Do differentiated service delivery models for HIV treatment in sub-Saharan Africa save money? Synthesis of evidence from field studies conducted in sub-Saharan Africa in 2017-2019.

Introduction : "Differentiated service delivery" (DSD) for antiretroviral therapy (ART) for HIV is rapidly being scaled up throughout sub-Saharan Africa, but only recently have data become available on the costs of DSD models to providers and patients. We synthesized recent studies of DSD model costs in five African countries. Methods : The studies included cluster randomized trials in Lesotho, Malawi, Zambia, and Zimbabwe and observational studies in Uganda and Zambia. For 3-5 models per country, studies collected patient-level data on clinical outcomes and provider costs for 12 months, and some studies surveyed patients about costs they incurred. We compared costs of differentiated models to those of conventional care and identified drivers of cost differences. We also report patient costs of seeking care. Results : The studies described 22 models, including facility-based conventional care. Of these, 13 were facility-based and 9 community-based models; 15 were individual and 7 group models. Average provider cost/patient/year ranged from $100 in Zambia to $187 in Zimbabwe, in both cases for facility-based conventional care. Conventional care was less expensive than any other model in the Zambia observational study, more expensive than any other model in Lesotho, Malawi, and Zimbabwe, and in the middle of the range in the Zambia trial and the observational study in Uganda. Models incorporating 6-month dispensing were consistently less expensive to the provider per patient treated. Savings to patients were substantial for most models, with patients' costs roughly halved. Conclusion : In five field studies of the costs of DSD models for HIV treatment, most models within each country had relatively similar costs, except for 6-month dispensing models, which were slightly less expensive. Most models provided substantial savings to patients. Research is needed to understand the effect of DSD models on the costs of ART programmes as a whole.