Background: Like many countries in sub-Saharan Africa, Uganda has scaled up differentiated service delivery models (DSDMs) for HIV treatment, but little information is available about the relative costs of the models. We estimated the total annual cost per patient and total cost per patient virally suppressed in five DSDMs, including facility- and community-based models and the standard of care.
Methods: We conducted a cost/outcome study from the perspective of the service provider, using retrospective patient record review of a cohort of patients over a two-year period, with bottom-up collection of patient resource utilization data, top-down collection of above-delivery level and delivery-level provider fixed operational costs, and local unit costs. We enrolled adults on ART (>18 years old) enrolled in 47 DSDMs located at facilities or community-based service points in four regions of Uganda with at least 24 months of follow-up data. DSDMs assessed included facility-based groups (FBG); fast-track drug refills (FDR); community client-led ART delivery (CCLAD); community drug distribution points (CDDP); and facility-based individual management (FBIM), which is the standard of care model for new, complex, and virally unsuppressed patients. Viral suppression was defined as <1000 copies/ml.
Results: Retention in care was 98% for the sample as a whole [96-100%]. Over viral suppression was 91%, which varied from 86% among patients in FBIM (with the largest share of complex / virally unsuppressed patients) to 93% among CDDP patients. The mean cost to the provider (Ministry of Health or NGO implementers) was $152 per annum per patient treated, ranging from $141 for FBG to $166 for FDR. Differences among the costs of the models were largely due to ARV regimens and proportions of patients on second line regimens. Service delivery costs, excluding ARVs, other medicines and laboratory tests, were modest, ranging from $9.66-16.43 per patient.
Conclusions: Differentiated ART service delivery in Uganda achieved excellent treatment outcomes at a cost similar to the standard of care (FBIM). While large budgetary savings might not be immediately realized, the reallocation of saved staff time could improve health system efficiency as facilities and patients gain more experience with DSD models.
Tuberculosis treatment within differentiated service delivery models in global HIV/TB programming