Is there scope for cost savings and efficiency gains in HIV services?

Mariana Siapka, Michelle Remme, Carol Dayo Obure, Claudia B Maier, Karl L Dehne & Anna Vassall Bulletin of the World Health Organisation, 2014; Vol. 92, No. 7, 465-544 Is there scope for cost savings and efficiency gains in HIV services?

The general efficiency of HIV services must be improved if core interventions are to be successfully scaled up in environments where resources are scarce.

Overall, the authors conclude that HIV programmes need to optimize the scale of service provision to achieve efficiency. Interventions that may enhance the potential for economies of scale include:

  • intensifying demand-creation activities
  • reducing the costs for service users
  • expanding existing programmes rather than creating new structures
  • reducing attrition of existing service users

Models for integrated service delivery – which is, potentially, more efficient than the implementation of stand-alone services – should be investigated further. 

This analysis is timely. Many low- and middle-income countries still need to scale up essential HIV services in order to achieve the Millennium Development Goals for HIV infection and the targets of the Political Declaration on HIV and AIDS. But decision-makers face increasing demands to reduce the costs of HIV services. Thus there is now an urgent need to update and synthesize the data on the technical efficiency of HIV services.

The systematic literature review analysed the costs of the six basic programmatic activities of the Strategic Investment Framework of the Joint United Nations Programme on HIV/AIDS (UNAIDS), which are:

  • antiretroviral therapy (ART) and counselling and testing
  • key-population programs
  • condom distribution and social marketing
  • voluntary medical male circumcision
  • programmes to eliminate HIV infections among children and keep their mothers alive
  • programmes of behaviour-change communications targeted at young adults and the general population

The authors conclude that

  • wide variation in unit costs indicates that there is general room for improvement in the technical efficiency of HIV services
  • where quality and costs were jointly examined, cost reduction often led to reduced quality
  • compared to small programmes, large-scale programmes were less likely to follow up patients actively
  • there are signs of recent improvements in the costing of HIV services and evidence that cost-reductions are already being achieved as HIV programmes mature

When setting national and international cost benchmarks, attention must also be taken not to create perverse incentives by emphasising measurable costs rather than the more intangible aspects of service quality.

While integrating HIV services with other health services may reduce costs, further studies are required to determine the best ways of improving efficiency of HIV services at site level, as well as establishing the likely impact of such improvements on the national costs of HIV services. 


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