise PMTCT project implemented in 21 sites in Mashonaland Province, Zimbabwe that sought to address whether a strengthened PMTCT package could improve:
PMTCT coverageOutcomes Cost and cost effectiveness Could a paediatric infection be averted in <500USD per infection? Slide4
Arise study sitesSlide5
Project timeline (45 months)
20122013April2014
Aug-Sept2011
Baseline survey
Aug-Sept 2011
End line survey
April 2014
ARISE intervention initiated
Dec 2011
ARISE intervention concludes
March 2014
May
2014
Sept
2010
Project closure
May 2014
Project start up
Sept 2010Slide6
Components of interventionFacility levelProvision of point-of-care CD4 machines Training & mentoring of providers
Strengthening completion of routine PMTCT registersStrengthening links with central laboratoryCommunity levelAwareness campaigns, dramasFollow up with clients who missed scheduled visits in the PMTCT cascadeSensitizing community leader & faith healersEstablishing support groupsOutreach and targeting of men Strengthening community and health facility linkagesSlide7
Data sources for the evaluationFinancial reports on expenditures for costingAn activity-based costing approach
Costing templates were developed Types of costs were definedInfections averted were calculated Sensitivity analysis was conductedCosting was determined Slide8
How many HIV infections were averted over the intervention period?Slide9
Estimating infant HIV infections avertedModeled estimates of infant HIV infections. Estimated number of HIV-exposed infants were derived from the HIV prevalence rate times the estimated number of live births per year in the project catchment area. Validated data from routinely completed PMTCT facility registers Slide10
Estimated number of infections averted
Lower LimitUpper Limit #
deliveries per year
15,968
20,508
HIV prevalence in pregnant women (as
proportion
)
16%
20%
Total number of HIV+ pregnant women delivering per year
2,554.9
4,101.6
Year 1
Year 2
Year 3
Year 4
(
Quarter 1)
Total
Lower
Limit
361
626
649
187
1,822
Upper Limit
580
1,005
1,041
300
2,925Slide11
What were the costs per infection averted?Slide12
Describing costs
Type of costCost category/cost itemsData sourcesStart upRecurrent
Indirect programmatic costs
Financial (
programmatic costs defined as DFATD funded financial expenditure used to deliver the services to beneficiaries
)
Micro-planning,
developing materials, training & mentoring, sensitization
Health commodities
& storage/transport, personnel, capital (annualized), transport & travel, office facilities, admin, & meetings
Cell phone &
communication costs for non-direct staff, rent &
office bills, office repairs &
upkeep
Project expense reports (ZAPP, CHAI &
PC
);Facility data;
Ministry of Finance;MoHEconomic(financial costs plus the value of shared project costs and the value of all donated goods and services)
Start-up financial costs value of all donated goods and services, and of resources already financed to provide comprehensive care and treatment
Recurrent economic costs and other shared costs including HCW costs and the laboratory and ARV health commodity costsFinancial indirect programmatic costs
plus that were shared with other programs, including rent for the CHAI officeSlide13
Costing Period (2011–2013)
Cost categoryDFATD upfront financialStart-up233,555Recurrent
363, 986
Indirect programmatic costs
58,014
Total costs (no indirect programmatic costs)
867,120
Total costs (with indirect programmatic costs)
655,555Slide14
Costing Period (2013-2014)
Cost categoryDFATD upfront financialStart-up34,500Recurrent
235,079
Capital costs
21,443
Indirect programmatic costs
58,014
Total costs (no indirect programmatic costs)
291,022
Total costs (with indirect programmatic costs)
349,036Slide15
Final CostingThe front line costs for 2011–2013 included both the facility and the community intervention. The community intervention continued until the end of the project (February 2014).
The cost of infections averted during 2013–2014 is a range between $ 537.81 and $ 335.30 when the prevalence is varied between 16 percent and 20 percent respectively. Slide16
ConclusionsThis project demonstrated that a combined community and health facility approach has the potential to improve access and retention across the PMTCT cascade. Community strategies on retention and male involvement as well as cost data will be important contributions as Zimbabwe now moves to Option B+.Slide17
Conclusions (con’t)Use of routine real world programmatic data for estimating infections averted is a strength of this study.Even though a more efficacious PMTCT program, Option A, costs more than previous
regimens, the cost of averting infections are lower compared to lifetime treatment costs. Slide18
ConsiderationsLack of control facilities. Contributions of other stakeholders and other donors to national and provincial level efforts.Investments in infrastructure and human capacity development will remain. Slide19
AcknowledgementsThis presentation was produced under Arise—Enhancing HIV Prevention Programs for At-Risk Populations, through financial support provided by the Canadian Government through Foreign Affairs, Trade and Development Canada, and via financial and technical support provided by PATH.
Arise implements innovative HIV prevention initiatives for vulnerable communities, with a focus on determining cost-effectiveness through rigorous evaluations.