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Objective To evaluate costs and outcomes of voluntary counselling and testing (VCT) service delivery models in urban Indonesia.
Methods We collected primary data on utilization, costs and outcomes of VCT services in a hospital clinic (568 clients), HIV community clinic (28 clients), sexually transmitted infection (STI) community clinic (784 clients) and prison clinic (574 clients) in Bandung, Indonesia, in the period January 2008–April 2009.
Results The hospital clinic diagnosed the highest proportion and absolute number of HIV infections, but with the lowest average CD4 cell count and with the highest associated travelling and waiting time. The prison clinic detected fewer cases, but at an earlier stage, and all enrolled in HIV care. The community clinics detected the smallest number of cases, and only 0–8% enrolled in HIV care. The unit cost per VCT was highest in the hospital clinic (US$74), followed by the STI community clinic (US$65), the HIV community clinic (US$39) and the prison (US$23).
Conclusion We propose a reorientation of the delivery models for VCT and related HIV/AIDS treatment in this setting. We call for the scaling up of community clinics for VCT to improve access, promote earlier detection and to perform (early) treatment activities. This would reduce the burden of the hospital clinic to orient itself towards the treatment of AIDS patients. This is one of very few studies addressing this issue in Asia and the first of its kind in Indonesia, which has a rapidly growing HIV epidemic. The conceptual framework and overall conclusions may be relevant to other low-income settings.
Objectif: Evaluer les coûts et les résultats des modèles de prestation des services de CDV dans les zones urbaines d’Indonésie.
Méthodes: Nous avons collecté des données primaires sur l’utilisation, les coûts et les résultats des services de CDV dans une clinique d’hôpital (568 patients), une clinique communautaire du VIH (28 patients), une clinique communautaire MST (784 patients) et une clinique de prison (574 patients) à Bandung, en Indonésie, durant la période de janvier 2008 à avril 2009.
Résultats: La clinique de l’hôpital a diagnostiqué la plus grande proportion et le plus grand nombre absolu d’infections VIH, mais avec le plus bas taux moyen de cellules CD4 et la plus longue durée pour le déplacement et l’attente associées. La clinique de la prison a détecté peu de cas, mais à un stade précoce et tous ont été inscrits aux soins VIH. Les cliniques communautaires ont détecté le plus faible nombre de cas et seulement de 0 à 8% inscrits aux soins VIH. Le coût unitaire par CDV était le plus élevé dans la clinique de l’hôpital (74 $ US), suivi par la clinique communautaire MST (65$ US), la clinique communautaire VIH (39$ US) et la prison (23$ US).
Conclusion: Nous proposons une réorientation des modèles de prestation du CDV et autres traitements associés du VIH/SIDA dans ce contexte. Nous appelons à l’élargissement des cliniques communautaires de CDV pour améliorer l’accès, promouvoir le dépistage précoce et initier tôt des activités de traitement. Cela permettrait de réduire la charge sur la clinique de l’hôpital afin de l’orienter vers le traitement des patients SIDA. Il s’agit ici d’une des rares études sur cette question en Asie et la première dans son genre en Indonésie, pays qui connaît une croissance rapide de l’épidémie VIH. Le cadre conceptuel et les conclusions générales peuvent être utiles à d’autres régions à faibles revenus.
Objetivo: Evaluar los costes y resultados de los modelos de entrega de servicios de aconsejamiento y prueba voluntarios (APV) en zonas urbanas de Indonesia.
Métodos: Se recolectaron datos primarios sobre utilización, costes y resultados de los servicios de APV en un hospital (568 clientes), un centro sanitario comunitario para VIH (28 clientes), un centro sanitario comunitario para ETS (784 clientes), y la clínica de una prisión (574 clientes) en Bandung, Indonesia, durante el periodo comprendido entre Enero 2008 y Abril 2009.
Resultados: En el hospital se diagnosticó la proporción más alta y el mayor número absoluto de casos de infección por VIH, pero con el menor promedio de recuento de células CD4 y con el mayor tiempo asociado de viaje y de espera. La clínica de la prisión detectó el menor número de casos, pero en una etapa más temprana, y todos ellos fueron incluidos dentro de un programa de atención del paciente con VIH. Los centros sanitarios comunitarios detectaron el menor número de casos, y solo 0–8% fueron incluidos en programas de atención de pacientes con VIH. El coste unitario del APV era mayor en el hospital (US$74), seguido por el centro sanitario comunitario para ETS (US$65), el centro sanitario comunitario para VIH (US$39) y la prisión (US$23).
