2. Achieving Value for Money: The scale-up of an integrated service package for the prevention of HIV and unplanned pregnancy in Zambia Christine Mazarire, Janeen Drakes, Katie Fox, Alexandra Hoagland, Ann Lockard, Change Kwesele, Kalonde Malama, Tyronza Sharkey, Robert Yohnka, Mubiana Inambao, William Kilembe, Susan Allen

3. Background For 20+ years, Zambia Emory HIV Research Project (ZEHRP) has provided Couples Voluntary Counseling and Testing (CVCT) as an effective and economical strategy to decrease HIV/AIDS transmission, as endorsed by the WHO and CDC. February 2013- ZEHRP was awarded a £4.5 million grant by the UK Department for International Development (DFID) to scale up CVCT integrated with Couples’ Family Planning and Counselling (CFPC), provide long acting reversible contraceptives (LARC) and to train counselors and nurses to provide these services in Zambia.

4. The Problem Zambia has one of the highest HIV burdens and highest fertility rates 14.3% of the adult population infected with HIV Treatment is not keeping pace with new infections Majority of infections are in cohabitating heterosexual couples Total fertility rate of 5.3 Less than 5% of women use a long-acting reversible contraception (LARC) method such as the copper IUD or hormonal implant

5. The Solution: An Integrated Reproductive Health Package Benefits: Easier for people to access holistic services Allows both partners to discuss their fertility goals, HIV status, and preferred LARC method together with the help of a counselor Cost-effective While there is agreement that integrated HIV and reproductive health services are beneficial and needed, programs are traditionally vertical and there is limited information on the cost- effectiveness of integration. CVCT + CFPC + LARC

6. InputProcessOutputOutcomeImpact Value for Money (VfM) Maximizing the impact of each pound spent/ getting the desired quality at the lowest price Economy Efficiency Effectiveness Cost-effectiveness

7. Methods: ZEHRP’s VFM Framework Economy Key cost drivers Efficiency Unit costs of providing services to clients Unit costs of training providers Cost- Effectiveness Unit costs of averting HIV and unintended pregnancy

8. Results: Key Cost Drivers Key cost drivers in Years 1 and 2 include travel, trainings, and provider and promotions payments Responses: Modal shift from cars to motorbikes Streamlined trainings- reduced per diem and accommodation costs Scheduled high performing providers who could provide the full integrated package Shifted from external to clinic-based promoters who increased demand and required less in travel subsidies

9. Results: From Years 1 to 2 IndicatorYear 1Year 2 Unit cost of providing CVCT/CFPC £8.50£6.70 Unit cost of providing LARC £23.03£6 Unit cost of training an urban CVCT provider £153.29£98.82 Unit cost of averting HIV £344£56 Transport cost per month £5,789.39£10,234.37 Unit cost to train a rural CVCT provider £509.33£627.26

10. Conclusions From Year 1 to Year 2, while costs did rise, they did so in an expected manner in order to scale up the project in rural areas and to meet project deliverables. ZEHRP’s ability to ensure VfM strengthens the case for integrating services. Due to competing priorities and limited funds within health systems, integrated packages should be pursued.

11. Next steps Further the integration of CVCT/CFPC and LARC by ensuring all services are offered through systematic referrals Continue to improve VfM Advocate for the provision of integrated CVCT/CFPC and LARC services as the standard of care at the national level in Zambia