Economic evaluation of non-financial incentives to increase Couples HIV Testing & Counselling uptake in Zimbabwe Good afternoon ladies & gentlemen I’m here to present results of an economic evaluation of non financial incentives to increase uptake of CHTC in Zimbabwe This study was conducted by CeSHHAR Zim together with MoHCC & our partners I would like to acknowledge the presence of our PI’s Euphemia Sibanda Frances Cowan Fern Terris Prestholt & Harsha Thirumurthy Mangenah C, Sibanda E, Hatzold K, Maringwa G, Mugurungi O, Terris-Prestholt F, Cowan FM, Thirumurthy H

No conflicts of interest to declare. Funders played no role in study design, data collection and analysis Authors have sole responsibility over content not representative of funders official views

Presentation Outline Background global situation study setting

Presentation Outline Background Methodology global situation study setting Methodology cluster-RCT Trial design cost analysis

Presentation Outline Background Methodology Results global situation study setting Methodology cluster-RCT Trial design cost analysis Results incremental cost analysis

Presentation Outline Background Methodology Results Conclusions global situation study setting Methodology cluster-RCT Trial design cost analysis Results incremental cost analysis Conclusions

Background - Global situation 2012 WHO HIV testing guidance recommends HIV Testing & Counseling Services for couples (CHTC) joint status disclosure & trained counsellor support higher uptake of prevention, treatment & support 2/3 decline in transmission among discordant couples post test 2012 WHO HIV testing guidance recommends CHTC Couples test & receive results jointly Mutual status disclosure Guarantees provision of support by trained counsellor Better uptake of HIV prevention, treatment & support options 2/3 reduction in HIV transmission among discordant couples CHTC uptake remains sub-optimal despite multiple HIV prevention benefits 30% of people seeking HIV testing take up CHTC Low uptake rates 18% (Zim), 5% (SA), 12% (Moz), 2% (Swaz) & 24% (Zam) 2014 PSI Zim prog data shows CHTC uptake lowest in rural areas (7%) 1.Trask, S.A., et al., Molecular epidemiology of human immunodeficiency virus type 1 transmission in a heterosexual cohort of discordant couples in Zambia. Journal of Virology, 2002. 76(1): p. 397-405. 2. Allen, S., et al., Sexual behavior of HIV discordant couples after HIV counselling and testing. Aids, 2003. 17(5): p. 733-40. 3. Rwanda Demographic and Health Survey 2010. 2011, National Institute of Statistics of Rwanda (NISR), Ministry of Health (MOH), and ICF International. 4.Sarna, A., et al., Sexual risk behaviour and HAART: a comparative study of HIV-infected persons on HAART and on preventive therapy in Kenya. International Journal of STD & AIDS, 2008. 19(2): p. 85-89. 5. Mlambo, M. and K. Peltzer, HIV serostatus disclosure and sexual behaviour among HIV-positive patients who are on antiretroviral treatment (ART) in Mpumalanga, South Africa. Journal of Human Ecology, 2011. 35(1): p. 29-41.

Background - Global situation 2012 WHO HIV testing guidance recommends HIV Testing & Counseling Services for couples (CHTC) CHTC uptake remains sub-optimal despite multiple HIV prevention benefits Only 30% of people seeking HIV testing take up CHTC 2012 WHO HIV testing guidance recommends CHTC Couples test & receive results jointly Mutual status disclosure Guarantees provision of support by trained counsellor Better uptake of HIV prevention, treatment & support options 2/3 reduction in HIV transmission among discordant couples CHTC uptake remains sub-optimal despite multiple HIV prevention benefits 30% of people seeking HIV testing take up CHTC Low uptake rates 18% (Zim), 5% (SA), 12% (Moz), 2% (Swaz) & 24% (Zam) 2014 PSI Zim prog data shows CHTC uptake lowest in rural areas (7%) 1.Trask, S.A., et al., Molecular epidemiology of human immunodeficiency virus type 1 transmission in a heterosexual cohort of discordant couples in Zambia. Journal of Virology, 2002. 76(1): p. 397-405. 2. Allen, S., et al., Sexual behavior of HIV discordant couples after HIV counselling and testing. Aids, 2003. 17(5): p. 733-40. 3. Rwanda Demographic and Health Survey 2010. 2011, National Institute of Statistics of Rwanda (NISR), Ministry of Health (MOH), and ICF International. 4.Sarna, A., et al., Sexual risk behaviour and HAART: a comparative study of HIV-infected persons on HAART and on preventive therapy in Kenya. International Journal of STD & AIDS, 2008. 19(2): p. 85-89. 5. Mlambo, M. and K. Peltzer, HIV serostatus disclosure and sexual behaviour among HIV-positive patients who are on antiretroviral treatment (ART) in Mpumalanga, South Africa. Journal of Human Ecology, 2011. 35(1): p. 29-41.

