Efficiency Gains from Integration of HIV-Related Services: Preliminary Findings

1. Efficiency Gains from Integration of HIV-Related Services:Preliminary Findings Sedona Sweeney, CarolDayo Obure, Anna Vassall The London School of Hygiene and Tropical Medicine was contracted by UNAIDSto conduct a literature review of the experience of efforts to integrate HIV prevention or HIV treatment, care and support activities into more general health services, and of the impact that these efforts have had on the efficiency with which services are delivered, both for HIV and for health in general. • The in this presentation, is complementary to the Integra initiative, a research project that is managed by IPPF in collaboration with the LSHTM and the Population Council, and is supported by the Bill and Melinda Gates Foundation

2. Overview • Focus is this meeting • Background • Literature review methods • Summary by each area • Way forward

3. Background • Definition of integration is complex • For the purposes of this review, we use the UNAIDS definition of programme integration: “joining together different kinds of services or operational programmes in order to maximize outcomes, e.g. by organizing referrals from one service to another or offering one-stop comprehensive and integrated services”

4. Types of integration • Integration of HCT/ ART into other services • SRH/FP/ANC clinics/TB clinics • Primary health clinics/Community health care • Integration of other services into services for HIV+ • VCT clinics adding FP/SRH services • VCT performing ICD/IPT for TB • ART clinics adding FP/SRH/TB services • Services for high risk groups into general services • Chronic care models

5. Possible efficiency gains • Technical Efficiency • ‘Economies of scope’ associated with sharing overhead, HR, management and infrastructure costs • Gains from ‘economies of scale’ associated with new clients and higher workloads • Improvements in effectiveness, associated with: • improved client experience (and adherence?) • earlier treatment, reduction in mortality (TB/HIV)

6. Different levels of potential gains from integration • At program/systems level • Reductions in systems and programme costs: joint procurement, IEC, sharing of middle managers, training and supervision • At facility level • Reductions in facility costs resulting from joint utilization of fixed factors of production • At patient level • Reductions in patient/community level costs resulting from fewer visits to facilities, proximity of services and reduced delays

7. Methodology • Research question: Does integration of HIV prevention or AIDS treatment, care and support activities into general health services have an impact on the efficiency with which services are delivered?

8. ‘Finding a needle in a hay stack’ • Comprehensive search of published and grey literature • Eldis • Integrat* or converg* or linkage$, within topic headings “HIV and AIDS”, “Health Systems and HIV and AIDS” • Pubmed • Keywords: (integrat* or converg* or linkage$ or coordinat* or vertical or scope[Title/Abstract]) AND (“Delivery of Health Care/organization and administration”[Majr] OR “Primary Health Care/organization and administration [Majr]) AND AIDS[sb] • Keywords: (((tuberculosis OR TB) AND AIDS[sb]) OR ((sexual and reproductive health OR SRH) AND AIDS[sb]) OR ((maternal and child health OR MCH) AND AIDS[sb]) AND (“Delivery of Health Care/organization and administration” OR “Primary Health Care/organization and administration”)[Majr] AND (efficien* OR cost-effective* OR cost-benefit OR economic*)

9. Methodology [3] • Global Health and EconLit • Keywords: (integrat* or converg* or linkage$ or linked or coordinat* or vertical or scope [Title]) AND( efficien* or cost-effective* or cost-benefit or economic*) AND (HIV or AIDS)  AND (program or programme or care or campaign or intervention or service) • Manual searches of websites for key organizations involved in sponsoring or reporting HIV-related research or cost-effectiveness studies: • Abt Associates, PSI, FHI, HLSP, MSH, PATH, CSIS, PAI, R4D, JSI, IPPF, PopCouncil, Options • ‘Snowballing’ for further references

10. Methodology [4] • Integration of HIV with other health services is a complex intervention posing difficulties for systematic reviews (BMJ. Shepperd et al, 2009) • We therefore took the following methodological decisions: • Inclusion of theoretical evidence where empirical evidence is weak • Evidence is synthesized in context, rather than quantitatively • Take into account qualitative reviews

11. Inclusion Criteria • Use of clearly identifiable economic or epidemiological measures to evaluate the effect of integration (but we did allow models) • Cost and/or cost-effectiveness studies • Focus on low-income settings • Included studies that did not have a ‘no integration’ comparator, but presented incremental costs or cost-effectiveness from do nothing base case (ie ART in PHC)

12. Grading of literature • Not yet time to include formal grading, but examined: • Costing methods • Source of effectiveness data • Level of evidence: • Model • Pilot study • At scale • Sustainably at scale

13. Types of studies found • 41 studies met inclusion criteria • 28 published cost / economic evaluations • 4 literature reviews • 8 project evaluations • 1 epidemiological model

