Costs along the service cascades for HIV testing and Counselling and prevention of mother-to-child transmission.

After a decade of increases in financing for HIV services in low-income and middle-income countries (LMICs), funding has levelled off [1]. In this context, to scale up HIV services, countries must optimize use of available funds [2–4]. Empirical data on the per person cost of HIV services are critical to making better use of resources; they can be used to assess the cost-effectiveness of services, model the cost and impact of alternative approaches, and identify and address inefficiencies. There is a growing body of information on the unit cost of evidence-based HIV services in sub-Saharan Africa including HIV testing and counselling (HTC) and the prevention of mother-to-child transmission (PMTCT) [5]. Previous studies have assessed the cost of client-initiated and provider-initiated HTC in facilities [6–17]. A few studies have examined the facility-level cost of PMTCT [7,18–23]. However, with few exceptions [14,15], existing empirical HTC and PMTCT cost data focus on one step of the service cascade – cost per person tested for HTC and cost per woman or per mother–baby pair receiving antiretroviral prophylaxis for PMTCT. These studies do not provide the cost data along service cascades that are critical for identifying and addressing implementation inefficiencies. In this article, we estimate the average cost per client along the HTC component of the HIV treatment and care cascade [24], which we refer to as the HTC cascade and several steps along the PMTCT cascade [25] across a range of facilities in Kenya, Rwanda, South Africa, and Zambia. We use data from the ‘Optimizing the Response in Prevention: HIV Efficiency in Africa’ (ORPHEA) study [26] – a cross-sectional, micro-costing study conducted from 2012 to 2013 to assess the cost, cost structure, cost variability, and efficiency determinants of HIV prevention interventions.