Cost and Cost-Effectiveness of Strategically Decentralized Community Posts Compared with Centralised Facilities for HIV Treatment Delivery in Lusaka, Zambia, 2020

Abstract

Financing for HIV treatment in sub-Saharan Africa is under pressure, and evidence on whether community-based delivery achieves good outcomes at lower cost is limited. Circle of Hope, a faith-based organisation in Zambia, established Community Posts that bring HIV testing, treatment and viral load monitoring to where people live and work. We conducted an economic evaluation from the provider perspective comparing four early Community Posts with four long-established centralised health facilities in Lusaka District over twelve months in 2020. Monthly cost records were linked to routine programme data on testing, case finding, treatment initiation, linkage, retention and viral suppression, and differences were estimated with mixed models that account for clustering within facilities. Community Posts cost a mean of US$2,054 per month compared with US$25,543 at centralised facilities, while serving fewer patients (1,720 versus 4,905). Cost per patient on treatment was US$1.21 versus US$5.44 per month (difference −US$4.23, 95% CI −5.21 to −3.24), or about US$15 versus US$65 per patient-year. Community Posts achieved higher testing yield (40.3% versus 10.9%), linkage (99.9% versus 89.9%) and retention (98.9% versus 95.1%), with no significant difference in viral suppression (96.9% versus 95.2%). Community Posts therefore dominated centralised facilities, with lower cost and equal or better outcomes. Their cost would need to be about 4.6 times higher than recorded before the advantage disappeared. Findings are exploratory because few sites were studied and some costs were not captured, but they support prospective full-cost evaluation and scale-up of the model.