Population growth is a driver of poverty in sub-Saharan Africa where the average woman bears more than five children . Family planning reduces unintended pregnancy, abortion, maternal death, and perinatal HIV infections when unintended pregnancies are averted in HIV-positive women . Zambia is one of only three countries in Africa with increasing fertility rates, rising from 5.15 in 2009 to 5.67 in 2016 . Unmet need for family planning in Zambia is 22% among married women . In particular, long-acting reversible contraceptives (LARC), such as the nonhormonal copper-T intrauterine device (IUD) and subcutaneous hormonal implants are highly effective, with typical-use failure rates of less than 1% per year . However, they are used by just 1.2 and 5.7% of Zambian women with stable partners, respectively , and access to LARC methods continues to be limited by a lack of trained providers and necessary equipment .
Unmet need for family planning is often higher among HIV-positive women than the general population [8–10]. In sub-Saharan Africa, family planning and HIV programs serve similar populations, primarily cohabiting heterosexual couples. The integration of family planning and HIV services is supported by the WHO, the United Kingdom Department for International Development, and the United States Agency for International Development (USAID) to improve health outcomes, client satisfaction, resource use, and to reduce stigma [11–13]. Sponsors have urgently called for development and evaluation of adaptable integrated models .
Previous studies have explored costs and/or cost-effectiveness of HIV services integrated with sexual and reproductive health services. Sweeney et al. conducted a systematic review, which concluded that integration of HIV with sexual and reproductive health services was cost-effective relative to standard-of-care alternatives. Obure et al. reviewed the costs of delivering six HIV service programs integrated with sexual reproductive health services in resource-limited settings and similarly concluded that savings are possible given more efficient allocation of human and capital resources . In Kenya, a home-based intervention where pregnant women and their partners received HIV counseling and testing was found to be cost-effective over a 10-year time horizon . However, no previous studies have evaluated couple-focused interventions integrating HIV and family planning.
Couples’ voluntary HIV counseling and testing (CVCT), in which both partners participate jointly in pretest and posttest counseling with mutual disclosure and development of prevention strategies based on joint HIV test results, is a cost-effective and affordable prevention strategy [17–19] endorsed by WHO, PEPFAR, Global Fund, and the Government of Zambia [20–23]. This intervention reduces HIV risk by increasing condom use in discordant couples and decreasing outside sex partners and is an entry point into family planning [18,24,25].
From 2013 to 2015, the Zambia Emory HIV Research Project (ZEHRP) was supported by providing CVCT with couples’ family planning counseling (CFPC) with a focus on fertility-goal-based LARC promotion combined with service provision was introduced in subset of clinics. The objective of this analysis is to report on the incremental cost and effectiveness of the integrated CVCT+CFPC program.
Materials and methods
Integrated couples’ voluntary HIV counseling and testing and couples’ family planning counselling program development and operations
HIV counselors were trained to provide CVCT using US CDC counselor training materials following WHO guidelines . Services were promoted to heterosexual women and their partners in 55 government facilities in seven Zambian cities using a combination of mass media and promotions by community health workers and influential network agents (opinion leaders within communities), and overtime pay for weekday and weekend service provision off-duty government health facility staff [26,27].
CFPC training materials and procedures were developed during the first 6 months of the program based on prior research  and adapted for use in government clinics. CFPC counseling was based on stated fertility goals with access to the full range of contraceptive options. LARC methods were emphasized for couples wishing to delay pregnancy for 2 or more years. After government clinics had a full complement of staff trained in CVCT+CFPC promotion and provision and LARC insertion and removal, staff from individual HIV testing and counseling, family planning, outpatient, antiretroviral treatment, and infant vaccination departments were provided $1 USD for each referral that resulted in a CVCT+CFPC visit or a LARC client. These reimbursements were provided to the healthcare facilities who distributed them to providers based on their performance whether the clients chose to receive the services after counseling or not.
Fertility-goal-based family planning counseling was also offered to women attending family planning alone with referral for CVCT+CFPC. Conversely, couples attending CVCT+CFPC who did not request LARC because of time constraints or the desire to think about options before deciding were referred for a later date.
The addition of CFPC to the CVCT training curriculum required one additional day of didactic training and added an average of 5 min to the pretest counseling flip-chart-guided group session and 2 min (for couples not eligible for LARC promotion) to 10 min (for couples educated about and offered LARC methods) to flip-chart guided-posttest counseling.
