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Costs and cost-effectiveness of HIV/noncommunicable disease integration in Africa: from theory to practice

Nugent, Rachela,b; Barnabas, Ruanne V.b,c; Golovaty, Ilyac; Osetinsky, Briannad; Roberts, D. Allenb,e; Bisson, Cristinaa; Courtney, Laurena; Patel, Pragnaf; Yonga, Geraldg; Watkins, Davidc

doi: 10.1097/QAD.0000000000001884
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The current article reviews economic aspects of selected HIV/noncommunicable disease (NCD) service delivery integration programs to assess the efficiency of integration in limited capacity settings. We define economies of scope and scale and their relevance to HIV/NCD integration. We summarize the results of a systematic review of cost and cost-effectiveness studies of integrated care, which identified 12 datasets (nine studies) with a wide range of findings driven by differences in research questions, study methods, and health conditions measured. All studies were done in Africa and examined screening interventions only. No studies assessed the cost of integrated, long-term disease management. Few studies estimated the cost-effectiveness of integrated screening programs. The additional cost of integrating NCD screening with HIV care platforms represented a 6–30% increase in the total costs of the programs for noncancer NCDs, with cervical cancer screening costs dependent on screening strategy. We conducted 11 key informant interviews to uncover perceptions of the economics of HIV/NCD integration. None of the informants had hard information about the economic efficiency of integration. Most expected integrated care to be more cost-effective than current practice, though a minority thought that greater specialization could be more cost-effective. In the final section of this article, we summarize research needs and propose a ‘minimum economic dataset’ for future studies. We conclude that, although integrated HIV/NCD care has many benefits, the economic justification is unproven. Better information on the cost, cost-effectiveness, and fiscal sustainability of integrated programs is needed to justify this approach in limited-resource countries.

aRTI International

bDepartment of Global Health

cDepartment of Medicine, University of Washington, Seattle, Washington

dDepartment of Health Services, Policy, and Practice, Brown University, Providence, Rhode Island

eDepartment of Epidemiology, University of Washington, Seattle, Washington

fCenter for Global Health, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA

gAga Khan University, Nairobi, Kenya.

Correspondence to Rachel Nugent, RTI International, Seattle, Washington, USA. E-mail: rnugent@rti.org

Received 10 November, 2017

Revised 10 May, 2018

Accepted 10 May, 2018

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (http://www.AIDSonline.com).

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Introduction

Integrated care for HIV/AIDS and noncommunicable diseases (NCDs) is defined (Supplement, http://links.lww.com/QAD/B291) as the coordination, colocation, or simultaneous delivery of HIV services [including antiretroviral drug treatment (ART)] and screening and/or treatment for various NCDs among people living with HIV (PLHIV)/AIDS [1]. The literature on HIV/NCD integration has focused predominately on cardiovascular disease (CVD) risk reduction, cancer screening and treatment, and management of comorbid mental health disorders [2]. A number of investigators have argued that integrated care has the potential to improve both HIV and NCD health [3]. This potential has become a desideratum in light of limited domestic and external funding to address rising NCD and HIV burdens [4]. However, numerous salient questions remain before integrated care can be recommended as standard practice, especially in very resource-constrained, endemic, or hyperendemic African countries. These questions include what scope of services and at what level integration should be attempted to achieve technical, productive, and allocative efficiency [5]. Impacts on health outcomes and cost per patient of integrated services need to be evaluated to suggest how to best preserve donor and public-sector investments and develop fiscally sustainable solutions.

Optimistic assumptions have been made about the possible economies of scope and scale that are achievable with integrated chronic disease care, and preliminary data presented here suggest this optimism may be warranted. Conversely, there is evidence of economic inefficiency when providing complex care for multiple morbidity in resource-limited settings [6]. Assumptions about achieving greater efficiencies in delivering quality integrated chronic care have not been sufficiently evaluated. In this article, we review the economic principles that make integration of HIV/NCD care attractive in theory, summarize the limited literature on the cost and cost-effectiveness of integrated HIV/NCD care, and present the perspectives of various global and national stakeholders on the economics of integration. We then propose a research agenda and a minimum economic dataset for future studies of HIV/NCD integration.

