Cost-effectiveness of integrated HIV prevention and family planning services for Zambian couples

Objective: Evidence-based models forintegrated family planning and HIV services have been called for byinternational stakeholders.

The objective of this study was to evaluate the cost-effectiveness of anintegrated program focusing on couple involvement in HIV testing and family planning counseling.Methods: In thisimplementation study, community health workers and personnel ingovernment health facilities promoted and delivered integrated couples’voluntary HIV counseling and testing and family planning counseling (the‘integrated program’) with long-acting reversible contraception (copperintrauterine device or hormonal implant) provision. From March 2013-September2015, the integrated program was offered in 55 government facilities in sevenZambian cities.Results: Program cost for training and servicedelivery was $3,582,187 (United States Dollars). Over 82,000 couples received theintegrated program and 56,409 long-acting reversible contraception insertionswere performed (10% intrauterine device, 90% implant). Cost-per-couple testedranged from $19-29 and cost-per-long-acting reversible contraception inserted rangedfrom $7-28. The integrated program averted an estimated 7,165 HIV infectionsand 62,275 unintended pregnancies (assuming three years of long-actingreversible contraception use).

Estimated cost-effectiveness outcomes were: $280-445per HIV infection averted; $3-51 per quality-adjusted life year saved; and assumingthree years of long-acting reversible contraception use, $5-21 per unintended pregnancyaverted and $618-5,453 per perinatal infection averted. In the final six monthsof the program when integrated services and mutual referrals were mature, 21%of integrated service couples reported prior long-acting reversible contraceptioninsertion and 54% of women requesting long-acting reversible contraception methodsreported prior integrated service use. Conclusions: Anintegrated program delivery model focused on couples and long-acting reversiblecontraception was feasible, acceptable, and highly cost-effective in preventingHIV and unintended pregnancy. This is one of very few studies to providecost-effectiveness evidence in support of such an integrated program. Thismodel is highly adaptable to other settings in sub-Saharan Africa. 

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