We carried out this study to estimate the unit cost of comprehensive FSW services in two drop-in centres in Mtwapa and Kilifi town, Kenya, building on previous research on HIV outcomes. While our previous research demonstrated that FSW-targeted programs as designed effectively reduced HIV incidence and prevalence, our goal here was to provide national programs and implementing partners with an estimate of the per-person cost of service delivery to guide funding allocation and to identify cost drivers. We found that the cost of services was 105.93 USD per FSW per year on average, with personnel accounting for nearly two-thirds of the cost. Furthermore, service costs were lower at the Mtwapa drop-in centre (DIC), the older DIC, and which served a larger number of FSWs, indicating that larger and more mature programs are likely to be more cost effective due to economies of scale.
When we compared our unit costs to other studies, we found large variations, ranging from as little as 10.70 USD in India to 1098.00 USD in Burkina Faso (25–27). This is not surprising; multiple factors contribute to the per-person costs; FSW programs have complex and different designs, different studies include different costs and studies perform analyses differently. The FSW population reached, services provided, in-country cost of goods, maturity of the program and the organization-level efficiency of the implementing partner all contribute to the per-person costs(25–32). Large programs that serve many FSW benefit from economies of scale which has been shown to result in lower unit costs even when the projects are implemented by the same organization(27,31). FSW programs that offer comprehensive antiretroviral treatment are more expensive than programs that offer peer education, counselling and testing alone because of the additional service delivery costs. Structural interventions, such as advocacy to decriminalize sex work, and measures to address violence when added to FSW interventions also increase the unit cost of programs(28). Community-based organizations, which generally have simpler structures and where salaries for management and other staff are likely lower are also likely to have cheaper running costs than local or international NGOs (27). Recently established programs have also been reported to cost more, presumably due to higher administrative costs associated with more intense supervision and coordination, and project overhead costs for FSW projects are likely to reduce over time (26). In Burkina Faso, for example, Cianci et al. reported an annual cost of 1098.00 USD per FSW, nearly ten times what we report(25). Included in their cost analyses were ART, laboratory testing for HIV monitoring (CD4 and viral load), and treatment for opportunistic infections, which we did not. Their clinic also served 305 FSW per year, roughly one-fifth of our population, and approximately 60% of their FSW population were HIV positive on ART, including second-line ART. Conversely, in Nigeria, Nance et al. sampled 31 community-based organizations and reported a mean cost of services of 22 USD per FSW per year(27). Only HIV education, counselling and testing with referral to other facilities were provided. It is worth noting that in our study, the unit cost at Mtwapa DIC was lower than at Kilifi town DIC, much as both DICs were operated by the same ICRHK program which underscores the importance of economies of scale as a cost determinant. This was also reported by the Avahan Program in India (26).
That Personnel costs contributed most to the per-person cost is consistent not only with FSW studies, but with other HIV service programs such as Prevention of Mother-to-Child Transmission (PMTCT), Voluntary Male Medical Circumcision (VMMC), and Pre-Exposure Prophylaxis (PrEP), and across various geographies (30,33,34). Personnel costs in this study included direct service provider salaries, such as nurses and clinical officers, as well as time and effort compensation for monitoring and evaluation and project management. While we were unable to provide a breakdown of the proportions for each service level (direct service delivery personnel costs versus costs for support project staff), studies such as the Avahan study report that direct service delivery personnel costs can account for up to 65% of unit costs (26). There are multiple ways through which FSW programs can improve their efficiency and reduce their costs for service delivery. For example, current Kenyan ART guidelines recommend differentiated service delivery for PLHIV beyond the first six months of ART for patients who are established to be adherent to medication(35) and such patients can be followed up less frequently, with up to six months between clinical appointments. This means that programs can deliver quality clinical care for more FSW with less clinical staff. The PEPFAR FY2024 technical considerations also recommend that KP programs consider a set of optimized testing approaches that includes social network strategy testing, index testing, risk network testing, self-testing, social media and information communication technology platforms to complement standard venue based HTS(36). These approaches could mean that a greater number of FSW can receive HIV services outside the DICs.
Another approach to reduce costs and ensure sustainability would be to integrate FSW services into the routine services within the public or private health facilities instead of stand-alone DICs. Another advantage would be that it contributes to decreasing stigma and discrimination by mainstreaming FSW services. Jilinde, Kenya's largest PrEP scale-up program successfully piloted PrEP services for FSW in public and private health facilities(37). Similarly, other Female Sex Worker (FSW) programs have established "link desks" within public health facilities, whereby a peer educator is assigned to a “link desk” to help FSW visiting the facility navigate through care. Protocols on providing FSW services are available, and these programs ensure strong links between Peer Educators and the facility to minimize referral loss and establish safe spaces for FSWs peer support. The staff at the health facility are also trained to provide non-discriminatory, stigma-free services. One big disadvantage of such an approach of integrating FSW services into available public and private health facilities is that FSWs typically prefer DIC services because of the privacy and tailored services and FSW could engage less with programs and interventions when services are integrated(38). Additionally, it is challenging for health facilities already stretched to provide focused care to a single population. It may also counterfactually increase stigma against FSW when the receive preferential care at public and private health facilities.
It is worth noting that family planning (FP) constituted only 10% of the total unit cost. This means that FP services can be easily added without significantly driving up the unit cost. While FP can be considered a cost-effective intervention, many FSW programs do not include FP services into the programs’ design, DICs do not routinely stock FP commodities and clients are often referred elsewhere. In many African counties, FSW have high unmet FP needs and high rates of unintended pregnancies and abortions(39,40). Unintended pregnancies can perpetuate FSWs' involvement in sex work and increase their likelihood of engaging in condomless sex(41). One of the major gaps for FSW programs in Africa is the inability to integrate other relevant health issues into HIV services; programs have been criticized for focusing on HIV and ignoring other health issues that contribute to the overall wellbeing of FSW, even when such interventions are inexpensive and easily integrated into whatever is already in place. However, this could be interpreted as inflexibility, which is common in many donor programs; FSW programs are frequently funded by HIV-designated funds, which are frequently ineligible for use to support other health issues.
In summary, this study provides a unit cost estimate for comprehensive FSW SRH programming providing a balance of biomedical, behavioural, and structural interventions, and includes both service delivery and above service costs. FSW programs should use these estimates when budgeting and advocating to donors. Our estimates of cost drivers should also guide policy makers in making decisions on how to structure programs and maximize cost efficiency. Our study has some significant limitations. Firstly, the cost analysis was from a single FSW program in two DICs in Kenya’s Coast region, and therefore, the findings may be considered not nationally representative. However, we believe that the programs’ design accurately represents the NASCOP model used by most programs in Kenya, and we therefore provide accurate information that can inform advocacy and decision-making at both the program and national levels. Secondly, our cost estimates did not include the cost of HIV test kits, ART, STI medication, and laboratory tests, which lead to an underestimate. However, it is important to note that these costs are not typically included in FSW program budgets, and our estimates may accurately represent the actual costs incurred by programs. Thirdly, costing data is collected differently in different settings which limits comparison between country programs. One major advantage of our study is that it is the first in Kenya to present a unit cost of comprehensive services provided to FSWs, whereas previous studies have only estimated the unit cost of HTS, ART, or PREP separately(28).