Conclusión: Proponemos un cambio en la orientación de los modelos de entrega del APV y de los tratamientos relacionados el VIH/SIDA en este emplazamiento. Insistimos en la importancia de llevar a mayor escala el APV en los centros sanitarios comunitarios, de mejorar el acceso, promover una detección más temprana y realizar actividades de tratamiento tempranas. Todo ello reduciría la carga sanitaria del hospital, permitiendo así su reorientación hacia el tratamiento de los pacientes con SIDA. Este es uno de los pocos estudios en los que se aborda este problema en Asia, y el primero en que se realiza en Indonesia, la cual tiene una creciente epidemia de VIH. El marco conceptual y las conclusiones generales podrían ser relevantes en otros emplazamientos de países con bajos ingresos.
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The HIV epidemic in Indonesia is among the fastest growing in Asia (UNAIDS 2007). It is concentrated among injecting drug users (IDUs) and their sexual partners in most parts of the country, with the exception of parts of Papua, where the epidemic is generalized. As of 2009, the cumulative Indonesian death toll of HIV/AIDS amounted to nearly 17 000, of which 42% were reported to be IDU-related, while hetero and homosexual transmission accounted for 48% and 4%, respectively (MOH-RI 2009). HIV/AIDS control efforts have increased considerably in Indonesia in recent years (Siregar et al. 2009), with voluntary counselling and testing (VCT) being a key component in the national strategic plan (Afriandi et al. 2009). VCT offers an entry point to treatment of HIV-positive individuals and is instrumental to prevent further spread of the disease by reducing risk behaviour of tested individuals (UNAIDS 2001). VCT services are only accessed by approximately 30% of all high-risk groups (UNAIDS 2007), and scaling up of services is warranted.
Various delivery models of VCT exist, ranging from integration in primary health services, specialized STD clinics to tertiary-level hospital services. In Indonesia, VCT is typically delivered by tertiary level hospitals, as this is where most individuals present for testing, while it has been stressed that more efforts are needed to increase early testing at community level (Wisaksana et al. 2009). Integration of VCT in primary health care in Tanzania shows that this may lead to improved VCT uptake, reduced stigma and improvement of general health service delivery (Mmbando et al. 2004). However, it is not clear which delivery models are most appropriate in which context. Different aspects may be important, such as VCT costs, outcomes of services including the number of positive cases identified and follow-up with treatment, sustainability of the services, accessibility for clients, provider capacity to accommodate scaling up of services and the target population of the specific delivery model.
This paper concentrates on the former two aspects, and presents the costs and outcomes of four VCT delivery models – as delivered at the hospital clinic, the HIV community clinic, the STI community clinic, and the prison clinic – in an urban setting in Indonesia. It thereby responds to the almost complete paucity of evidence on the costs of VCT services in Asia (Walker 2003) – so far the evidence-base only comprises two studies on costs of VCT in Thailand (Teerawattananon et al. 2005; HITAP 2008), one study at the south-east Asian sub-regional level (Hogan et al. 2005), and one in India (Dandona et al. 2008). The present costing study is unique for three reasons. First, it provides the first costing study on VCT in Indonesia, which is an important input for rational decision-making on the scaling up of service delivery (Siregar et al. 2009). Second, the study does not only estimate costs of VCT service delivery, but also costs of implementing VCT as incurred at the more administrative level (so called programme costs) – these costs are typically ignored in economic analysis (Johns et al. 2003). Third, the study also estimates costs of clients of seeking and undergoing VCT. Both programme costs and patient costs are also important criteria when making decision on scaling up VCT services.
The analysis of costs and outcomes of VCT delivery models serves as a basis for a broader elaboration of scaling up the respective models – taking into account all other aspects as well. The objective of the paper is to inform policy makers on the options and limitations of scaling up alternative VCT delivery models in Indonesia.
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There is a need to scale up VCT services in Indonesia, and a variety of service delivery models has been developed, each with its own characteristics in terms of its clients and services. The findings of this paper are summarized in Table 4 in dimensions of economic aspects (costs and accessibility), clinical aspects (VCT performed, % HIV positive, CD4 cell count, enrolment in HIV care) and other aspects (VCT target group), and lead to the following observations.
Table 4. Economic, clinical and other aspects of VCT delivery models†
|Service delivery model||Economic aspects||Clinical aspects||Other aspects|
|Unit cost per VCT (US$)||Physical Accessibility||VCT performed||% HIV positive||CD4 count||Enrollment in HIV care||VCT target group|
|At present||If scaled up||At present||If scaled up|
|HIV community clinic||Low||Low||High||Few||Few||NA||Low||Mostly IDU||All|
|STI community clinic||High||High||High||Many||Few||High||Low||Mostly sex workers and transgenders||All|
The hospital clinic does not seem the most appropriate venue for scaling up the delivery of its VCT services to the broader population. The costs per VCT performed at the hospital-based clinic (US$74) are higher than those provided at the HIV and STI community clinics. Also, the clinic is operating at full capacity and thus further economies of scale from scaling up services along with cost reductions may not be possible. The clinic is also less physically accessible than the other clinics as indicated by the relatively long travelling and waiting time. The role of the clinic merely seems to be that of a referral centre for treatment of late and/or complicated cases and for treatment of opportunistic infections, given that it is frequented by individuals presenting for testing with symptomatic and late-stage disease (as indicated by the relatively low CD4 count among HIV-positive-tested patients) (Wisaksana et al. 2009).