Background - Global situation 2012 WHO HIV testing guidance recommends HIV Testing & Counseling Services for couples (CHTC) CHTC uptake remains sub-optimal despite multiple HIV prevention benefits fears around relationship instability/dissolution revelation of undisclosed sexual behaviour clients discount longer-term CHTC benefits even if > testing alone 2012 WHO HIV testing guidance recommends CHTC Couples test & receive results jointly Mutual status disclosure Guarantees provision of support by trained counsellor Better uptake of HIV prevention, treatment & support options 2/3 reduction in HIV transmission among discordant couples CHTC uptake remains sub-optimal despite multiple HIV prevention benefits 30% of people seeking HIV testing take up CHTC Low uptake rates 18% (Zim), 5% (SA), 12% (Moz), 2% (Swaz) & 24% (Zam) 2014 PSI Zim prog data shows CHTC uptake lowest in rural areas (7%) 1.Trask, S.A., et al., Molecular epidemiology of human immunodeficiency virus type 1 transmission in a heterosexual cohort of discordant couples in Zambia. Journal of Virology, 2002. 76(1): p. 397-405. 2. Allen, S., et al., Sexual behavior of HIV discordant couples after HIV counselling and testing. Aids, 2003. 17(5): p. 733-40. 3. Rwanda Demographic and Health Survey 2010. 2011, National Institute of Statistics of Rwanda (NISR), Ministry of Health (MOH), and ICF International. 4.Sarna, A., et al., Sexual risk behaviour and HAART: a comparative study of HIV-infected persons on HAART and on preventive therapy in Kenya. International Journal of STD & AIDS, 2008. 19(2): p. 85-89. 5. Mlambo, M. and K. Peltzer, HIV serostatus disclosure and sexual behaviour among HIV-positive patients who are on antiretroviral treatment (ART) in Mpumalanga, South Africa. Journal of Human Ecology, 2011. 35(1): p. 29-41.

Background - Study Setting Zimbabwe’s prevalence = 14% Generalised HIV epidemic CHTC uptake remains low (7%) along with rest of Southern Africa South Africa = 5% Mozambique = 12% Swaziland = 2% Zambia = 24 Extensive mobile HTC testing by MoHCC, PSI & ISP partners Community mobilisation visits 1 week prior to impending visits Meetings, posters & pamphlets Dates, times, & specific locations Low CHTC uptake Couples discount long-term HTC benefits even if > testing alone Fear of possible revelation of undisclosed sexual beh Fear of potential re/ship instability/dissolution Studies (both HLIC’s) show small fin & non-fin incentives can increase uptake of public health services Counteract present-biased preferences (Provides immediate benefits vs costs) Offset real & perceived costs of accessing public health services

Background - Study Setting Zimbabwe’s prevalence = 14% Generalised HIV epidemic CHTC uptake remains low (7%) Despite extensive mobile testing + community mobilisation visits Extensive mobile HTC testing by MoHCC, PSI & ISP partners Community mobilisation visits 1 week prior to impending visits Meetings, posters & pamphlets Dates, times, & specific locations Low CHTC uptake Couples discount long-term HTC benefits even if > testing alone Fear of possible revelation of undisclosed sexual beh Fear of potential re/ship instability/dissolution Studies (both HLIC’s) show small fin & non-fin incentives can increase uptake of public health services Counteract present-biased preferences (Provides immediate benefits vs costs) Offset real & perceived costs of accessing public health services