Experienced ZEHRP staff trained government counselors and nurses to provide the integrated program in their clinics. Initially, counselors previously trained in CVCT received CFPC training, and subsequently new counselors received CVCT+CFPC training concurrently. ZEHRP staff also trained community health workers, influential network agents, and clinic staff to promote the integrated program in the clinic and community. Data shown are from March 2013 to September 2015.
Integrated program costs
We report costs following Global Heath Cost Consortium guidance . We report incremental financial costs of actual expenditures to add CVCT+CFPC into existing services. We report the additional costs incurred without including costs of the existing programs. This is a primary costing study of actual resources used (i.e. costs related to integrated service provision were observed and not modeled). Costs reflect the cost of scaling up CFPC with LARC training integrated with CVCT services. Cost data were recorded by ZEHRP staff during program implementation and entered in AccPac (Sage Group). Expenditures are reported both by activity [CVCT+CFPC service delivery, LARC service delivery, and training and monitoring and evaluation (M&E)] and by category in 2015 United States Dollars (USD). We apply straight-line depreciation for capital goods resulting in an annual cost over the life of the project .
Observed integrated program outcomes
ZEHRP staff recorded the number of nurses who completed didactic and practicum LARC training and were certified by two physicians accredited by the Ministry of Health, and the number of counselors trained in CVCT+CFPC. Clinic staff were given logbooks to record service delivery outcomes (couples receiving CVCT and CFPC, HIV serostatus results, IUD/implant insertions, removals, and replacements) and referral information. Data was entered into a Microsoft Access database for data management, cleaning, quality control, M&E, and analysis by ZEHRP staff.
Cost-effectiveness and modeling analyses
We adhere to Consolidated Health Economic Evaluation Reporting Standards  for cost-effectiveness analyses. All costs and outcomes are discounted at 3% per year. The counterfactual comparison in our analyses constituted the services offered prior to our implementation for which outcomes were abstracted from existing medical records: individual HIV testing and counseling and separate family planning programs serving women only and generally not offering LARC with no demand creation activities.
Modeling outcomes and cost-effectiveness of couples’ voluntary HIV testing
We used a compartmental model transitioning couples between HIV and/or antiretroviral treatment use status to estimate outcomes of adult HIV infections averted and cost-per infection-averted over a 5-year time horizon. Details of the model and its parameters, which were derived from a study in 73 Zambian government clinics among 207 428 couples (roughly 414 856 individuals) in Zambia, have been published  and key parameters are shown in Table 3. Briefly, we apply the HIV seroincidence rates in patients undergoing CVCT and individual VCT (the counterfactual) by couple serostatus and ART use status and the distribution of ART use among CVCT and individual VCT patients observed in the previous study . In this model, we evaluated the effect of possible differential loss to follow-up, informative censoring, and confounding when using observational data to estimate the effect of treatment and found that our model was robust in sensitivity analyses . Here, we model the HIV prevention impact among the 108 399 couples tested in the present integrated program, 6.3% of whom were discordant and 80.4% of whom were concordant negative. We apply the costs of service delivery and training observed during our integrated program implementation (Table 1) and did not include any additional costs to the healthcare system, such as the future lifetime costs of adult HIV infection.
Modeling outcomes and cost-effectiveness of long-acting reversible contraception uptake
Among women who selected LARC, we calculated counts and costs-per: pregnancies averted, cumulative couple-years of protection (CYP, a commonly used estimate of the length of contraceptive protection against pregnancy provided per unit of that method ) gained, and perinatal infections averted in HIV-positive women. All LARC impact and cost-effectiveness model parameters are shown in Table 2 and described below. The counterfactual applied the baseline distribution of contraceptive method use by the 56 409 women who had received standard-of-care family planning services prior to LARC uptake in our integrated program.
To calculate pregnancies averted by LARC use, we used published estimates of annual pregnancy risk for each method of contraception  and assume that all pregnancies among contraceptive users are unintended. We conservatively assumed 3 years of LARC use before discontinuation. To estimate CYP gained after LARC uptake, we used published CYP estimates . Finally, we calculated perinatal infections averted in HIV-positive women who initiated LARC, assuming that 17% of women were HIV-positive (as observed in this study) and 5% of HIV-positive women who become pregnant transmit to their child (as observed in Zambian PMTCT program data ). Using published data for pregnancy outcomes, we assume that 53% of pregnancies end in live birth, 14% in miscarriage/stillbirth/death, and 33% in abortion (including spontaneous and induced, the latter being legal in Zambia) .