The HIV community clinic holds potential to function as an entry point to VCT for the broader population, and the following observations in the present study qualify this perspective. The clinic has the lowest costs per VCT performed (US$39) compared with the hospital clinic and STI community clinic. Considering its recent establishment and currently low capacity utilization, cost reductions can be expected when these services are scaled up. Also, the HIV community clinic is relatively physically accessible as indicated by the short travelling time, and this holds potential for a high uptake of VCT when scaled up. However, as the present clinic is now mainly frequented by IDUs, more efforts are needed to target and also attract the (symptomatic and asymptomatic) population as a whole. Concerns are the (present) absence of HIV care or a good referral system to a clinic with HIV care, and its current inability to cover all costs by collecting fees (nor does it receive financial support from the government).
The STI community clinic could play an important role in scaling up VCT services, specifically by continuing its focus on high-risk groups as it does now. The clinic appears to be able to detect HIV-positive cases in an early stage, as indicated by the relatively high CD4 cell count of HIV positive clients tested. The clinic’s outreach activities and the resulting network with high-risk groups probably contribute to its success. The present clinic is located near the area of where the sex workers live and work, which improves physical accessibility, as indicated by relatively low travel and waiting time. Moreover, the clinic’s active campaign on delivering STI services gives it good access to other high-risk groups such as transgenders and male having sex with male. This holds potential for a high uptake of VCT when this decentralised service model is scaled up. In relation, the focus of the clinic on the provision of STI services may also reduce HIV transmission (Kreiss et al. 1989; Schwandt et al. 2006). The absence of a good referral system to a clinic with HIV care is a matter of concern, and currently the discounted price charged cannot cover the full cost of delivering the services (the clinic relies heavily on donor funds).
The VCT services as delivered in the prison clinic hold potential to be scaled up to other prisons. During the period of study, both the number of VCT performed and the CD4 cell counts of the HIV-positive clients were relatively high, as was the enrolment in HIV care. This demonstrates the ability of the clinic to identify and treat HIV infection in prison at an early stage, although one should realize that HIV care for prisoners after release might pose a bigger challenge. Furthermore, the delivery of VCT in the prison clinic is relatively cheap (US$23). Personnel costs are relatively low and patient cost of seeking and undergoing the service are absent. Currently, the prison clinic is relying on donor funding for its VCT services. Whether VCT services should also be implemented in other prisons targeting other groups is difficult to answer in the present study and warrants further investigation.
Based on our study findings we can make several recommendations (Table 5). VCT services may best be scaled up in community-based clinics to the broader population, to improve their uptake and hence early detection of HIV/AIDS. These clinics may also initiate treatment of early/uncomplicated cases. A system should be developed for referral of late cases and those with opportunistic infections to the hospital. The HIV clinic in the hospital should be less oriented towards conducting VCT. We also emphasize the need for measures that address the general barriers to VCT such as (travel) costs, lack of confidentiality of test results, and perceived lack of benefit of conducting HIV test (Suherman et al. 2009).
Table 5. Recommendation on role of clinics in VCT and treatment†
|Service delivery model||VCT||Uncomplicated ART||Complicated ART||Treatment of opportunistic infections|
|HIV community clinic||+||+||−||−|
Our results should be interpreted with some caution. First, this study evaluated highly contextualised VCT service delivery models, which hampers their generalizibility. Yet, the conceptual decision framework can be applied to other settings. Second, we estimated patient costs of seeking and undergoing care on the basis of (assumed) productivity losses – these may not be realized in practice and we may then have overestimated the total patient costs. Differences in these patient costs are related to income levels of the clinic’s clients and do therefore not necessarily reflect differences in access to the different clinics. Third, personnel costs in clinics may include inefficiencies in the delivery of VCT services, and we may have overestimated total costs – a time motion study is warranted to assess the required resources to scale up VCT services in further detail.
In conclusion, we propose a reorientation of the delivery models for VCT in Indonesia, which would improve access and promote earlier detection, and reduce the burden of the hospital clinic to orient itself towards the treatment of complicated HIV/AIDS cases. Whereas this study is specific to Bandung, Indonesia, the conceptual framework and overall conclusions may also hold relevance to other low-income settings.