Background - Study Setting Zimbabwe’s prevalence = 14% Generalised HIV epidemic CHTC uptake remains low (7%) Low cost strategies for increasing uptake are clearly necessary Zimbabwe LIC’s Extensive mobile HTC testing by MoHCC, PSI & ISP partners Community mobilisation visits 1 week prior to impending visits Meetings, posters & pamphlets Dates, times, & specific locations Low CHTC uptake Couples discount long-term HTC benefits even if > testing alone Fear of possible revelation of undisclosed sexual beh Fear of potential re/ship instability/dissolution Studies (both HLIC’s) show small fin & non-fin incentives can increase uptake of public health services Counteract present-biased preferences (Provides immediate benefits vs costs) Offset real & perceived costs of accessing public health services

Methodology – Cluster RCT trial design Lancet Global Health in press Cluster-RCT measuring impact of incentives on CHTC uptake n=68 rural community clusters n=4 rural Zimbabwe districts Small non-financial incentives can increase CHTC uptake counteract present-biased preferences focus on incentives vs costs Clients randomized incentives for CHTC (1 of 3 grocery items worth US$1.50) (bar of laundry soap, petroleum jelly, cooking oil) standard mobilization Primary outcome = proportion of individuals testing with partner

Methodology – cost analysis Measure of value Incremental costs of incentive arm over standard mobilisation arm Perspective Provider/implementer perspective Outcomes Cost ($)/ individual client tested with a partner Cost ($)/ individual tested, Cost ($)/ HIV diagnosis Data types Actual purchase prices from provider Quantity & cost (incentives, HR, equipment, HIV test kits, stationary & other supplies Amortization period Between 3 & 10 years Exchange rate US$1 = US$1(US$ is principal currency in Zim post 2009) Costs & benefits are discounted if >1 year to reflect PV No discounting as intervention ran for few months (May 2015 – Jan 2016) Actual fin (US$1 = US$1) expenses (US$ is principal currency in Zim post 2009) Qty & cost (incentives, HR, equip, HIV test kits, stationary & other supplies Actual res usage (inventory lists & purchase price quotes from provider PSI/Z) Outreach team staffing & associated salaries data (PSI/Z HR dept)

Results – cluster RCT Lancet Global Health in press Outcome No incentive arm (n=34) Incentive arm (n=34) Outreach-team days 195 214 Number tested & counselled 10,839 14,932 Number tested/day 56 (95% CI 50-62) 70 (95% CI 62-77) Couple testers 1062 (10.0%) OR=1 7852 (55.7%) OR=13.5 (10.5 – 17.4) HIV prevalence 676 (6.5%) 1206 (8.8%) Yield per day 3.5 (2.8-4.2) 5.6 (4.8-6.5) Male testers 4892 (46.2) 6377 (45.2) C-RCT in 4 rural district communities Outcomes based on program data Effectiveness of incentives for CHTC up-take, and HIV case diagnosis 4 rural Zim districts (Chegutu, Murehwa, Goromonzi & UMP) N=68 outreach communities (34 standard community mobilization vs 34 incentive) For the incentive arm in addition to standard community mobilisation 1 week prior to outreach visits HTC clients were offered + choice of 1 of 3 incentives worth $1.50 (laundry bar, petroleum jelly jar, or bottle of cooking oil) if tested together with partner

Results - cost analysis Cost category No incentive ($) Contribution Incentive ($) Incentives $0.00 0% $10,859.22 10% HR $69,423.75 80%  $78,705.00 70% Equipment $1,154.95 1% Medical supplies $1,919.76 2% $2,541.42 HIV test kits $1,537.96 $2,266.16 Other supplies $12,556.78 15% $16,753.95 Total cost ($) $86,593.20 $112,280.70 # of clients 10,580 14,099 Cost/client $8.18   $7.96 Cost/HIV+ client  $128.10  $93.10 Equipment, HIV test kits, & medical supplies costs similar across arms Equipment, HIV test kits, & medical supplies were however minor cost contributors across arms For both incentive & std mobilisation arm major contributors HR (80% & 70%), Stationary & other supplies (15% & 15%), Incentives added only 10% to cost to incentive arm HR was key cost contributor in both arms indicating potential existence of economies of scale. Crucial to intensify community mobilization efforts if such incentive interventions are to achieve higher numbers of CHTC tests & lower costs as HR costs are incurred whether outreach teams deployed in any scale up conduct HTC’s or not.