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The economics of integration: economies of scale and scope

The economic rationale for integrating NCD and HIV care stems from maximizing efficient health production through economies of scale and scope. Both kinds of efficiencies are theoretically possible to achieve through integration of HIV and NCD services. These efficiencies are measured by means of the ‘unit cost’, defined as the total expenditure to produce one unit of a product or service. Unit costs combine fixed costs (which are unchangeable in less than 1 year, such as facilities) and variable costs (which are changeable within 1 year, such as most labor or consumable supplies).

Economies of scale are depicted with a U-shaped curve (Fig. 1). Economies of scale in healthcare delivery may arise from spreading fixed costs (facilities, equipment) over more treatment cases; learning by doing, such as increased experience or repetition of treatments; lowering supply input prices through bargaining power, purchasing in bulk, strengthening supply chains; and creating opportunities for specialization. Diseconomies may arise from overcrowded clinics, longer wait times, and disenrollment, and from provider burnout due to expanding the range of services offered in a very constrained setting. Recent studies have found larger HIV prevention and treatment programs are associated with decreased unit costs across multiple countries and programs [7,8].

Fig. 1

Fig. 1

Economies of scope are efficiency gains that occur from producing several outputs together, producing cost savings by using proportionally fewer inputs than when the products are produced separately (Fig. 2). Economies of scope can arise when producing multiple types of services reduces the unit costs, either through cost complementarity or sharing fixed costs like overhead and other indivisible resources [9]. Economies of scope are already possible within HIV care as programs often include multiple different services. In programs that produce highly complementary services cost savings may even occur [10,11]. For instance, some programs are clinically recommended to integrate, like HIV and tuberculosis (TB) screening of asymptomatic patients, and also do not require a large burden of extra inputs beyond what is needed for stand-alone programs [12,13]. Finally, even if unit costs for integrated care are higher than for nonintegrated care, HIV integration between HIV and general health services such as primary care and family planning can be cost-effective if joint production yields better health outcomes.

Fig. 2

Fig. 2

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Review of cost and cost-effectiveness studies of HIV/noncommunicable disease integration

Methods

We reviewed the current economic evidence for integrated HIV/NCD strategies in low and middle-income countries (LMICs), focusing on the scope of conditions and countries addressed by this journal supplement. We conducted a systematic review following the Cochrane Collaboration [14] and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (refer to Supplemental Content Appendix A for search strategy and protocol, http://links.lww.com/QAD/B291) [15]. Briefly, we searched Medline, EMBASE, Global Health database, and Econlit from 1 January 2007 to 1 March 2018 for studies that reported the results of integrated HIV/NCD care including economic outcomes. To obtain unpublished primary costing data, in early 2017, we surveyed colleagues to obtain a list of integrated HIV/NCD studies in progress and contacted the primary investigator. Four study groups responded to our request for primary costing data for integrated HIV/NCD treatment services (CDC-Malawi, Ampath, ICAP-Aga Khan, and Linkages).

Studies were eligible for inclusion if they reported cost data on the integration of NCD screening and/or care into HIV programs. NCD program terms included counseling, health promotion, screening, treatment, and/or adherence monitoring. NCDs were defined as hypertension, diabetes, hyperlipidemia, cervical cancer screening, and/or depression, within HIV programs, with an economic evaluation in at least one LMIC. Data were extracted by two independent reviewers. We used the Drummond Checklist to score the quality of the economic evaluation [16]. Unit cost data for integrated services were abstracted from the cost analyses. All cost data were adjusted to 2013 USD to facilitate comparison across studies.

