Comparison of the costs of HPV testing through Community health campaigns versus Home-based testing in rural western Kenya: A micro-costing study

Objectives: To estimate the cost of HPV-based screening through Community health campaigns (CHCs) and home-based testing. Setting: Community health campaigns (CHCs) and home-based testing in six communities in rural western Kenya. Participants: CHCs and home-based screening reached 2297 and 1002 women aged 25 to 65 years respectively. Outcome measures: Outcome measures were overall cost per woman screened achieved through the CHCs and home-based testing, and the cost per woman for each activity comprising the screening intervention. Results: The mean cost per woman screened through CHCs and home-based testing were similar, at $37.7 (range $26.4 - $52.0) and $37.1 (range $27.6 - $54.0), respectively. For CHCs, personnel represented 49% of overall cost, supplies 25%, services 5%, and capital goods 23%.  For home-based testing, these were: personnel 73%, supplies 25%, services 1%, and capital goods 2%. A greater number of participants was associated with a lower cost per participant. Conclusions: The mean cost per woman screened is comparable for CHC and home-based testing, with differences in type of input. The CHCs generally reached more eligible women in the 6 communities, whereas home-based strategies more efficiently reached populations with low screening rates. This micro-costing study was part of a two-phase cluster-randomized trial in Nyanza, Kenya to determine the uptake rates of implementation strategies for HPV self-testing. Between February and October 2018, six rural communities were offered HPV screening through Community Health Campaigns (CHCs). We defined a community as one or two sub-locations within a defined administrative boundary. Each community had a total population size of between 4500 to 9500 and had either a level II, III or IV Ministry of Health facility. Though each community had between 10-12 villages, we only measured costs at the community level. Women aged between 25 and 65 years who did not screen at the CHCs (46.4% of the target populations) were offered home-based screening in November 2018. The implementation strategy for both CHCs and home-based testing consisted, in different intensities, of outreach and mobilization, screening, and notification of results. In all communities, we informed all the eligible women about CHC based screening first through community outreach. We then conducted a second outreach for the home-based testing to reach the women who did not screen at the CHCs. We offered HPV-testing through self-collection to women from both CHCs and home-based testing. Outreach for the CHCs were conducted for two weeks before the screening services were available and involved door-to-door mobilization and meetings with key stakeholders. Resources used were the study vehicle, fuel, and personnel, including two research assistants, ten community health volunteers (CHVs), one study coordinator, one study driver, and one study administrator.  Resources used were similar across the six communities, except for two (Olasi and Osingo) where the study vehicle broke down, requiring transport reimbursement for the research assistants. For home-based testing, outreach and mobilization took place concurrently with screening. At least ten CHVs from each community, accompanied by the research assistants, identified the homes of eligible women who did not screen at the CHCs and offered them the HPV self-collection kits to be completed at home. Activities dedicated to screening included registration, group education, informed consent, and HPV self-collection. A multi-disciplinary team that included experts in cervical cancer prevention, health care providers with knowledge of community strategies, and CHVs with experience delivering health education in Kenya conceptualized and designed an education module. The education module was delivered before screening for both the CHCs and homes to educate the women on anatomy, definitions of cervical cancer and HPV, how screening works, how to conduct self-HPV testing, result interpretation and the available treatments. A positive test result meant having a type of high-risk HPV that is linked to cervical cancer. We strongly emphasized early treatment to prevent that progression to cervical cancer in the future. Follow-up test was recommended in a year or three years for HIV positive and negative women respectively, to see if the infection had cleared or to check for signs of cervical cancer. The HPV screening campaigns lasted ten days per community for the CHCs and four days per community for home-based testing. The CareHPV™ testing system used was not a point-of-care test therefore the collected specimens were transported daily from the CHCs and homes to the study laboratory at Migori County Hospital for processing. The tests were run in batches of 90, with a turnover time of approximately 1–2 weeks for the women from both sites to know their results. Options for notification of results included: home visits, text messaging, and phone calls. However, there were implementation differences between the two strategies during notification. At the CHCs, both HPV-positive and negative women who opted for home visits were notified by the research assistants over ten days per community. The study vehicle was used for transport during notification in four of the six communities. For women screened at home, the CHVs conducted home visits for HPV negative women while the assistant study coordinator conducted home visits for the HPV-positive women using the study motorbike. The hrHPV positivity rate in this population was 17%. A total of 505 women tested positive for hrHPV.  