Integrating PrEP provision through routine ante-/post-natal care (ANC/PNC) and family planning (FP) clinics is a potential strategy for efficient PrEP delivery to women in high HIV burden settings. The cost of delivering PrEP through ANC/PNC and FP clinics is unknown.
We estimated the incremental economic cost of PrEP delivery from the provider perspective within the PrEP Implementation for Young Women and Adolescents (PrIYA) program in western Kenya. We abstracted program data from November 2017 to June 2018 in 16 facilities and estimated annual numbers of PrEP screening and dispensation visits. We identified all within- and above-facility activities supporting PrEP delivery and measured clinical service time using time-and-motion studies. We obtained input costs from program budgets, expenditure records and staff interviews. We also projected costs under Ministry of Health (MOH) implementation assuming MOH salaries and PrEP supervision by county and sub-county health teams. Under this scenario, we explored the impact of task shifting PrEP screening to HIV counsellors, deferring creatinine (Cr) testing from initiation to first follow-up visit, and varying uptake (proportion of counseling encounters that result in PrEP initiation) and continuation (average number of follow-up visits among returning clients) on program costs. We report the cost per client-month of PrEP dispensed in 2017 USD.
For an annual program output of 24,005 screenings, 4198 PrEP initiations, and 4427 follow-up visits, the average cost per client-month was $27. Personnel, drugs, and lab tests comprised 43%, 25%, and 14% of program costs, respectively. In the MOH scenario assuming no changes in outputs, the projected cost per client-month of PrEP dispensed reduced to $17, with drugs (41%), personnel (33%), and lab testing (15%) accounting for the majority of costs. Deferring Cr testing and task shifting PrEP counseling reduced projected costs by 5% and 8%, respectively. Halving both PrEP uptake and continuation increased the cost per client-month of PrEP to $25, while doubling uptake and continuation lowered the cost to $13.
The cost of PrEP delivery through ANC/PNC and FP was similar to costs reported for delivery to other key populations ($11-$44 per client-month). Streamlining service delivery and increasing volume may reduce unit costs. Empirical cost data on PrEP is essential for program planners to assess the cost-effectiveness and affordability of scaling up PrEP.