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Findings of the review

Our search strategy identified 896 abstracts for review. Data extraction forms were completed for 22 full-text articles, of which 12 reports (nine studies) met the inclusion criteria (refer to Appendix A, Fig. 1, http://links.lww.com/QAD/B291). Current evidence on the cost of HIV/NCD integration is limited to integrated screening within HIV programs in sub-Saharan Africa. Five studies included cervical cancer screening (including dysplasia), four included cardiometabolic screening, and one screened for depression. No studies clearly evaluated the costs of integrating NCD care (treatment, adherence, retention) within an HIV program. Most of the cervical cancer screening programs were facility based, whereas the cardiometabolic screening were all community based. All but one study took a provider perspective. One study took a societal perspective by incorporating costs outside the health system such as patient time and transport. Only three studies (all of cervical cancer screening) reported effectiveness outcomes (Tables 1 and 2).

Table 1

Table 1

Table 2

Table 2

There was limited evidence of the cost or cost-effectiveness of integration among noncancer NCDs, including hypertension, diabetes, and associated risk factors, in HIV [17–22]. All four studies identified were community-based HIV testing programs. Although the absolute costs of screening varied widely depending on the site, we provide the amount attributable to NCD screening in both absolute terms and percentage terms [Tables 1 and 2; (NCD unit cost)/(Integrated unit cost)]. The estimated additional per-person cost of adding NCD screening to a nonfacility program ranged from 6 to 30% of total HIV testing and counseling (HTC) program costs (Tables 1 and 2) [17–19,22].

The SEARCH platform in Kenya and Uganda (a multiphase integrated HIV/NCD community-based screening campaign with home-based follow-up) was one of the largest integrated programs studied. The attributable cost for hypertension and diabetes screening was USD 1.14 (or 6%), on top of a cost for HIV counseling and testing of USD 20.10. A majority of costs were counted as fixed, and personnel represented 50% of total costs [19]. de Beer et al. [21] evaluated a mobile-van-based integrated program in South Africa with an additional NCD screening cost of USD 12.31 (19% of the total screening cost of USD 65.72) and an additional time burden of 15 min (∼20% of program time).

The Linkages study, a prospective study of home-based HIV testing and linkage to care in South Africa, estimated the cost per NCD screening to be USD 3.95 (30%) for a total cost of USD 13.31 for an integrated HIV/NCD screening program [17]. The NCD component of Linkages included screening for hypertension, diabetes, tobacco consumption, hyperlipidemia, and depression, providing the broadest integrated screening services in the studied settings [23]. There was a 15–20% decrease in the number of clients able to be screened per day with integration, based on a time assessment.

For cervical cancer screening among HIV-positive women on ART, two studies explored the cost of integrating several cervical cancer screening methods into existing HIV treatment programs. For visual inspection with acetic acid (VIA), the cost ranged from USD 3.24 to 3.67, Papanicolaou smear (Pap) cost USD 8.17–24.08, and human papillomavirus testing costs ranged from USD 17.92 to 54.34 [24,25]. Three studies reported additional costs ranging from USD 18 to 26 per visit per person receiving integrated cervical cancer screening (Pap or VIA) within HTC (Sexual Reproductive Health/HTC strategies) [26–28]. A number of cervical cancer screening strategies indicated a higher proportion of fixed costs compared with HIV services, as cervical cancer screening may depend heavily on staff and capital costs. However, in these instances, staff salaries were reported as fixed costs that could possibly change with more creative staffing arrangements, such as task-sharing [11,26–28]. Variable costs for Pap testing included cytology, transport, and specimen collection [24,27].

Few studies estimated cost effectiveness. In one instance in rural Zambia, integrated HIV-cervical cancer screening with enhanced counseling (including motivational interviewing and linkage to care) was more cost-effective compared with a nonintegrated standard of care which included stand-alone HIV-testing and referral to other services [26]. This finding relied heavily on model assumptions of projected treatment costs and morbidity/mortality based on the study's 6-month outcome (HTC and cervical cancer uptake). From the societal perspective, integrating cervical cancer screening within an HIV treatment program in Kenya may be cost-saving; Vodicka et al. [25] found decreased costs of cervical cancer screening strategies in an integrated platform compared with stand-alone through reductions in overhead costs, patient transport, and time burden. Based on the same costing analysis, Zimmermann et al. [29] projected lifetime societal costs ranging from USD 192 to 218 by integrated varying screening and preventive cryotherapy in an HIV treatment program, with around 17 years projected life expectancy.

