Donor pull-out: how much will it cost to fill the gap for HIV testing in Viet Nam?

Expenditure analysis of HIV testing and counseling services using the cascade framework in Vietnam.

Nguyen VT, Nguyen HT, Nguyen QC, Duong PT, West G. PLoS One. 2015 May 15;10(5):e0126659. doi: 10.1371/journal.pone.0126659. eCollection 2015.

Objectives: Currently, HIV testing and counseling (HTC) services in Vietnam are primarily funded by international sources. However, international funders are now planning to withdraw their support and the Government of Vietnam (GVN) is seeking to identify domestic funding and generate client fees to continue services. A clear understanding of the cost to sustain current HTC services is becoming increasingly important to facilitate planning that can lead to making HTC and other HIV services more affordable and sustainable in Vietnam. The objectives of this analysis were to provide a snapshot of current program costs to achieve key program outcomes including 1) testing and identifying PLHIV unaware of their HIV status and 2) successfully enrolling HIV (+) clients in care.

Methods: We reviewed expenditure data reported by 34 HTC sites in nine Vietnamese provinces over a one-year period from October 2012 to September 2013. Data on program outcomes were extracted from the HTC database of 42 390 client records. Analysis was carried out from the service providers' perspective.

Results: The mean expenditure for a single client provided HTC services (testing, receiving results and referral for care/treatment) was US $7.6. The unit expenditure per PLHIV identified through these services varied widely from US $22.8 to $741.5 (median: $131.8). Excluding repeat tests, the range for expenditure to newly diagnose a PLHIV was even wider (from US $30.8 to $1483.0). The mean expenditure for one successfully referred HIV client to care services was US $466.6. Personnel costs contributed most to the total cost.

Conclusions: Our analysis found a wide range of expenditures by site for achieving the same outcomes. Re-designing systems to provide services at the lowest feasible cost is essential to making HIV services more affordable and treatment for prevention programs feasible in Vietnam. The analysis also found that understanding the determinants and reasons for variance in service costs by site is an important enhancement to the cascade of HIV services framework now adapted for and extensively used in Vietnam for planning and evaluation.

Abstract [1]  Full-text [free] access [2]

Editor’s notes: Some 91% of expenditure for HIV testing and counselling (HTC) in Viet Nam is funded by international donors. As donors start to reduce their contributions in the coming years, more of the costs will have to be fronted by the government of Viet Nam. Consequently, this paper looks at the cost around diagnosing HIV within the context of the care and treatment cascade, including not only the cost per person diagnosed, but also the cost of successfully enrolling people who have tested positive for HIV into care and treatment. This is particularly important in the context of Viet Nam, where only 29% of people estimated to be living with HIV have ever been enrolled in care and treatment services. 

An important finding of the paper is in the break-down of costs by input by facilities. The authors found that the cost of personnel account for 40% of total costs. More importantly, they also found that the personnel costs vary widely between facilities, which may suggest that some facilities are over-staffed and are not allocating tasks efficiently. This is a key finding. As financial resources become scarcer, savings may need to be found by determining the optimal level of staffing and task-shifting.

The paper illustrates, as is to be expected, that the cost per person successfully enrolled in care and treatment is substantially higher than the costs per person tested and per person testing positive.  However, it is not entirely clear whether the extra cost is explained simply by the fact that the overhead and start-up costs are allocated to a smaller number of people, or whether there are additional costs involved in a successful referral. This area needs further exploration. Additionally, an interesting follow-up to this paper could take on the costing from a societal perspective with the aim to understand the relation between patient-level costs and the successful link between testing and referral to care and treatment services.

Asia [8]
Viet Nam [9]
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