To estimate cost-effectiveness measures, we included the costs to deliver LARC in the integrated program (service delivery and training). We also included additional costs to the healthcare system including the costs of: live birth (estimated using data from Zambia and including costs of personnel, administration, training, quality control, medical supplies, equipment, and pharmaceuticals, infrastructure, and utilities ); miscarriage/stillbirth/death (estimated using data from low and middle income countries and including costs for facility stay, personnel, medications, supplies, equipment, disinfection, and services [34,35]); abortion (estimated using data from Zambia and including costs of safe and unsafe abortions, medications for medical abortion, manual vacuum aspiration for surgical abortion, treatment for incomplete abortion, abortion complications, drugs, equipment, diagnostics, personnel, and administration ); antenatal care (assuming four visits for women whose pregnancies ended in live birth and two visits for women whose pregnancies end in miscarriage/stillbirth/death, and including costs of personnel, drugs and consumables, equipment, and overhead/facilities ); PMTCT for HIV-negative women [estimated using data from Zambia and including costs of repeat HIV testing (three HIV tests per guidelines for women with live births and one HIV test for women with miscarriage/stillbirth/death), personnel, recurrent inputs and services, capital, training, and supervision ]; and PMTCT for HIV-positive women (estimated using data from Zambia and including costs of receiving nevirapine prophylaxis, one-time infant HIV testing, personnel, recurrent inputs and services, capital, training, and supervision) .
We did not include the future costs of perinatal HIV infection to the healthcare system (only costs through PMTCT). We assume no antenatal care or PMTCT costs for women whose pregnancies ended in abortion, and PMTCT costs were only applied to estimates of cost-per-perinatal HIV infection averted. All costs are in 2015 USD.
One-way sensitivity analyses
We conducted one-way sensitivity analyses on all model variables by varying each parameter by +/−20% and applying a range of discounting rates (2, 5, 7). Inputs, which most influence model results are reported.
Probabilistic sensitivity analyses
Because of uncertainty around healthcare system costs, we conducted a Monte Carlo simulation probabilistic sensitivity analyses using SAS v9.4 (Cary, North Carolina, USA) with 1000 draws (using a uniform distribution, defined at +/−50% of the primary analysis estimates) for each cost parameter of interest. The median and 95% confidence interval of those simulated estimates were calculated. A uniform distribution was selected to not place a functional form on the parameter estimates in sensitivity analyses, reflecting a large degree of uncertainty around the estimates.
Demand creation through cross-referral between couples’ voluntary HIV testing with couples’ family planning counselling and long-acting reversible contraception
We compared LARC use prior to implementation of CVCT+CFPC in the first 6 months (April to September 2013) to the last 6 months (July to December 2015) to estimate the impact of referrals from CVCT+CFPC on LARC uptake. Belatedly, in December 2014 the converse measurement (proportion of clients requesting LARC in family planning clinics who reported prior CVCT+CFPC) was added to LARC logbooks and reported for the last year of the program.
The Emory Institutional Review Board determined that that no ethical approval was required for anonymized data collected during program service delivery (nonresearch).
Integrated program costs
The total program cost was $3 582 186 USD. Key costs for CVCT+CFPC and LARC service delivery included part-time staffing, and advocacy/promotional activities. Key costs for training included full-time staff and travel. Expenses shared across activities were a substantial part of the overall budget (Table 1).
Integrated program outcomes
The integrated program was delivered in 55 urban facilities in seven cities. We trained n = 391 counselors, n = 257 nurses in LARC delivery, and n = 3999 promotional agents. Of 108 399 couples tested for HIV, 16% of men were HIV-positive, 17% of women were HIV-positive, and 6% of couples were HIV-discordant. Of couples who received CVCT, 82 231 also received CFPC. LARC services included insertion (n = 56 409, 10% IUD and 90% implant) and removal/replacement (n = 19 415) (11% IUD and 89% implant). Prior to the integrated program, most women were using injectables (30%) or no modern method of contraception (46%) (data not shown). The majority of LARC removals were methods inserted prior to initiation of our program . CVCT uptake, CVCT+CFPC uptake, and LARC insertions are shown over calendar time in Fig. 1 (Table 3).
Couples’ voluntary HIV testing//couples’ family planning counselling client demographics (data not tabled)
The average age in years for men was 33.5 (standard deviation, SD = 10.3), for women was 27.8 (SD = 9.0), and 78% of women and 64% of men reported ever previously testing for HIV. Almost one-quarter (24%) of couples reported previously receiving joint CVCT services, and 22% of women reported current pregnancy. Ninety-eight percent of couples reported cohabiting for longer than 3 months [(5.9 years (SD = 6.8)].