In sum, the increased unit cost of the noncancer NCD screening integrated with HIV care platforms ranged from USD 1.14 to 12.31, representing a 6–30% increase in the total costs. Cervical cancer screening costs ranging from USD 3.24 to 54.34 depending on screening strategy. This review did not identify an economic evaluation of integrating NCD care services following screening in an HIV program. An additional evidence gap is the lack of studies estimating the cost of facility-based integration for noncancer NCDs, given the reality that management of NCDs is usually facility based. Lastly, few studies coupled costs with outcomes data to estimate efficiency and benefit; only one study provided a measure of improved health outcomes from cervical cancer screening.

The current review has numerous limitations. For the noncancer NCD integration studies, significant differences in study design and reporting limit the ability to compare programmatic costs across time and settings. The studies reviewed did not allow a direct comparison of integrated programs with programs that provided all components of integrated care separately. Other limitations included vague reporting on quantities and prices, unclear methods of time allotment for NCD integration, and limited data on efficacy and adjustments for differential timing of screening activities. The scope of the review focused on a limited number (five) of disease conditions. Future work would expand this search to a broader range of diseases.

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Qualitative assessment of economics of HIV/noncommunicable disease integration

To better understand the expectations about the cost-effectiveness of integrated HIV/NCD care with the reality we found in the literature, we conducted a small number of focused interviews to explore the understanding and perceptions of the economics of HIV/NCD integration with key interested parties. The purpose was to inquire about the most likely sources of economies of scale and scope from using an integrated model, if at all, and learn of any first-hand observations regarding the existence of such efficiencies in service delivery.

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Methods

We conducted semistructured, in-depth interviews with 11 individuals specializing in HIV program implementation, HIV/NCD integration, and/or economics from a variety of backgrounds, including ministry of health (n = 2), donors (two), in-country implementers (two), policy advisor (one), and academics/researchers focused on HIV (two) and health economics (two). Respondents worked in Kenya, Malawi, South Africa, Swaziland, and globally. We asked the respondents 10 questions (Supplemental Content Appendix B, http://links.lww.com/QAD/B291) about integration of HIV/NCDs, initially to ascertain their perspectives and knowledge, and then to learn more about their understanding and impressions of the economic aspects of integration. Responses were transcribed and thematically analyzed to identify notable similarities and differences across respondents.

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Results

Half of the respondents had direct experience integrating HIV/NCD services. Settings for this experience ranged from minimal NCD screenings conducted at HIV clinics to more complex integration of NCD and HIV, including treatment services. Most experiences were basic screening of NCDs within a vertical HIV program. Among the respondents, hypertension was most commonly screened for, followed by diabetes and cervical cancer. Treatment was often provided through referrals to other health facilities, not at the HIV clinic.

According to respondents, the three most common challenges facing national health programs trying to integrate HIV and NCDs were funding streams, drug procurement for medical management of NCDs, and monitoring and evaluation systems. Country-level managers and ministry officials reported struggling to make services and chronic care more accessible for patients, as they had to work around vertical funding streams. A related challenge was the cost of NCD treatment itself. The cost to procure the range of medications needed to treat CVD, diabetes, and cancer far exceeded health budget lines. Moreover, there was a concern that NCD expenses would compete with other health needs. However, respondents consistently mentioned screening as a cost-effective intervention.

Respondents showed a clear understanding of cost effectiveness by providing an accepted definition, but responses varied about its importance in guiding the appropriateness of integrated care. Several respondents (donors, ministries of health, and health economists) indicated that program cost-effectiveness was of primary importance. Their view was that decision makers with limited funds need to be responsible and prioritize where healthcare funds are spent, such as what to screen and when. Others reported that cost is just one of many factors that must be considered. Some offered an ethical rationale for providing NCD treatment.