14. Costs methods used

15. Effectiveness data

16. Results

17. VCT into SRH/PHC • Consistent , but limited evidence that HIV/AIDS counselling and testing integrated into SRH /PHC setting is less costly per person tested than in stand-alone VCT sites • Integrated VCT increases testing rates, (even tested – but no control Liambila) *Cited from: Sweat, et al. 2000

18. VCT into SRH/PHC • Weak evidence on the comparative advantage of direct testing by the same service provider vs. referral to a different service provider within the facility

19. VCT into PHC/SRH • No clear evidence on comparative costs of where to integrate HCT

20. VCT + PHC/SRH Summary • Integration of VCT and SRH is feasible and affordable (Mullick, Reynolds) • Integration has been shown to be more less costly than stand-alone VCT at a small scale (2 - 23 facilities) (Twahir, Forsythe, Liambila) • But questions remain on how integration impacts effectiveness and best method of implementation (Liambila, Mullick, Homan, Routh, Menzies) and whether gains made at scale • Concerns about over-loading health staff  Sufficient evidence to support further scale-up and sustainability of integration of VCT and SRH in a wide variety of settings (assuming evidence sufficient on effectiveness of VCT more generally)

21. Family Planning for HIV+ (integrated in PMTCT) • Models estimated that meeting unmet FP need of HIV-positive is cost-effective

22. Family Planning for HIV+ • Beyond this, models also estimate that meeting unmet FP need for HIV-positive women has cost-saving potential, but almost no information on whether FP should be added to ART clinics

23. Family Planning for HIV+ • No empirical information on cost-effectiveness on FP into ART clinics (condom use) • Reynolds 2006 – quality of care, but only includes training costs • Potential for significant cost-savings established. But no real evidence yet on how best to provide integrate services. Pilot and evaluate models of care.

24. ART + PHC and beyond • It is feasible and cost-effective to attach ART to PHC/ ANC, increased uptake of services, but difficult to establish whether (or when) integrated or non-integrated services are less costly • Yesterday Lori Bollingers presentation • Mead Overs presentation (higher costs at clinics)

25. ART + PHC and beyond • Integration with primary health care may lead to better health outcomes, as well as broader health service benefits

26. ART + PHC and beyond • Relative costs of hospital vs primary health care vs home care • Is TB an example (DOTs) – Five pronged model • Role of adherence in cost, • Evidence some countries (middle-income countries/ concentrated epidemics) • Patient costs important

27. TB/HIV - IPT • IPT is cost-effective in low-income settings, and potentially cost-saving. TST does not significantly affect the cost-effectiveness of IPT.

28. Intensified case detection (ICD) + IPT (the ProTEST Package) Cost per HIV infection averted by VCT was US$ 67–112 (Hausler 2006).

29. IPT / ICD/ HCT - Conclusions • ICD and IPT are cost-effective in a low income setting, The cost-effectiveness of the ProTEST package has been established at a small scale (2 and 12 facilities), • Larger potential benefits (58% in S. Africa of those with TB have HIV) – cost-effective in Hausler study • => Potential for scale-up, but as with VCT needs to be evaluated • However, as smear negative diagnosis is limited (but will improve with new diagnostics), the added benefit in terms of numbers of TB cases still needs to be established

30. Xpert • New technology for point of care use to diagnose TB (including smear negative) • Paper presented at WHO on cost-effectiveness • Roll-out in South Africa and Brazil • With co-ordinated effectiveness modelling • Still other low cost options: presumptive treatment of TB in ART initiation

31. Way forward

32. Methodological • Faced with high degree of variation, isolating the effect of integration (next slide) • Typical economies of scope analysis are econometric and look at numbers of services • Integration is more complex • Integration index – use of latent variable analysis on a number of different variables (resources, services, provided , physical location, client flow) – reveals breadth and sophistication

33. Quasi-experimental design • Hard to control for at baseline and over time • PARs to measure integration during the project/ mixed methods/ cohort/ community surveys • Alternatives • Comparative DEA (Kittelsen 2009) • Econometric analysis of cost functions (Weaver and Deolalikar, 2003; Weaver et al, 2009)

34. Other issues • Outcomes (and costs) associated with delay • Externalities • Missing health systems costs • Impact on financing • The question is when? • Few examine true additional cases at the population level, demand side studies • Tipping point, assuming HR constrained

35. Opportunity for comparison? Episode/unit costs (US$ 2009)

36. Average visits per clinical staff FTE per day

37. Why? • Understand why certain facilities under-performing • Three layers (direct, management, system) • Poor management/ management systems • HR / capital planning/ global budgeting • Engagement in • Decentralisation/management systems • HSSPs/ (HS)MTEFs/ PERs • Integration key to efficiency at all levels