Modeled outcomes and cost-effectiveness
Seven thousand, one hundred and sixty-five adult HIV infections were averted over a 5-year time horizon, corresponding to 56% of new infections averted. The cost-per-HIV infection averted was $384. Among those selecting LARC, 62 265 pregnancies were averted, 387 726 CYPs were gained, and 842 perinatal HIV infections were averted. Cost-per-pregnancy averted, -CYP gained, and -perinatal HIV infection averted were cost-saving (Table 4).
One-way sensitivity analyses indicated our models were most sensitive to HIV seroincidence rates among concordant negative couples before CVCT (reducing the rate to 0.8/100PY increased the cost-per-adult HIV infection estimate by 65%). Our model was also sensitive to years of LARC use (assuming 2 years of LARC use increased the cost-per-perinatal HIV infection averted by 54%, though it was still cost-saving). Our findings were robust to probabilistic sensitivity analyses.
Demand creation through referral between couples’ voluntary HIV testing and /couples’ family planning counselling and long-acting reversible contraception
In December 2014, 41% of clients requesting LARC in family planning clinics reported prior CVCT+CFPC, rising to 54% in December 2015 when service integration and mutual referral mechanisms were fully optimized. In the first 6 months of the program, 4% of CVCT couples had already received a LARC method, rising to 21% in December 2015, reflecting improved referrals from family planning clinics to CVCT services.
We show that an innovative, integrated model combining CFPC and CVCT with access to LARC leveraged prevention of adult and perinatal HIV and unintended pregnancy and increased CYP. In a 2017 systematic review, though promoting integrated HIV and family planning services to women and couples was highlighted as important, no studies described couple-focused programs . This is a missed opportunity since engaging couples in HIV testing is a high-impact HIV prevention strategy [17,19,24,25,41] that enables couples to discuss fertility goals in light of their HIV status, and couples’ family planning counseling improves LARC knowledge and uptake .
Our cost-per-adult HIV infection averted estimates are comparable with other highly cost-effective interventions including individual VCT (estimated in a previous systematic review of studies in sub-Saharan Africa at $1315/HIV infection  and $483/HIV infection averted for either individual or couples testing in Kenya [42,43]). Similarly, our cost-per-perinatal HIV infection averted via family planning findings (cost-savings) are comparable with those from a systematic review ($663/perinatal HIV infection averted via family planning) . For further context, another, more recent systematic review of 60 studies reporting the cost-effectiveness of HIV prevention interventions in Africa, median cost-per-HIV infection averted have been estimated for PMTCT via ART ($1144/HIV infection averted), preexposure prophylaxis ($13 267/HIV infection averted), male circumcision ($2965/HIV infection averted), treatment-as-prevention interventions ($7903/HIV infection averted) .
We found that CFPC was cost-saving in preventing unintended pregnancy, and other studies have found similar findings. A modeling study in Uganda of universal access to modern contraception compared with status quo found the hypothetical program averted unintended pregnancies at a low cost . A hypothetical study of scaling up a new diaphragm in South Africa lead to a cost-per-unintended pregnancy averted of $153 from the payer's perspective  and another modeling study found self-injectable contraception versus facility-based administration in Uganda to be cost-effective ($15/unintended pregnancy averted) . Relatively few studies have focused on integration of HIV services specifically with family planning services (and none focus on couples). In a 2017 systematic review, while integrated HIV and family planning services were associated with a higher prevalence of modern contraceptive use and knowledge, the authors found insufficient evidence to evaluate program impact on unintended pregnancy or cost-effectiveness . Only one study, a randomized controlled trial in Kenya , reported integrated HIV/family planning program costs. In this trial, a ‘One-stop shop’ intervention integrated family planning (counseling and full method mix access including LARC) into HIV clinics, while control HIV clinics referred clients to family planning services within the same health facility. Effective contraceptive use increased from 17 to 37% in intervention clinics versus 21--30% in control clinics (P less than 0.05). The authors estimated a cost-per-pregnancy averted of $1368 .
