Introduction
Methods
Study setting
PrEP provision in primary care clinics
Health care worker cadres involved in PrEP care
Study design
Data collection and processing
Data analysis
Uncertainty analyses
Results
Sample characteristics
Human resource needs
Health care worker time for sequences of PrEP activities (minutes) | N | Mean (range) | Median (IQR) |
---|---|---|---|
PrEP initiation visit | |||
Pre-PrEP counseling | 2 | 9 (8–10) | 9 (8–10) |
HIV risk assessment | 2 | 11.5 (6–17) | 11.5 (6–17) |
PrEP eligibility screening | 1 | 30 | 30 |
PrEP initiation | 7 | 24.9 (19–31) | 24 (20–30) |
Pre-PrEP counseling/HIV risk assessment | 42 | 12.2 (5–24) | 11 (10–14) |
Pre-PrEP counseling/–/blood testing | 1 | 23 | 23 |
Pre-PrEP counseling/–/–/–/PrEP initiation | 1 | 20 | 20 |
–/–/–/PrEP eligibility screening/PrEP initiation | 41 | 19.4 (8–31) | 20 (15–23) |
Pre-PrEP counseling/HIV risk assessment/blood testing | 40 | 16.8 (4–30) | 15 (12–21) |
Pre-PrEP counseling/HIV risk assessment/–/PrEP eligibility screening | 18 | 18.1 (5–29) | 17.5 (15–23) |
–/–/blood testing/PrEP eligibility screening/PrEP initiation | 1 | 16 | 16 |
Pre-PrEP counseling/HIV risk assessment/blood testing/PrEP eligibility screening | 2 | 23.5 (15–32) | 23.5 (15–32) |
Pre-PrEP counseling/HIV risk assessment/–/PrEP eligibility screening/PrEP initiation | 6 | 28.3 (19–37) | 28 (23–35) |
Pre-PrEP counseling/HIV risk assessment/blood testing/PrEP eligibility screening/PrEP initiation | 9 | 29 (13–42) | 31 (20–37) |
PrEP follow-up visit | |||
Follow-up counseling | 56 | 13.1 (3–36) | 11 (8–15) |
Follow-up counseling/blood testing | 27 | 15.7 (5–37) | 15 (10–19) |
PrEP blood testing | |||
Blood testing | 28 | 11.9 (3–30) | 10 (7.5–15) |
Health care worker time | Model 1 Coef. (95% CI) | Model 2 Coef. (95% CI) |
---|---|---|
PrEP activity (estimated minutes) | ||
Pre-PrEP counseling | 3.0 (− 1.3–7.2) | 4.3 (− 0.14–8.7) |
HIV risk assessment | 1.8 (− 2.6–6.1) | 3.3 (− 1.4–7.9) |
PrEP eligibility screening | 3.2 (0.0042–6.4)* | 3.8 (0.37–7.2)* |
PrEP initiation | 8.9 (4.8–13)*** | 11 (6.9–16)*** |
Follow-up counseling | 4.1 (1.2–7.0)** | 4.7 (1.7–7.7)** |
Blood testing | 3.2 (1.3–5.0)*** | 4.0 (1.8–6.2)*** |
Covariates (estimated minutes) | ||
Number of provided PrEP activities | − 1.5 (− 2.7 to − 0.30)* | |
Interrupted workflow | 3.4 (0.69–6.0)* | |
Fixed time cost (estimated minutes) | ||
Constant | 8.8 (6.1–12)*** | 8.9 (5.8–12)*** |
PrEP clinic visit (predicted minutes) | ||
PrEP initiation visit | 29 (25–32)*** | 28–32 (25–36)***,† |
PrEP follow-up visit | 29 (25–32)*** | 15–18 (12–21)***,† |
Model statistics | ||
Adjusted R2 | 0.24 | 0.26 |
AIC/BIC | 1894/1920 | 1891/1924 |
Human resource costs
Human resource costs ($) | Nursing sister | Nurse | Nurse assistant | Phlebotomist | HTS counselor | Peer supporter |
---|---|---|---|---|---|---|
Unit cost of time | ||||||
Salary per minute | 0.26 (0.24–0.27) | 0.16 (0.12–0.20) | 0.11 (0.11–0.12) | 0.063 (0.055–0.072) | 0.047 | 0.014 |
Fixed time cost | ||||||
Fixed cost per PrEP visit | 2.26 [1.48–3.13] | 1.39 [0.76–2.27] | 0.99 [0.66–1.36] | 0.56 [0.34–0.83] | 0.42 [0.29–0.54] | 0.12 [0.086–0.16] |
Cost of PrEP activity | ||||||
Pre-PrEP counseling | 0.76 [0–1.95] | 0.47 [0–1.42] | 0.33 [0–0.85] | 0.14 [0–0.34] | 0.042 [0–0.10] | |
HIV risk assessment | 0.45 [0–1.66] | 0.28 [0–1.21] | 0.20 [0–0.72] | 0.083 [0–0.29] | 0.025 [0–0.087] | |
PrEP eligibility screening | 0.82 [0.0010–1.74] | 0.51 [0.00052–1.26] | 0.36 [0.00045–0.76] | |||
PrEP initiation | 2.28 [1.17–3.51] | 1.40 [0.60–2.55] | 1.00 [0.52–1.53] | |||
Follow-up counseling | 1.06 [0.30–1.91] | 0.65 [0.15–1.38] | 0.46 [0.13–0.83] | 0.19 [0.058–0.33] | ||
Blood testing | 0.82 [0.32–1.37] | 0.50 [0.16–0.99] | 0.36 [0.14–0.59] | 0.20 [0.072–0.36] | 0.15 [0.062–0.24] |
Task sharing and cost savings
Scenario | Pre-PrEP counseling | HIV risk assessment | PrEP eligibility screening | PrEP initiation | Follow-up counseling | Blood testing | PrEP initiation visit ($)# | PrEP follow-up visit ($)# |
---|---|---|---|---|---|---|---|---|
Base case† | Nurse | Nurse | Nurse | Nurse | Nurse | Nurse | 4.47 [1.24–11] | 2.31 [0.71–4.98] |
Scenario 1† | Nursing sister | Nursing sister | Nursing sister | Nursing sister | Nursing sister | Nursing sister | 7.27 [2.43–15] | 3.76 [1.40–6.87] |
Scenario 2‡ | HTS counselor | HTS counselor | Nurse | Nurse | Nurse | Phlebotomist | 2.89–4.25 [0.83–9.19] | 1.44–2.60 [0.35–5.44] |
Scenario 3‡ | HTS counselor | HTS counselor | Nurse | Nurse | Nurse | HTS counselor | 2.85–4.21 [0.83–9.04] | 1.20–2.56 [0.30–5.29] |
Scenario 4‡ | HTS counselor | HTS counselor | Nurse | Nurse | Nurse assistant | HTS counselor | 2.85–4.21 [0.83–9.04] | 1.06–1.86 [0.30–3.28] |
Scenario 5‡ | Peer supporter | Peer supporter | Nurse | Nurse | Nurse assistant | HTS counselor | 2.30–4.06 [0.62–8.51] | 1.06–1.86 [0.30–3.28] |