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The costs and effectiveness of four HIV counseling and testing strategies in Uganda

Menzies, Nicka,b,c; Abang, Bettyd; Wanyenze, Rhodae; Nuwaha, Fredf; Mugisha, Balaamg; Coutinho, Alexh; Bunnell, Rebeccai; Mermin, Jonathani; Blandford, John Ma

doi: 10.1097/QAD.0b013e328321e40b
Epidemiology and Social

Objective: HIV counseling and testing (HCT) is a key intervention for HIV/AIDS control, and new strategies have been developed for expanding coverage in developing countries. We compared costs and outcomes of four HCT strategies in Uganda.

Design: A retrospective cohort of 84 323 individuals received HCT at one of four Ugandan HCT programs between June 2003 and September 2005. HCT strategies assessed were stand-alone HCT; hospital-based HCT; household-member HCT; and door-to-door HCT.

Methods: We collected data on client volume, demographics, prior testing and HIV diagnosis from project monitoring systems, and cost data from project accounts and personnel interviews. Strategies were compared in terms of costs and effectiveness at reaching key population groups.

Results: Household-member and door-to-door HCT strategies reached the largest proportion of previously untested individuals (>90% of all clients). Hospital-based HCT diagnosed the greatest proportion of HIV-infected individuals (27% prevalence), followed by stand-alone HCT (19%). Household-member HCT identified the highest percentage of discordant couples; however, this was a small fraction of total clients (<4%). Costs per client (2007 USD) were $19.26 for stand-alone HCT, $11.68 for hospital-based HCT, $13.85 for household-member HCT, and $8.29 for door-to-door-HCT.

Conclusion: All testing strategies had relatively low per client costs. Hospital-based HCT most readily identified HIV-infected individuals eligible for treatment, whereas home-based strategies more efficiently reached populations with low rates of prior testing and HIV-infected people with higher CD4 cell counts. Multiple HCT strategies with different costs and efficiencies can be used to meet the UNAIDS/WHO call for universal HCT access by 2010.

aUS Centers for Disease Control and Prevention (CDC), Global AIDS Program, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, USA

bMacro International Inc, Atlanta, Georgia, USA

cHarvard University, Cambridge, Massachusetts, USA

dCDC-Uganda, Global AIDS Program, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC, and Uganda Virus Research Institute, Entebbe, Uganda

eMulago-Mbarara Teaching Hospitals' Joint AIDS Program (MJAP), Uganda

fMakerere University, School of Public Health, Uganda

gThe AIDS Information Centre (AIC), Uganda

hThe AIDS Support Organization (TASO), Kampala, Uganda

iCDC-Kenya, Coordinating Office for Global Health, CDC, Nairobi, Kenya.

Received 8 August, 2008

Revised 1 November, 2008

Accepted 11 November, 2008

Correspondence to Nick Menzies, Harvard University Health Policy Program, 14 Story Street, Cambridge, MA 02138, USA. Tel: +1 404 217 1076; fax: +1 617 496 2860; e-mail:

© 2009 Lippincott Williams & Wilkins, Inc.