Costs and cost–effectiveness of HIV community services: quantity and quality of studies published 1986–2011

Figures & data

Figure 1. Annual international and domestic HIV expenditure 2002–2011.

Data taken from [101].

Figure 2. Total number of studies performed in Organisation for Economic Co-Operation and Development countries by year of publication 1986–2011.

Figure 3. A country’s health sector resource cycle, describing the complementary nature of expenditure tracking and costing health services in countries.

Table 1. Community services scoring sheet.

Author Article title Citation Year of publication Country of study
National perspective	National Subnational
Contains cost data?	No: stop scoring Yes: continue scoring
Question	Response	Score	Maximum
1. Peer-reviewed publication	No Yes	0 1	1
2. Geographical settings covered	Not mentioned Unclear Capital city Urban – other cities Peri-urban Rural	0 0 1 1 1 1	4
3. Original utilization data	No Yes	0 1	1
4. Source of utilization data	No utilization data Unclear Estimates (expert opinion, and so on) Cross-sectional Longitudinal	0 0 1 2 3	3
5. Utilization data client sample size	Unclear Less than 30 persons Between 30 and 100 persons More than 100 persons	0 1 2 3	3
6. Duration of follow-up	Unclear Less than 1 month Between 1 and 6 months Between 7 and 12 months More than 12 months	0 1 2 3 4	4
7. Utilization data collection mechanism	Not applicable Client interviews Patient-completed questionnaires/diaries Retrospective data from registries/databases Prospective monitoring	0 1 2 3 4	7
8. Nature of basic unit cost data	Estimates Charges Cost-adjusted charges Costing exercise	1 2 3 4	8
9. Type of basic cost data if estimates	Not applicable Unclear General/average costs HIV-specific costs	0 0 2 3	3
10. Source of cost data if charges or cost-adjusted charges	Not applicable Unclear NHA or general DRG/HRG NASA or HIV-specific DRG/HRG	0 0 1 2	2
11. Number of sites if costing exercise	Not applicable Unclear Single client site Multiple client sites	0 0 3 4	4
12. Use and cost data sources if charges or costing exercise	Not applicable Unclear Use and cost data from different sites Use and cost data from same site	0 0 1 2	2
	Maximum subtotal score		42
13. Cost data client sample size	None mentioned Less than 30 persons Between 30 and 100 persons More than 100 persons	0 1 2 3	3
14. Components included in costing exercise	None mentioned Staff Tests Procedures Consumables (e.g., condoms) Drugs Transportation Capital costs Overheads	0 1 1 1 1 1 1 1 1	8
15. Cost perspective of analysis	Patient Program Healthcare system Societal	1 2 3 4	4
16. Client/patient characteristics reported	Not mentioned Demographics: age Demographics: sex Demographics: ethnicity Infection risk factors Comorbidities Severity of illness (WHO/CDC/CD4/VL)	0 1 1 1 1 1 2	7
17. Populations targeted	Unclear Key populations (IDUs, MSM and CSWs) Vulnerable populations (women, girls, children, prisoners, immigrants and orphans) General population	0 1 1 1	3
18. Type of community service	Unclear Publicly funded – free at the point of delivery (program, taxation-based or insurance) Fee-for-service (social health insurance) Fee-for-service (private insurance)	0 1 1 1	1
19. Out-of-pocket (fee-for-service)	No Yes	0 1	1
20. Cost and utilization data presentation	Point estimate for utilization data Presents variability of utilization data Point estimate for cost data Presents variability of cost data	1 1 1 1	4
21. Costs disaggregated by patient characteristics	Not disaggregated Demographic categories Risk factors for infection Severity of HIV or opportunistic illness Comorbidities (e.g., HCV)	0 1 1 1 1	4
22. Community costs by type of setting	Not specified Outreach Clinic or community clinic Community health worker Home-based care	0 1 1 1 1	4
23. Cost per visit or outcome	Not applicable No Yes	0 0 1
24. Cost per patient-time period reported	Not applicable No Yes	0 0 1	1
25. Statistical analysis for utilization or cost data	None Bivariate analysis/univariate modeling Multivariate analysis or modeling Tested or adjusted for skewness	0 1 1 1	3
	Maximum subtotal score		43
	Maximum total score		85

CSW: Commercial sex worker; DRG: Diagnostic-related group; HCV: Hepatitis C virus; HRG: Health-related group; IDU: Injecting drug user; MSM: Men who have sex with men; NASA: National AIDS spending assessment; NHA: National health accounts; VL: Viral load.

