Do not ignore higher level costs - only 35% of programme costs for service delivery in Indian HIV prevention programmes

The costs of scaling up HIV prevention for high risk groups: lessons learned from the Avahan programme in India.

Chandrashekar S, Guinness L, Pickles M, Shetty GY, Alary M, Vickerman P, Group C-E, Vassall A. PLoS One. 2014 Sep 9;9(9):e106582. doi: 10.1371/journal.pone.0106582. eCollection 2014.

Objective: The study objective is to measure, analyse costs of scaling up HIV prevention for high-risk groups in India, in order to assist the design of future HIV prevention programmes in South Asia and beyond.

Design: Prospective costing study.

Methods: This study is one of the most comprehensive studies of the costs of HIV prevention for high-risk groups to date in both its scope and size. HIV prevention included outreach, sexually transmitted infections (STI) services, condom provision, expertise enhancement, community mobilisation and enabling environment activities. Economic costs were collected from 138 non-government organisations (NGOs) in 64 districts, four state level lead implementing partners (SLPs), and the national programme level (Bill and Melinda Gates Foundation (BMGF)) office over four years using a top down costing approach, presented in US$ 2011.

Results: Mean total unit costs (2004-08) per person reached at least once a year and per monthly contact were US$ 235(56-1864) and US$ 82(12-969) respectively. 35% of the cost was incurred by NGOs, 30% at the state level SLP and 35% at the national programme level. The proportion of total costs by activity were 34% for expertise enhancement, 37% for programme management (including support and supervision), 22% for core HIV prevention activities (outreach and STI services) and 7% for community mobilisation and enabling environment activities. Total unit cost per person reached fell sharply as the programme expanded due to declining unit costs above the service level (from US$ 477 per person reached in 2004 to US$ 145 per person reached in 2008). At the service level also unit costs decreased slightly over time from US$ 68 to US$ 64 per person reached.

Conclusions: Scaling up HIV prevention for high risk groups requires significant investment in expertise enhancement and programme administration. However, unit costs decreased with programme expansion in spite of an increase in the scope of activities.

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Editor’s notes: This paper captures the costs of one of the largest HIV prevention programmes among key populations to date. In the four states of study, Avahan focussed on a comprehensive set of activities among female sex workers and men who have sex with men. In addition to intervening with key populations the programme also focussed on strengthening technical expertise among providers. Most costing studies have focussed on costs at the service delivery level. It is widely acknowledged that the costs incurred at higher levels of the system are largely unknown. This study applies a top down cost allocation, which followed funding from the national, state and district levels as well the service delivery level. Only 35% of programme costs were at the service level, though this increases as programmes mature and scale up. This emphasises how detrimental ignoring higher level costs can be when making projections of budget impact and may provide insights into why so many new programmes and individual activities are not sustained.

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