Cost-outcome analysis of HIV testing and counseling, linkage, and defaulter tracing services in Bukoba, Tanzania

ABSTRACT

Effective services along the HIV continuum of care from HIV testing and counseling to linkage, and from linkage to antiretroviral therapy (ART) initiation and retention, are key to improved health outcomes of persons living with HIV. A comprehensive analysis of the costs and outcomes of cascade services is needed to help allocate and prioritize resources to achieve UNAIDS targets. We evaluated the costs and population-level impact of a community-wide, integrated scale-up of testing, linkage, and defaulter-tracing programs implemented in Bukoba Municipal Council, Tanzania. Costs per identified HIV-positive client for provider-initiated, and home- and venue-based testing and counseling were $92.64 United States dollars (USD), $256.33 USD, and $281.57 USD, respectively. Costs per patient linked to HIV care and ART were $47.69 USD and $74.12 USD, respectively, during all ART-eligibility periods combined. Costs per defaulter traced and returned to HIV care were $47.56 USD and $206.77 USD, respectively. The provider-initiated testing and counseling was the most cost-effective modality. Testing approaches targeted to populations groups and geographic location with high testing positivity rates may improve the overall efficiency of testing services. The expansion of ART eligibility criteria and high linkage rate also result in efficiency gains and economies of scale of linkage services.

KEYWORDS:

• HIV testing and counseling
• linkage to care
• defaulter-tracing
• cost-outcome

Acknowledgements

We are grateful to the support from the Tanzania MOHCDGEC, National AIDS Control Program, Tanzania Commission for AIDS, Bukoba Municipal Council and Kagera region leadership, and staff at the 11 healthcare facilities. We would like to show our gratitude to study participants, BCPE project team and staff, healthcare workers, and data clerks. In memory of our dear colleague and friend Dr Fernando Morales who sadly passed away before publication of this article. He was a loving father, inspiring leader, and dedicated mentor who humbly dedicated his career trying to improve the health of those less fortunate throughout sub-Saharan Africa.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data that support the findings of this study are available on request from the corresponding author. The data are owned by the Government of the United Republic of Tanzania and are not publicly available due to data transfer agreements according to Tanzanian regulations. Data are available from the corresponding author with the permission of the Government of the United Republic of Tanzania.

Disclaimer

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the funding agencies.

Ethics approval

The study was approved by Institutional Review Boards at the National Medical Research Institute, Dar es Salaam, Tanzania, and Columbia University Medical Center, New York City, United States. The study was also reviewed in accordance with U.S. CDC human research protection procedures and was determined to be research, but CDC investigators did not interact with human subjects or have access to identifiable data or specimens for research purposes.

Additional information

Funding

This work was supported by the U.S. President’s Emergency Plan for AIDS Relief through the U.S. Centers for Disease Control and Prevention [terms of cooperative agreement number 5UGPS001998].