Table 2. Type of community services identified and reviewed.

Type of service	Services reviewed (n)
Voluntary counseling and testing or testing and counseling services (Table 4)	21
Outreach and community mobilization for HIV services (Table 5)	19
Community-based provision of antiretroviral therapy (Table 6)	17
Home-based services (Table 7)	15
Condom services (Table 8)	7
Community services for men who have sex with men (Table 9)	7
Community services for female sex workers (Table 9)	5
Community services for injecting drug users (Table 9)	4
Community services for transgender persons (Table 9)	2

Table 3. Number of community services studies performed by continent and by the Organisation for Economic Co-Operation and Development country classification, mean raw score across studies, range and percentage of maximum score.

Country classification	Studies (n)	Mean score (%)	Range of scores (%)
By continent
Sub-Saharan Africa	33	40 (47)	21–58 (25–68)
North America and the Caribbean	25	36 (42)	14–50 (17–59)
Asia	9	47 (55)	37–54 (43–64)
Europe	4	48 (56)	35–61 (41–69)
South America	2	37 (44)	28–45(33–53)
Australia	1	59 (69)	NA
By OECD classification
High income	28	39 (46)	14–61 (17–72)
Upper-middle income	14	38 (45)	16–53 (19–62)
Lower-middle income	13	46 (54)	27–54 (32–64)
Low income	19	40 (47)	21–55 (25–65)

NA: Not applicable; OECD: Organisation for Economic Co-Operation and Development.

Table 4. Unit costs and cost–effectiveness of voluntary testing and counseling services by the Organisation for Economic Co-Operation and Development country classification (2010 purchasing power parity in US$).

Cost category	High-income country	Upper-middle-income country	Lower-middle-income country	Low-income country
Per client tested
In CBOs	20–1494 [37,67,87]			21–39 [53]
Outreach	125–222 [52]
Clinic	88–226 [52,65]	33–250 [26,60]	17–144 [80]
Home-based care			204 [80]	4 [76]
Mobile testing				24–64 [34]
Door-to-door counseling				15–24 [35]
Household member HCT				37–39 [53,75]
Rapid testing in transgender community	650–693 [86]
Peer referral for MSM	392 [65]
Per HIV-positive client tested				428–515 [34]
Per client notified of serostatus
HIV-negative client	26–359 [23,65]
HIV-positive client	46–2354 [23,65,87]		490–3545 [77]	217–647 [34]
Person notified of new diagnosis	4013–18,740 [52]
Transgender community	3817–8874 [86]
Newly infected MSM	10,165–13,439 [66]
Per person confirmed with HIV diagnosis
Use of nucleic acid amplification testing after rapid testing or ELISA	14–8216 [56]
Transgender community	3966–10,846 [86]
Range of unit costs	14–18,740	33–250	17–3545	4–647
Cost–effectiveness studies
Cost per infection averted through VCT				204–287, 607[84]
Clinics		103–4129 [26]
CBOs				301–555 [53]
Outreach				4265 [41]
Cost per tuberculosis case averted through VCT		476–794 [26]
Range for cost–effectiveness studies		103–4129		301–4265

CBO: Community-based organization; HCT: Home counseling and testing; MSM: Men who have sex with men; VCT: Voluntary counseling and testing services.

Table 5. Unit costs and cost–effectiveness of outreach and community mobilization services by the Organisation for Economic Co-Operation and Development country classification (2010 purchasing power parity in US$).

