There are 1 million Zambians receiving antiretroviral treatment (ART) for HIV, severely straining existing healthcare infrastructure and human resources. To address this challenge, community-based differentiated service delivery (DSD) models of care have been implemented to reduce provider workload and improve quality of care. The costs and impact of these DSD models have not yet been evaluated in routine settings.
We conducted a cost and outcomes analysis of ART patients whom entered into DSD models in Zambia between 2015-2017 to estimate the average cost per patient per year. We evaluated the former standard of care (SOC), in which stable patients received care and medication refills at healthcare facilities every 3 months, and four out-of-facility models of care (which, per country guidelines, require two clinical facility-based visits per year): community adherence groups (CAGs), urban adherence groups (UAGs), home ART delivery, and mobile ART services. Using patient-level data, we captured individual resource utilization in each model over the first 12 months of model participation, then estimated the cost/patient by assigning unit costs to each resource. Retention in care at 12 months was defined as attending a clinic visit at 12 months +/- 3 months. We then used percentage of patients retained in care after 12 months to estimate an average cost/outcome for each model. To account for missing patient-level data in the number of DSD visits for three of the models, we also considered high and low visit utilization scenarios. Costs are reported in 2018 USD.
Differentiated models of service delivery cost more per patient/year than the standard of care for all models assessed, as illustrated in Table 1. Costs ranged from as little as an annual $116 to $199 for the DSD models, compared to an annual $100 for SOC. CAGs and UAGs increased retention by 2% and 14%, respectively. All DSD models also cost more per patient retained at 12 months than the standard of care. The CAG had the lowest cost/patient retained for DSD models ($140-157) followed by the UAG ($155-$169).
Though they achieve equal or improved retention in care, out-of-facility models of ART delivery should be expected to be more expensive than traditional, facility-based care. Future studies should focus on comparison of these models of care to newer facility-based models of care currently implemented in Zambia, such as fast-track ART refills and 6-month ART scripting and dispensing.