Jilinde Costing Study of PrEP in Kenya

Related studies:

JILINDE Prospective Cohort Study

Background:
In recent years, oral pre-exposure prophylaxis (PrEP) has been positioned squarely on the prevention agenda of many countries with a high burden of HIV. In 2016, the Kenya Ministry of Health, following the guidance of the WHO, revised the national "Guidelines on Use of Antiretroviral Drugs for Treatment and Prevention of HIV Infection " (NASCOP, 2016), and recommended the provision of PrEP to all individuals at substantial ongoing risk of acquiring HIV infection. Subsequently, the government launched a national PrEP scale-up program in May 2017.

However, as the government of Kenya continues to scale up PrEP, there is limited knowledge on the cost of scaling up the use of oral PrEP among Key and Vulnerable Populations (KVPs). The Jilinde (Bridge to Scale) project commenced in July 2016 with an overall objective of supporting the government of Kenya to scale-up oral PrEP across the country. Jilinde conducted this study to assess the cost of PrEP for various KVPs using various models of service delivery and geographic regions of Kenya.

In this study we estimated the cost of PrEP from two different perspectives: the service delivery perspective and the client perspective. The service delivery perspective involved collecting cost data from health facility managers and by type of service delivery model (drop in service centres, youth friendly centres, public health facilities that have integrated PrEP into the existing services and private clinics or social franchise clinics). This was to enable an analysis of the average unit cost of PrEP, as well as an analysis of the incremental costs associated with adding PrEP to Kenya 's existing prevention strategy among KVPs. The output of the activity is an estimate of cost per person year (PPY) of service delivery. The second perspective involved measuring costs borne by the clients (financial and opportunity costs). By understanding what costs are incurred by the clients, it is then possible to better understand if these costs represent a significant barrier to PrEP uptake.

In addition, the costing study also examined the client willingness to pay for oral PrEP services (medications, laboratory procedures, etc.). This contingent valuation analysis was critical in not only understanding how much clients are willing to pay, but also to better understand the factors that cause clients to have greater or lesser motivation to seek out these services.

Objectives: The aim of the study was to estimate the full cost and unit cost of the PrEP scale-up program for different KVPs in Kenya.
Specific objectives:

To determine the current unit costs of providing PrEP by mode of service delivery (drop in service centres, youth friendly centres, private sector and social franchise clinics and public health facilities) for various KVPs and geographic regions of Kenya;
To estimate direct costs incurred by clients (financial and opportunity costs) in accessing PrEP;
To analyze the incremental costs associated with adding PrEP to Kenya's existing prevention strategy among KVPs;
To determine willingness to pay for PrEP services.

Methodology:

Geographic Location/Study Sites: Data was collected from ten counties in Kenya where the Jilinde (Bridge to Scale) project was implemented. The counties were clustered based on geographical proximity; Nairobi cluster (Nairobi, Kiambu, and Machakos); Coast cluster (Mombasa, Kilifi, Kwale, and Taita Taveta); Lake cluster (Kisumu, Kisii and Migori counties).
Dates of Data Collection: Data were collected from October 2017 to August 2018.

Study Design: This was a cross-sectional study that collected both quantitative and qualitative data through surveys with PrEP clients and key informant interviews with health facility managers.
Eligibility Criteria:
For the health facility costing, the study population included all public and private health facilities and community drop in centres in the three regions (Coast cluster, Lake Cluster and Nairobi Cluster) which had integrated PrEP services. Respondents were the health facility managers.
For the client costing survey, the study population included female sex workers (FSW), men who have sex with men (MSM) and adolescent girls and young women (AGYW) who had initiated PrEP through the different facilities supported by the Jilinde project. For the willingness to pay survey, the study population included clients (FSW, MSM and AGYW) who had initiated PrEP and those who had been offered PrEP services but had declined.

Data Collection:
Costing and utilisation data were collected from a sample of 44 facilities consisting of 23 public health facilities (County Referral Hospital, Sub-County Hospital, Health Centres and Dispensaries), 5 private facilities/clinics and 16 drop-in centres (DICEs). Six research assistants (two for each cluster), and the study investigators were responsible for data collection in all the sampled facilities.
For the facility costing, the study team conducted a semi-structured in-depth interview with facility managers to obtain information on the costs of resources used in delivering PrEP services. Data on all resources used in delivering PrEP services (personnel, equipment, medications, consumables, lab tests and reagents, test kits, utility, maintenance, and utilities) was collected for each visit (initial visit or first contact, refill visits and revisits) and for each stage of client flow in a facility: i) Reception, ii) Triage, iii) Health education, iv) HTS and STI testing, v) Prescription of drugs and vi) Dispensing drugs client). This service delivery process was useful in assisting the research team obtain relevant data for PrEP costing at each stage.
The client costing and willingness to pay data were collected through a structured, exit interview questionnaire, which was administered by the six Research Assistants at each of the 44 service delivery sites. PrEP clients were informed about the study by service providers, and those who expressed interest were referred to the research team within the facility, who screened for eligibility and administered consent. The research assistants documented whether it was an initial or follow-up refill or monitoring visit.
The client costing questionnaire was designed to gather, among others, demographic and socio-economic data, direct cost of accessing PrEP services (out-of-pocket expenses), and indirect cost in the form of productivity loss by the client (opportunity cost) when seeking services. The willingness to pay (WTP) questionnaire documented the participants personal and household characteristics (age, religion, marital status, individual income, household income, level of education, employment status, etc.), their willingness to pay for PrEP services, and reasons informing their decisions. Respondents who indicated a willingness to pay were shown 14 random payment cards, with various amounts, which varied from Kshs 0 to Kshs 10,000 (US$100) and asked to indicate which card represented the highest amount they would be willing to pay on a monthly basis for PrEP services. Once an amount was selected, they were then shown the card with the next highest amount and asked if they would pay that amount. If the respondent indicated "no", then the original amount selected would be identified as the maximum WTP. If the respondent indicated "yes", then the next highest card was selected, and they were again asked if they would be willing to pay this amount. In this way, the respondent is "bid up" until they confirm that the amount indicated is truly the maximum WTP. After two attempts to "bid up" the respondent, the bidding process ended, and the highest amount was confirmed.
Study Documentation:

Questionnaire 1: Client questionnaire
Questionnaire 2: Client WTP questionnaire
Questionnaire 3: Facility Questionnaire

ClinEpiDB Data Integration: Data files were provided to ClinEpiDB as cleaned .csv files with all personal identifiers removed. All dates were obfuscated per individual through the application of a random number algorithm that shifted dates no more than seven days to comply with the ethical conduct of human subjects research.

Financial Support: The Jilinde project was funded by the Bill & Melinda Gates Foundation under investment number INV-007340. In addition, the project received a donation of PrEP commodities (TDF/FTC) from Gilead sciences.

Ethics Statement: Ethical approvals for this study were obtained from:

Kenya Medical Research Institute (KEMRI) Scientific Ethics Review Unit (Non KEMRI 583)
Johns Hopkins Bloomberg School of Public Health (JHSPH) institutional review boards (IRB 7657).

Last Updated: October 12, 2022In order to help government of Kenya to better understand the cost of scaling up oral pre-exposure prophylaxis (PrEP), this Jilinde study was conducted to assess the cost of PrEP for various Key and Vulnerable Populations (KVPs) using various models of service delivery and geographic regions of Kenya. From October 2017 to August 2018, 1890 participants were surveyed from the service delivery perspective and the client perspective in Kenya.