Efficiency of introducing novel person-centred HIV prevention, testing and treatment models in Zimbabwe: Economic evaluations to inform policy

Abstract

Introduction
The economic costs of HIV can be substantial for both programme implementers and patients including user fees, transport, food and in-direct costs such as lost productivity. In this prospective PhD by paper publication I investigate methods to improve programme efficiencies in order to assist health policymakers with evidence for resource prioritisation.

Materials and methods
The main research questions were: (1) How do constraints to demand-generation and user continuation influence demand and efficiency of HIV programmes?; (2) Can increased demand and supply and hence efficiency gains be attained through innovative health system approaches such as integration?; (3) Can increased demand and supply and hence efficiency gains be attained through innovative health system approaches such as demand generation and service delivery in community settings where users are found?; (4) What is the impact of providing longer term support in community-based programmes on demand for HIV programmes and efficiency?

Results
A scoping review analyses the state and factors that influence cost-effectiveness of HIV programmes in southern Africa. Chapter three evaluates economic costs of delivering pre-exposure prophylaxis, identifying continuation (adherence) as a key factor that drives up economic costs. As with many HIV programmes with intensive investment in demand generation there was high demand for PrEP initiation followed by a steep drop off in client continuation numbers in the first month leading to rapid increase in average costs. The downward impact of providing integrated rather than standalone HIV services (supply side) on economic costs is analysed in chapter four, suggesting how sexual and reproductive health services can be better integrated with HIV programmes for more efficient use of shared resources. Chapter five evaluates efficiency impacts of innovative demand generation approaches conducted in the community which lead to increased uptake of VMMC.
Chapter six evaluates efficiency impacts of community-based approaches to provision of HIV self-testing services leading to higher numbers of screenings. Still in chapter six, the impact of community-led approaches and learning by doing on efficiency of HIV self-testing services is assessed (sub-chapter 6.1) followed by efficiency impacts of innovative retention approaches in community-led differentiated service delivery models for adolescents living with HIV (ALHIV) (sub-chapter 6.1). In chapter 7, a Markov decision-analytical model (extrapolated over 40 years beyond the trial) parameterized with data from an earlier cluster randomised trial (Zvandiri) simulated the potential costs and benefits of an enhanced adherence intervention on viral suppression, mortality rates, life-years and quality adjusted life years gained compared with standard of care.

Conclusion
Intensive and innovative demand generation and retention approaches would benefit from economies of scale and achieve lower unit costs through fuller utilisation of fixed capital inputs. Combined, these strategies can help policymakers, implementers and funders scale up sustainable lower cost HIV programmes.

Date of Award	7 Nov 2025
Original language	English
Awarding Institution	Liverpool School of Tropical Medicine
Supervisor	Frances Cowan (Supervisor), Euphemia Sibanda (Supervisor), Hendramoorthy Maheswaran (Supervisor) & Fern Terris-Prestholt (Supervisor)