5.2.3.1 Direct health provider costs
I undertook economic costing of both the HIVST service and facility HTC services using a health provider perspective (UNAIDS, 2011, Drummond et al., 2005b). For the HIVST service, I interviewed community counsellors to determine resources used in providing the service, and programme managers and accounting staff to estimate costs of identified resources and other service delivery costs. All research-related costs were excluded. Appendix XII shows the data extraction tool used to record the resources used at each of the clinics during interviews with staff.
I obtained the HIVST service output records to find out the number of HIV self- testing episodes for each community counsellor, and total numbers for the service. I interviewed counsellors working at the facility HTC services, and administrative staff at the Blantyre District Health Office (which manages the two health facilities at Ndirande and Chilomoni), and at the Queen Elizabeth Central Hospital. I obtained programme output data to determine numbers of individuals tested and number of HIV positive individuals identified. I divided resources used in providing HIV testing into: (1) staff salaries; (2) staff training; (3) monitoring and evaluation; (4) consumables and equipment; and (4) capital/overheads.
Staff salaries included employer contributions and fringe benefits. For staff training, I included all training provided to staff that related specifically to service provision.
For facility-based HTC, I included the cost of HTC refresher training, but did not include the cost of the initial HIV counseling training course. For HIVST, I included the cost of the initial HIV counseling training course, as the community workers were not previously trained as HIV counselors. I also included the cost of all other training provided to the community counselors providing HIVST, but excluded all training for research related activities. The cost of staff training was annuitized over their useful life with an annual discount rate of 3% (WHO, 2003a), and with the useful life based on how often the training would be repeated.
The costs of consumables and equipment’s were obtained from the Malawi Ministry of Health (MoH) price catalogue, which includes the cost of shipping for imported goods. For items not supplied by the MoH, I used the on-land costs obtained from local suppliers. I used the international price for items bought internationally (e.g. HIV self-test kits), and included the cost of shipping and insurance. Equipment costs were likewise annuitized over their useful life with an annual discount rate of 3% (WHO, 2003a). As the majority of the equipment was office equipment, I assumed the useful life to be 3 years.
The cost of monitoring and evaluation (M+E) was estimated based on activities undertaken locally and centrally. For facility-based HTC, I asked all staff working at the facilities about time spent doing M+E activities or providing local supervision, and allocated this cost to M+E. In addition, I included the costs of M+E visits from
the HIV teams at the Blantyre District Health Office and the Malawi Ministry of Health. For the HIVST service, I included all M+E activities undertaken centrally by staff working on the main trial, but excluded research-related M+E activities. The M+E costs were based on the proportion of total working hours spent by personnel at the sites of interest.
Overhead and capital costs included the costs of utilities, security and building maintenance. I obtained these costs from the Blantyre District Health office which manages the Ndirande and Chilomoni health facilities. The HTC clinic at Queen Elizabeth Central hospital (QECH) is managed by the hospital administration. As QECH provides both inpatient and outpatient care, I allocated all capital and overhead costs based on the ratio of clinical personnel working in the HTC clinic to the total number of clinical personnel working at the hospital, and only included costs relevant to the outpatient HTC service. The costs of buildings were estimated from rental costs for equivalent space. The HIVST service did not incur any capital or overhead costs as it is provided in the community counselors’ homes at no additional cost.
5.2.3.2 Direct non-medical and indirect costs
I developed a questionnaire (Appendix XI), administered by an interviewer, which asked all participants about direct non-medical costs that they or accompanying
family member or carers incurred in accessing HIV testing services, and their associated work losses. User fees were not charged for either modality of testing.
The direct non-medical costs included cost of transportation, food and drinks whilst waiting, and other costs incurred as a consequence of getting an HIV test. Indirect costs were estimated by recording whether participants, or accompanying family member or carers, had taken time off work and multiplying work losses by self- reported income (Pritchard and Sculpher, 2000). In addition, total time taken to access the testing service, including travel and waiting time, was recorded. The questionnaire eliciting direct non-medical and indirect costs was translated into Chichewa, the local language of the study population, and back translated by two independent bilingual Malawians to ensure accuracy. The final version of the questionnaire was developed following pilot testing and discussions with senior Malawian staff working at the Malawi-Liverpool Wellcome Trust Clinical Research Programme.
5.2.3.3 Cost conversions
All costs were converted into 2014 US Dollars and International Dollars (Drummond et al., 2005b) using data reported by the World Bank (Evans et al., 2005). For all unit costs, the currency, price year and country were recorded. A Gross Domestic Product (GDP) deflator index, provided by the World Bank, was used to adjust the cost from the price year to the year of reporting (2014). As some prices were for goods
purchased, all costs were then converted to 2014 US Dollars using the market exchange rate, and to 2014 International dollars using purchasing power parity conversion factor (Krijnse Locker and Faerber, 1984, Shemilt et al., 2010).