Some respondents indicated that NCD treatment is often not funded as it is not considered cost effective. There was a general belief that there would initially be higher costs to integrate treatment and care for patients with HIV/NCD comorbidity. Among the additional costs mentioned were staff training, tools, supplies, treatment, monitoring systems, and laboratory tests. The up-front costs were expected to be high for service design and training, whereas full service integration was expected to eventually cause costs to fall.

Nearly all respondents suggested that integration could be done efficiently and cost-effectively, if certain conditions are met. For instance, careful budget planning is necessary to support the rollout of integration, and the most effective integration model probably varies for each setting. An alternative point of view emerged suggesting that integration does not necessarily lead to efficiency; rather, that specialization leads to efficiency gains. Arguments for this viewpoint pointed to more challenging workflow for integrated service delivery. Most respondents cautioned that integration is complex and multilayered and must be examined in context for costs and cost-effectiveness to be demonstrated.

Respondents’ perceptions of the literature were consistent with the findings of our review that there is a serious shortage of data demonstrating cost effectiveness or cost savings from integration. One donor indicated that much of the cost data they use to prioritize funding is outdated, and the field is changing rapidly, even within 2–3 years. There is a need for primary cost data from a variety of countries and settings, including clinical services, commodities, and lab services.

Respondents made suggestions:

  1. Longitudinal data would be valuable to look at the long-term costs and benefits of HIV/NCD treatment.
  2. Data are needed on who pays for NCD treatments and how much; patient costs as well as program costs must be collected.
  3. There is a need to compare NCD treatment costs within an integrated system to a standalone system.
  4. Purchasing NCD and HIV treatment drugs together may provide economies of scale.
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What are the critical gaps in knowledge on the economics of HIV/noncommunicable disease integration?

Our systematic review has highlighted the divergence of methods and findings within the small literature on the cost and cost-effectiveness of integrated care. To address the knowledge gaps related to the economics of integration and encourage consistency and comparability in future research, we have proposed a minimum economic dataset (Table 3) for any economic evaluation of integrated care, and a set of research questions for understanding the economics of HIV/NCD integration. Ideally these data would become part of routine epidemiological studies and program evaluations, and these research questions would be integrated into HIV outcomes research. Evaluation of economies of scale and scope require reporting of program size, breakdown of costs, and size and cost of comparable standalone programs, as comparators. In the absence of comparable standalone programs, economies of scope will be difficult to measure.

Table 3

Table 3

The current review has addressed the efficiency of delivering clinical services using integrated (as compared with nonintegrated) care models. Cost-effectiveness analysis (CEA) is a flexible approach that can be used to assess various means by which to deliver the same types of services for NCDs. Cost-effectiveness ratios for process outcomes or intermediate clinical outcomes (e.g., cost per case of cervical dysplasia detected) are probably adequate for this sort of CEA; it may not be necessary to extrapolate to long-term outcomes [like deaths or disability-adjusted life years (DALYs) averted from CVD or cancer] if the efficiency of producing certain services is the policy question.

As a separate problem, related to but outside the scope of this review, we know very little about cost-effective approaches to managing NCDs in PLHIV, whose risk profile is in some cases dramatically different than the general population. CVD risk provides a useful example here. Analyses conducted for Disease Control Priorities, 3rd Edition, and other publications have produced recommendations for screening and medical management of CVD risk factors in LMIC populations [30]. Key lessons learned from these analyses are that baseline level of risk matters greatly in determining whether specific treatments are cost-effective, and that combination therapy is generally preferred to focusing on single risk factors like blood pressure or cholesterol [30].