Results – Incremental cost analysis Intervention incremental cost (Incentive - Standard mobilization) $25,687.50 Intervention effect (incentive effects - non-incentive effects) 46% Additional clients tested as a couple (14,099*46%) 6437 Additional clients tested HIV positive 530 Incremental cost/client tested as a couple ($25,687.50/6437) $3.99 Incremental cost/client tested HIV positive $48.47 Non-financial incentives for CHTC uptake in Zim were highly CE ICER’s ($3.99 /individual testing as a couple & $48.47 /HIV+) <common thresholds NICE CE threshold = <£30,000 health technologies or public health interventions funded by the UK’s NHS are considered value for money For LMICs, WHO’s Choosing Interventions that are Cost Effective (WHO-CHOICE) recommends 1 to 3 times /capita income/GDP (This is no longer WHO’s recommendation) +/-$500 is more realistic for severely resource constrained countries e.g SSA Many interventions offering health gains at +/-$500 remain unfunded

Conclusions Simple low-cost interventions to scale-up services close the tap on new infections Provision of non-financial incentives innovative strategy to increase CHTC uptake highly affordable Non-financial incentives for CHTC therefore highly recommended for policymakers & providers Simple cost effective interventions are key to ending AIDS ICER’s < accepted cost effectiveness thresholds are cost effective & maximise public health outcomes ICER’s > given thresholds = lost/forgone health outcomes Non-financial incentives for HIV preventive behaviours Innovative strategy Highly cost effective Non-financial incentives for CHTC therefore highly recommended for policymakers & providers

Acknowledgements Partners Centre for Sexual Health, HIV & AIDS Research (CeSHHAR) Zimbabwe Ministry of Health & Child Care (MoHCC) Zimbabwe Population Services International Zimbabwe London School of Hygiene and Tropical Medicine (LSHTM) University College London (UCL) Liverpool School of Tropical Medicine (LSTM) University of North Carolina at Chapel Hill (UNC-CH)

Acknowledgements Funding Partners Zimbabwe’s ISP ISP contributors (DFID, SIDA, Irish AID), through PSI Zimbabwe Partners Centre for Sexual Health, HIV & AIDS Research (CeSHHAR) Zimbabwe Ministry of Health & Child Care (MoHCC) Zimbabwe Population Services International Zimbabwe London School of Hygiene and Tropical Medicine (LSHTM) University College London (UCL) Liverpool School of Tropical Medicine (LSTM) University of North Carolina at Chapel Hill (UNC-CH)

Acknowledgements Funding Ethical approval Partners Zimbabwe’s ISP ISP contributors (DFID, SIDA, Irish AID), through PSI Zimbabwe Partners Centre for Sexual Health, HIV & AIDS Research (CeSHHAR) Zimbabwe Ministry of Health & Child Care (MoHCC) Zimbabwe Population Services International Zimbabwe London School of Hygiene and Tropical Medicine (LSHTM) University College London (UCL) Liverpool School of Tropical Medicine (LSTM) University of North Carolina at Chapel Hill (UNC-CH) Ethical approval Medical Research Council of Zimbabwe (MRCZ) University College London (UCL) Ethics Committee Trial registration - Pan African Clinical Trial Registry, PACTR201606001630356

Thank you Questions? Comments? Contact Collin Mangenah Centre for Sexual Health and HIV/AIDS Research (CeSHHAR), Harare, Zimbabwe +263774094023 collin@ceshhar.co.zw cmangenah1@gmail.com Skype: Collin.mangenah1