1. 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

2. 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

3. Presentation Outline
Background
global situation
study setting

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

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

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

7. 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, (1): p
2. Allen, S., et al., Sexual behavior of HIV discordant couples after HIV counselling and testing. Aids, (5): p
3. Rwanda Demographic and Health Survey , 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, (2): p
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, (1): p

8. 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, (1): p
2. Allen, S., et al., Sexual behavior of HIV discordant couples after HIV counselling and testing. Aids, (5): p
3. Rwanda Demographic and Health Survey , 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, (2): p
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, (1): p

9. 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, (1): p
2. Allen, S., et al., Sexual behavior of HIV discordant couples after HIV counselling and testing. Aids, (5): p
3. Rwanda Demographic and Health Survey , 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, (2): p
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, (1): p

10. 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

11. 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

12. 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

13. 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

14. 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)

15. 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 ( )
5.6 ( )
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

16. 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.

17. 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

18. 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

19. 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)

20. 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)

21. 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, PACTR

22. Thank you Questions? Comments?
Contact
Collin Mangenah
Centre for Sexual Health and HIV/AIDS Research (CeSHHAR), Harare, Zimbabwe
Skype: Collin.mangenah1