Our estimates of cost-per-CYP gained from LARC methods were cost-saving. This is in-line with literature estimating a cost-per-CYP in Zambia of $9 for the IUD and $15 for the implant . In Ethiopia, Uganda, Burkina Faso, and Cameroon, cost-per-CYP was lowest for the IUD ($4--$23) and higher for oral contraceptive pills ($17--$31) and implants and injectables ($20--$58) . Data from 13 USAID tier one priority reproductive health countries estimated that the cost-per-CYP was less than $2 for the copper IUD and roughly $4 for Sino-Implant, $7 for injectables and oral contraceptive pills, and $8 for Jadelle . Most studies have found costs-per-CYP to be lowest for the copper IUD and higher for the implant versus the copper IUD (largely because of differences in commodity costs ), which is important given that 90% of LARC uptake in this study was implant. Other LARC implementation studies in Africa have similarly found higher uptake of the implant versus the IUD [7,52], a trend that has been reversed with provider re-training on IUD insertion and targeted efforts to increase IUD knowledge among clients using mass media and community-based efforts [53,54]. These targeted efforts are important as the IUD is less well known relative to the implant in much of sub-Saharan Africa [55–59].
An evaluation of peer-reviewed literature conducted by FHI360 highlighted facilitators for successfully integrated HIV and family planning programs  including government and community leadership, evidence-based services tailored to local contexts, capacity building among providers and promoters with task-shifting, M&E systems for integrated program data collection, strong referral systems and supply chains, and involvement of men and high-risk groups. We recently published implementation and operation research conducted during our implementation in the 55 urban clinics described here as well as 215 rural clinics and report that with shifting of services from weekend to weekday, task-shifting, and well coordinated training of providers plus facility-based and community-based demand creation, CVCT+CFPC was highly feasible .
Limitations of our study include that we did not collect extensive couple-level demographics to explore predictors of uptake. Recognizing that many clients needed time to consider their options, we belatedly added queries about prior CVCT+CFPC to LARC data tools and prior LARC use to CVCT+CFPC tools. We did not include cost to patients (the societal perspective) and second and third order transmission benefits are also not captured in this model; thus are likely underestimating cost-effectiveness estimates.
Ours is one of very few studies to provide cost-effectiveness evidence supporting a novel integrated family planning and HIV testing program with a focus on couples and LARC methods. Our intervention was cost-savings for the CFPC outcomes modeled. Additionally, the estimated cost-per-HIV infection averted because of CVCT is low compared with other HIV prevention interventions, and as we have demonstrated  affordable in Zambia. Family planning and HIV services will need to coalesce around funding, promotions, service delivery, and M&E. We recommend future integrated programs focus on fertility-goal-based LARC promotion, engage couples, ensure accessible services alongside demand creation, and conduct cost-effectiveness evaluations. In Zambia, our work allowed for development of a model and tools for national monitoring of couple-focused and integrated HIV and family planning services. This model is highly adaptable and could be explored in other locales in sub-Saharan Africa.
The authors are grateful to all of the participants who made this study possible including staff and counselors at the government clinics, all ZEHRP staff, the District Health Management Teams, and the Ministry of Health in Zambia. We would also like to thank our funding agencies for their support.
Authors’ contributions: K.M.W. contributed to the analysis and interpretation of data; drafted the article and revised it critically for important intellectual content; and gave final approval of the version to be published. W.K. contributed to the conception and design of the study, revised the article critically for important intellectual content, and gave final approval of the version to be published. M.I. contributed to the conception and design of the study, revised the article critically for important intellectual content, and gave final approval of the version to be published. A.H. contributed to the conception and design of the study, revised the article critically for important intellectual content, and gave final approval of the version to be published. T.S. contributed to the analysis and interpretation of data; revised the article critically for important intellectual content; and gave final approval of the version to be published. K.M. contributed to the analysis and interpretation of data; revised the article critically for important intellectual content; and gave final approval of the version to be published. B.V. contributed to the conception and design of the study, revised the article critically for important intellectual content, and gave final approval of the version to be published. R.P. contributed to the analysis and interpretation of data; revised the article critically for important intellectual content; and gave final approval of the version to be published. S.S. contributed to the analysis and interpretation of data; revised the article critically for important intellectual content; and gave final approval of the version to be published. K.H. contributed to the analysis and interpretation of data; revised the article critically for important intellectual content; and gave final approval of the version to be published. C.M. contributed to the analysis and interpretation of data; revised the article critically for important intellectual content; and gave final approval of the version to be published. A.T. contributed to the study conception and design, revised the article critically for important intellectual content, and gave final approval of the version to be published.
S.A. contributed to the study design and conception, contributed to the analysis and interpretation of data; revised the article critically for important intellectual content, and gave final approval of the version to be published.
Conflicts of interest
There are no conflicts of interest.
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