Abstract
Introduction: "Differentiated service delivery" (DSD) for antiretroviral therapy (ART) for HIV is rapidly being scaled up throughout sub-Saharan Africa, but only recently have data become available on the costs of DSD models to providers and patients. We synthesized recent studies of DSD model costs in five African countries. Methods: The studies included cluster randomized trials in Lesotho, Malawi, Zambia, and Zimbabwe and observational studies in Uganda and Zambia. For 3-5 models per country, studies collected patient-level data on clinical outcomes and provider costs for 12 months, and some studies surveyed patients about costs they incurred. We compared costs of differentiated models to those of conventional care and identified drivers of cost differences. We also report patient costs of seeking care. Results: The studies described 22 models, including facility-based conventional care. Of these, 13 were facility-based and 9 community-based models; 15 were individual and 7 group models. Average provider cost/patient/year ranged from $100 in Zambia to $187 in Zimbabwe, in both cases for facility-based conventional care. Conventional care was less expensive than any other model in the Zambia observational study, more expensive than any other model in Lesotho, Malawi, and Zimbabwe, and in the middle of the range in the Zambia trial and the observational study in Uganda. Models incorporating 6-month dispensing were consistently less expensive to the provider per patient treated. Savings to patients were substantial for most models, with patients' costs roughly halved. Conclusion: In five field studies of the costs of DSD models for HIV treatment, most models within each country had relatively similar costs, except for 6-month dispensing models, which were slightly less expensive. Most models provided substantial savings to patients. Research is needed to understand the effect of DSD models on the costs of ART programmes as a whole.
Highlights
Throughout sub-Saharan Africa, governments are rapidly scaling up “differentiated service delivery” (DSD) for antiretroviral therapy (ART) for HIV
Research is needed to understand the effect of DSD models on the costs of ART programmes as a whole
DSD models are expected to reduce the cost of service delivery per ART patient for providers and the cost of accessing ART for patients themselves[2]
Summary
Throughout sub-Saharan Africa, governments are rapidly scaling up “differentiated service delivery” (DSD) for antiretroviral therapy (ART) for HIV. DSD is intended to improve the “conventional” model of service delivery, in which all ART patients received the same, resource-intensive, clinic-based care regardless of their conditions, constraints, or preferences. DSD models are expected to reduce the cost of service delivery per ART patient for providers and the cost of accessing ART for patients themselves[2]. This expectation follows logically on the notion that DSD models are designed to be “less intensive” than conventional care, and presumably utilize fewer resources per patient served[3]. Few empirical data drawn from DSD models implemented in routine care settings have been available to compare the costs of differentiated service delivery to conventional, facility-based care[4]
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