Research Setting: This study focused on community-based HIV interventions implemented by Non-Governmental Organizations (NGOs) as Implementing agencies (IAs) under RRTTR program in the provinces highly affected by HIV epidemic in Thailand (as shown in Figure 1). This was a cohort study, and the data were collected covering a period of 21 months (from January 2015 to September 2016).
Interventions and Program Activities: Depends on type of targeted KAPs, each intervention package included a combination of 1) behavioral change interventions through outreach activities, harm reduction intervention (for PWID only), distribution of commodities i.e., condoms, lubricants, needles, syringes and behavior change communication (BCC) & IEC materials etc., 2) HIV testing and counselling, referral to health facilities for HIV testing and/or STI testing, TB screening and testing (Migrant population only), 3) referral to treatment, providing care & support for those who tested positive, and following up on those who are on ART for treatment adherence, and 4) community health system strengthening.
Peer-led community outreach activities were organized by outreach workers and peer educators who were recruited, trained, and supervised by IAs. Outreach sessions were often provided at a meeting venue in the community closed to where KAPs live or work i.e., beauty salons, parks, stadium, universities, local markets, department stores, entertainment venue, public transportation stations, campaign events, beauty contests, and drop-in-centers (DiCs) etc. KAPs were encouraged for HIV testing at the outreach session and those who were willing to get tested will be referred to receive service for Voluntary Confidential Counselling and Testing (VCCT) in collaboration with local government health service providers. VCCT services were often provided at the local public hospital/ health service center, mobile clinic, and community-based HIV testing centers (or DiCs). Outreach workers of SRs provided pre-test and post-test counselling, while HIV testing was done by professional health staffs (nurses and medical technicians) from local government hospitals using pin-prick blood testing with Same Day Result (SDR). It is worth noted that HIV testing and provision of ARV were delivered at the government health facilities, and the cost of which were incurred under the public health system.
Program Outputs: The numbers of KAPs reached out by community-based HIV intervention in the provincial level were defined as the program outputs of in this study. This number included KAPs reached by outreach activities (through individual or group session) and social media (clients registered with unique identification code (UIC) using on-line applications) who received a tailored package of HIV service, participated in behavioral change program, received IEC materials regarding HIV and STI prevention, commodities (such as condom, lubricants, or clean needles & syringes), counselling services and were referred for HIV/STI testing (for those who were willing to undertake the test). The data were collected from IAs routine reports covering reporting period of January 2015 to September 2016.
Costing Methodology
This study used top-down costing approach and focuses on health care providers perspective whereas interventions were implemented by IAs at the community level. Patients’ costs were not collected and included in this study. We collected data from expenditures records and progress update annual reports of IAs covering expenditures from 1st January 2015 to 30th September 2016. The data were keyed into excel sheets, pivotal tables were constructed to summarize and calculate unit cost. Shared costs between two or more interventions incurred by the same IAs were allocated proportionally by using different allocation strategies based on type of activities as they were described on records or by looking into program outputs yielded by interventions.
Direct Program Cost (IAs Operational Cost): All cost incurred at site (provincial) level or IAs level were defined as Direct Program Cost. Costs were disaggregated into different level, firstly by program areas then by interventions, activities, and cost inputs. Shared cost across different KAPs or program area were allocated accordingly using allocation criterion based on their program outputs.
The cost included both recurrent and capital costs utilized by IAs which were reported into 13 cost inputs; Human Resources (HR), Travel related costs (TRC), External Professional services (EPS), Health Products - Pharmaceutical Products (HPPP), Health Products - Non-Pharmaceuticals (HPNP), Health Products - Equipment (HPE) including HIV test kit, Procurement and Supply-Chain Management costs (PSM), Infrastructure (INF), Non-health equipment (NHE), Communication Material and Publications (CMP), Indirect and Overhead Costs, and Living support to client/ target population (LSCTP).
Indirect Program Cost (Overhead cost): At above site level, overhead costs (include program management, health system strengthening, monitoring and evaluation etc.) were calculated and allocated accordingly to all 15 IAs who received funding through primary recipient (PR) agency who received funding through the Global Fund program.
Unit Cost: We calculated unit cost per targeted KAP reached by a community-based HIV intervention or unit cost per person to receive service from a community-based HIV intervention. The unit cost was defined as total cost divided by total program outputs. The unit cost at IAs level was first calculated by allocating all direct program cost (operational cost) at site level while excluding overhead cost. The unit costs including both direct program cost and overhead cost from above IAs level were then calculated. The overhead costs were allocated proportionally to IAs’ individual intervention by using allocation strategies based on each intervention program outputs.
Table 1: Characteristics of community outreach HIV interventions in this study
Characteristics
|
Number
|
%
|
No. of Implementing Agencies (IAs)
|
20
|
|
No. of Provinces covered
|
27
|
|
No. of HIV intervention Package Delivered
|
38
|
|
No. of TB intervention Package Delivered
|
7
|
|
Total Cost spent for all intervention programs (USD)
|
9473316
|
|
- Cost for HIV interventions (USD)
|
7837234
|
(82.7%)
|
- Cost for TB interventions (USD)
|
1636082
|
(12.3%)
|
- Total Direct Program Cost by IAs (USD)
|
6686157
|
(70.6%)
|
- Total Indirect Program Cost or overhead cost (USD)
|
2787160
|
(29.4%)
|
HIV Intervention Package
|
|
|
- Cost spent by IAs for HIV interventions (USD)
|
|
|
- Direct Program Cost by IAs
|
5576092
|
(71.1%)
|
- Overhead Cost above IAs level
|
2261142
|
(28.9%)
|
|
146739
|
|
|
31122
|
|
|
294562
|
|
|
104474
|
|
- No. of Targeted KAP reached by HIV Interventions (Person)
|
|
|
|
190931
|
|
|
5025
|
|
|
161
|
|
|
25438
|
|
|
5367
|
|
- No. of Targeted KAP received HIV tests (Person)
|
|
|
- Total No. of targets tested
|
32309
|
|
|
850
|
|
|
20
|
|
|
1548
|
|
|
936
|
|
TB Intervention Package
|
|
|
- Cost spent by IAs for TB interventions (USD)
|
|
|
- Total Cost (Direct Program Cost)
|
1110065
|
|
- Total No. of targets reached (Person)
|
56099
|
|
- Total No. of TB suspect found (Person)
|
878
|
|