Estimated costs for the delivery of safer conception strategies for HIV-discordant couples in Zimbabwe: a cost analysis

Abstract

Background: In recent years, safer conception strategies have been developed to help HIV-serodiscordant couples conceive a child without transmitting HIV to the seronegative partner. The SAFER clinical trial assessed implementation of these strategies in Zimbabwe.

Methods: As a part of the SAFER study, we estimated the costs (in 2017 $US) associated with individual and combination strategies, in the trial setting and real-world practice, from a healthcare system perspective. Safer conception strategies included: 1) ART with frequent viral load testing until achieving undetectable viral load (ART-VL); 2) daily oral pre-exposure prophylaxis (PrEP); 3) semen-washing with intrauterine insemination; and 4) manual self-insemination at home. For costs in the trial, we used a micro-costing approach, including a time and motion study to quantify personnel effort, and estimated the cost per couple for individual and combination strategies for a mean of 6 months of safer services. For real-world practice, we modeled costs for three implementation scenarios, representing differences from the trial in input prices (paid by the Ministry of Health and Child Care [MOHCC]), intervention intensity, and increments to current HIV prevention and treatment practices and guidelines. We used one-way sensitivity analyses to assess the impact of uncertainty in input variables.

Results: Individual strategy costs were $769-$1615 per couple in the trial; $185-$563 if using MOHCC prices. Under the target intervention intensity and using MOHCC prices, individual strategy costs were $73-$360 per couple over and above the cost of current HIV clinical practices. The cost of delivering the most commonly selected combination, ART-VL plus PrEP, ranged from $166-$517 per couple under the three real-world scenarios. Highest costs were for personnel, lab tests, and strategy-specific consumables, in variable proportions by clinical strategy and analysis scenario. Total costs were most affected by uncertainty in the price of PrEP, number of semen-washing attempts, and scale-up of semen-washing capacity.

Conclusions: Safer conception methods have costs that may be affordable in many low-resource settings. These cost data will help implementers and policymakers add safer conception services. Cost-effectiveness analysis is needed to assess value for money for safer conception services overall and for safer strategy combinations.

Trial registration: Registry Name: Clinicaltrials.gov.

Trial registration number: NCT03049176 . Registration date: February 9, 2017.

Keywords: ART; Conception; Cost; Discordant; HIV; PrEP; Semen-washing.

Fig. 1

Target resource intensity and components for safer conception strategy delivery by clinic visit and safer conception strategy. ART = Antiretroviral therapy. ART-VL = Antiretroviral therapy with frequent viral load testing. AVI = Artificial vaginal insemination, at home. HBV = Hepatitis B virus. PrEP = Pre-exposure prophylaxis (with TRUVADA [emtricitabine/tenofovir disoproxil fumarate]). STI = Sexually transmitted infection

Fig. 2

Individual strategy cost per couple (2017 $US) by input and activity type: Scenario 1 (High Intensity, Real-world Prices).ART-VL = Antiretroviral therapy with frequent viral load testing. AVI = Artificial vaginal insemination, at home. PrEP = Pre-exposure prophylaxis. SW = Semen-washing

Fig. 3

Individual strategy cost per couple (2017 $US) by input and activity type: Scenario 2 (Target Intensity, Incremental Cost Added to Current Practice). ART-VL = Antiretroviral therapy with frequent viral load testing. AVI = Artificial vaginal insemination, at home. PrEP = Pre-exposure prophylaxis. SW = Semen-washing

Fig. 4

Individual strategy cost per couple (2017 $US) by input and activity type: Scenario 3 (Target Intensity, Incremental Cost Added to Standard of Care). ART-VL = Antiretroviral therapy with frequent viral load testing. AVI = Artificial vaginal insemination, at home. PrEP = Pre-exposure prophylaxis. SW = Semen-washing