On the contrary, as the CVD risk profile of PLHIV is not comparable with the general population, existing guidelines may recommend care that is not cost-effective. PLHIV may be considered to have higher risk of CVD due to inflammatory effects of the virus itself, although in the African context PLHIV are (currently) a relatively young and cardio-metabolically healthy group compared with the general population. Reflecting these uncertainties, the development and validation of CVD risk calculators in PLHIV remains an active area of research [31]. Further, the impact of ART itself on NCD risk is not well understood [32]; it is plausible that viral suppression may reduce inflammation and hence reduce some risks (such as the risk of vascular disease or cervical dysplasia) [33], whereas some ART regimens may precipitate mood disorders or induce metabolic derangements that increase risk of vascular disease [34].

Given all these uncertainties, it would be perilous simply to apply the conclusions of CEAs conducted on CVD interventions in the general population to the HIV population. CEAs that assess CVD management strategies among HIV-affected populations, particularly African populations, are urgently needed. These studies should generally be modeling long-term outcomes (e.g., measured in deaths or DALYs) rather than process and intermediate outcomes.

We identify four major research needs in this area for LMICs. First, a range of additional economic evaluations are needed. They include costing of multiple models of integrated strategies with linkage across levels of the treatment cascade; CEA that compare standard care with integrated care, preferably using multisite, longitudinal clinical and epidemiological studies; microeconomic studies that can generate production functions across different types of facilities to demonstrate economies of scope and scale; and methodological advances that incorporate those supply-side characteristics into existing health economic evaluations.

A second major need is better longitudinal data on NCD risk and outcomes in PLHIV. Third, studies are needed that assess the interactions of multiple NCDs. Fourth, from a technical standpoint, the methods, data sources, and assumptions of the HIV and NCD economic modeling communities need to be harmonized and standardized. Economic analysis from integration of HIV services with other chronic diseases, such as TB, may be a useful guide for NCD–HIV integration economic studies.

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Conclusion

Economic evaluation of new service delivery models can guide countries seeking to offer efficient and effective HIV programs. The differentiated service delivery model that offers care to PLHIV who are stable on ART with suppressed viral loads will be an important test case of cost-effectiveness, especially when the goal is integration with community and other primary healthcare. How to manage the long-term chronic care needs for both HIV-positive and HIV-negative persons in a financially sustainable manner presents clear choices among care sites, populations reached, and services provided. Economic assessment of optimal services and policy packages will be most useful when it is fine-tuned to the population needs and projected resources available, incorporating the most cost-effective interventions, settings, and regions. Until such assessments are more widely available on a more comprehensive basis, the notion that integrated care for HIC and NCDs is cost-effective is more theory than reality.

Beyond economic assessment of integrated service delivery models, it is useful to take a step back and question how to best serve and meet population-wide needs. Even when integrated service delivery models are demonstrated to be cost-effective, they may not be affordable in the near-term. Many countries are only beginning to identify and provide NCD services to their populations in need. The scale and scope of those services will remain very limited until new funding sources are in place. Universal health coverage provides the framework for countries to choose a chronic care service model that best suits their choice of health system platforms, while also aiming to provide those services to the whole population. Integrated delivery within HIV services programs may be understood best as a temporary response to a funding model in transition (Table 4).

Table 4

Table 4

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Acknowledgements

Sources of support: this article as part of the Research to Guide Practice: Enhancing HIV/AIDS Platform to Address Non-Communicable Diseases in sub-Saharan Africa was supported by the US National Institutes of Health Fogarty International Center.

Author contributions: R.N., R.V.B., I.G., and D.W. designed the study and wrote multiple drafts. I.G., R.V.B., and D.A.R. conducted the literature review. B.O. contributed the section on economies of scope and scale. R.V.B. and I.G. contributed data and analysis from the Linkages study. P.P. contributed data and analysis from the Malawi study. G.Y. contributed data and analysis from the Aga Khan study. C.B. and L.C. conducted the qualitative analysis and provided results. All authors approved the final draft.

CDC disclaimer: the findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

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

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Conflicts of interest

There are no conflicts of interest.

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Keywords:

cost; cost-effectiveness; HIV/noncommunicable disease integration

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