Cost category	High-income country	Upper-middle-income country	Lower-middle-income country	Low-income country
Street outreach	8–537 [21]
Risk reduction behavior + HCT for IDUs	202–317 [29]
Recruitment strategies (per HIV-infected client tested)	223–328 [49]
Opinion leaders for MSM (per MSM reached)	54 [50]
Community mobilization on prevention of STIs/HIV, law enforcement of condom use per CSW reached		181–187 [40]
Outreach services to CSW, MSM and transgender persons
Per person registered			42–1512 [58]
Per person receiving STI services			86–956 [58]
Youth peer-education in schools
Per student covered			30 [89]
Per peer educator			300–1748 [90]
Community mobilization for voluntary medical male circumcision				5–23 [59,82]
Adherence case management for HIV-infected patients on ART (per patient)				90–229 [88]
Use of volunteers to provide ARVs, monitor compliance and adverse reactions in patients in rural areas (per patient)				250 [89]
Range of unit costs	8–328	181–187	30–1748	5–250
Cost–effectiveness studies
Cost per infection averted
Outreach	12,274–49,429,105 [21,25,38,50]
Community mobilization with HIV/STI prevention		12,337–32,057 [40]
Cost per DALY averted
Community mobilization with HIV/STI prevention		520–1348 [40]
Cost per QALY gained
HIV education and condom distribution	44,692 [38]
Range for cost–effectiveness studies	12,274–49,429,105	520–32,057

ART: Antiretroviral therapy; ARV: Antiretroviral; CSW: Commercial sex worker; DALY: Disability-adjusted life year; HCT: Home counseling and testing; IDU: Injecting drug user; MSM: Men who have sex with men; QALY: Quality-adjusted life year; STI: Sexually transmitted infection.

Table 6. Unit costs and cost–effectiveness of community-based provision of antiretroviral therapy services by the Organisation for Economic Co-Operation and Development country classification (2010 purchasing power parity in US$).

Type of service/cost category	High-income country	Upper-middle-income country	Lower-middle-income country	Low-income country
Adherence management of patients on ART
Directly administered HAART; per patient	2482 [71]	2981 [28]
Intensive adherence case management for patients on HAART	1935 [71]			90–229 [88]
Home visits to monitor ART and ongoing ART support; per patient visit		76–96 [22]
Use of patient tracer to reduce LTFU among patients on ART; per patient returned to care		465–767 [24]
Per patient attempted to be traced		20–32 [24]
Use of volunteers to provide ARVs, monitor compliance and adverse reactions in patients in rural areas (per patient)				250 [89]
Provision of ART
Home-based care	2167–5039 [44,70]	1061 (ppy) [42]		17,575 [51]
Primary health clinic
Per patient per year		431 [42]
Per patient initiated on treatment and in care		2201–2897 [74]		2045 [55]
Dedicated ART community clinic
Per patient per year		1410 [48]
Per patient initiated on treatment and in care		1822–2894 [74]
Using village doctors to provide direct primary care, distribute medicines and monitor compliance of patients on ART		2687 [43]
Range of unit costs	1935–5039	20–2981		90–17,575
Cost–effectiveness studies
Cost per DALY averted through ART provision
Provision of VCT and ART				717 [55]
Home-based delivery of ART				2000 [61]
Cost per QALY gained
Infants whose mothers received DOT HAART in third trimester of pregnancy	14,802 [62]
Range for cost–effectiveness studies	14,802			717–2000

ART: Antiretroviral therapy; ARV: Antiretroviral; DALY: Disability-adjusted life year; DOT: Directly observed therapy; HAART: Highly active antiretroviral therapy; LTFU: Long-term follow-up; ppy: Per patient year; QALY: Quality-adjusted life year; VCT: Voluntary counseling and testing services.

Table 7. Unit costs and cost–effectiveness of home-based services by the Organisation for Economic Co-Operation and Development country classification (2010 purchasing power parity in US$).