hrHPV-positive women from both the CHCs and home-based testing were referred to one of four government health facilities based on proximity to their community for a visual exam with acetic acid and treatment with cryotherapy/LEEP per the WHO guidelines. The government health facilities were Migori County Referral Hospital, Macalder Sub-County Hospital, Ogwedhi Health Centre and Karungu Sub-County Hospital. Timely and effective linkage to cryotherapy/LEEP treatment for both screening strategies was achieved by decentralization of treatment centers, making follow up phone calls and sending text message reminders to the hrHPV women who had received their HPV test result but had not yet accessed treatment within one month. These strategies were developed in collaboration with the Ministry of Health and based on feedback from health-care providers and participants in the ongoing study. Costing methods We applied micro-costing methods from the provider’s perspective to estimate the delivery cost of HPV screening in CHCs and home-based testing. We adopted an economic perspective, whereby all resources were costed at full value even if donated or subsidized. We enumerated the resources used, multiplied by the price paid or market quotes, and summed to estimate the total cost in each community, and finally divided by the total number of screening participants to arrive at unit costs per woman screened. All costs are reported in U.S. dollars, converted from Kenyan shillings at a commercial exchange rate of 101.7 Kenyan shillings per U.S. dollar (17 January 2018). We classified resources into four main input categories: personnel, recurrent supplies, services, and capital goods. We estimated personnel compensation from project financial records. For staff with multiple responsibilities, we obtained information on the time dedicated to the interventions via interviews (e.g., for outreach and notification activities), supplemented by time and motion data (collected during screening activities). When the two methods covered the same issue, e.g. hours per week on different tasks, we relied on time and motion data, which was collected in real-time. Recurrent supplies refer to items consumed within one year as well as longer-lived resources of low value. These included careHPVTM (QIAGEN Inc., Gaithersburg, MD; USA) collection media, test kits and brushes, pipette tips, motor vehicle fuel, and staff t-shirts. Services include expenditures on consultant fees, IT support, utilities, and vehicle maintenance. We estimated the cost of recurrent supplies and services from expenditure records, and then conducted interviews with the staff to establish allocation across different functions and time periods. Capital goods and equipment are items with more than one year of useful life and value of >$250; examples study vehicle, careHPV™ test system, study motorbike and tablets. Costs of capital goods were amortized on a 0% real discount rate basis over five years (useful life) assuming no salvage value. We extracted cost information from expenditure records and study logs, supplemented by interviews with administrative staff and the team that delivered the services at each site. For both the CHCs and home-based testing, we collected time and motion data daily on paper-based forms to estimate personnel time spent on CHC activities. We omitted time explicitly used for research, including regulatory activities and administering research questionnaires. We enumerated the items (based on numbers used for the community), multiplied the number by the cost of each item whether purchased or donated, and estimated unit (per-screening) costs from the sum of costs. Once total economic cost of each item was calculated, each cost item was further allocated to program and non-program purposes. To arrive at a unit cost (per completed screening), total economic cost of each item that was designated for program purposes was divided by the number of women screened at each community. Using the unit-cost estimations, the micro-costing data was then aggregated to estimate total costs per woman screened at a CHC and Home-based testing. In the costing analyses, we compared costs across the six CHC communities, and conducted a similar comparison across the six Home-based testing communities. The costs per woman screened at each community was broken down by type of costing input (personnel, services, recurrent goods, capital), and phase (outreach, screening, and notification). Outcome measures were overall cost per woman screened achieved through the CHCs and home-based testing, and the cost per woman for each activity comprising the screening intervention. The overall cost per woman screened was calculated by dividing the total cost of all six sites, designated for program purposes, by population uptake of HPV-based screening. There are no missing values.