Type of service/cost category	High-income country	Upper-middle-income country	Lower-middle-income country	Low-income country
Per home visit	632 [33]	8–18 [63]
Per patient contacted	212 [33]
Home-based services without ART costs
Per patient	2167–9571 [70,73]	1061 [19]
Per patient per year		295–1358 [41]
Home-based services with ART costs
Per patient per year	10,886–28,884 [69,72]
Per patient		1806 [46]		17,575 [51]
Range of unit costs	212–28,884	8–1806		17,575
Cost–effectiveness studies
Cost per DALY averted
Home-based CD4/VL monitoring of patients on HAART				1294 [85]
Home-based delivery of ART				2000 [61]
Cost per QALY gained
Infants whose mothers received DOT HAART in third trimester of pregnancy	14,802 [62]
Range for cost–effectiveness studies	14,802			1294–2000

ART: Antiretroviral therapy; DALY: Disability-adjusted life year; DOT: Directly observed therapy; HAART: Highly active antiretroviral therapy; QALY: Quality-adjusted life year; VL: Viral load.

Table 8. Unit costs and cost–effectiveness of provision of condoms by the Organisation for Economic Co-Operation and Development country classification (2010 purchasing power parity in US$).

Type of service/cost category	High-income country	Upper-middle-income country	Lower-middle-income country	Low-income country
Per person reached with condoms	5 [39]			5 [39]
Bleach, condom distribution + risk-reduction counseling per IDU per year	277 [36]
Range of unit costs	5–277			5
Cost–effectiveness studies
Cost per infection averted
HIV education and condom distribution	24,921–874,050 [38,39]
Condom social marketing				1914 [51]
Cost per QALY gained
HIV education and condom distribution	44,692 [38]
Range for cost–effectiveness studies	24,921–874,050			1914

IDU: Injecting drug user; QALY: Quality-adjusted life year.

Table 9. Unit costs and cost–effectiveness of community services for men who have sex with men, female sex workers, injecting drug users and transgender people by the Organisation for Economic Co-Operation and Development country classification (2010 purchasing power parity in US$).

Type of service/cost category	High-income country	Upper-middle-income country	Lower-middle-income country	Low-income country
Community services for MSM
Outreach services per MSM reached	8–537 [21]	199 [18]	85–182 [81]
Cost per MSM tested	173–392 [66]
Community-based treatment and care for MSM	408–1500 [45]
Range of unit costs	8–1500	199	85–182
Cost–effectiveness studies
Cost per infection averted
Peer-driven prevention outreach for MSM	12,274–23,643 [25]
Opinion leaders	92,440 [40]
Cost per DALY averted
Peer counseling and treatment of STIs	2539–2575 [18]
Range for cost–effectiveness studies	2539–23,643
Community services for FSWs
Outreach services per FSW reached		150–257 [18,40,47]	17–194 [20,31,68,81]
Range of unit costs		150–257	17–194
Cost–effectiveness studies
Cost per infection averted
Community mobilization and HIV/STI prevention communication to FSWs		12,337–32,056 [40]		117–756 [68]
Mobile STI clinic for FSWs		4432–11,642 [47]
Cost per DALY averted
Community mobilization and HIV/STI prevention communication to FSWs		106–1348 [18,40]
Mobile STI clinic for FSWs		170–388 [47]
Range for cost–effectiveness studies		170–32,056		117–756
Community services for IDUs
Peer-driven outreach per IDU recruited	23 [19]
Traditional outreach per IDU recruited	665 [19]
Bleach and condom distribution and risk-reduction counseling for risk behaviors per IDU per year	277 [36]
Per IDU tested and counseled	355 [65]
Range of unit costs	23–665
Community services for transgender people
Outreach services per transgender person reached			235 [81]
Per transgender person tested	650–693 [86]
Per transgender person notified of new HIV diagnosis	3817–8874 [86]
Per transgender person confirmed with new HIV diagnosis	3966–10,846 [86]
Range of unit costs	650–10,846		235

DALY: Disability-adjusted life year; FSW: Female sex worker; IDU: Injecting drug user; MSM: Men who have sex with men; STI: Sexually transmitted infection.

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