(introduction...)

This worksheet calculates the cost of voluntary counseling and testing (VCT). It does so by accepting data on each cost element (e.g., test kits, personnel, and rent) and on the percent of women who drop out at various stages during the VCT process. It provides two methods for calculating costs: (1) a detailed method likely to yield a more accurate result but requiring more time to complete, and (2) a summary approach that can be useful for generating a “quick and dirty” estimate. We strongly recommend the detailed approach for costing VCT because VCT can represent a large portion (up to 75% or more) of total program costs.¹ The added accuracy and flexibility of detailed VCT costing compared with the summary approach is worth the added effort. Data sources: The needed information should be obtained from the setting in which the intervention is to be implemented or a similar setting. It is unlikely to be available in published or even unpublished reports. Instead you will probably have to generate your own estimates. You may find that pages 5-43 of the book Cost analysis in primary health care edited by Andrew Creese and David Parker and published by WHO in 1994 provides useful additional guidance. A companion volume to this book entitled Costing Guidelines for HIV/AIDS Prevention Strategies is another very useful reference. It can be downloaded from the Internet at http://www.unaids.org/unaids/document/economics/costguid.

¹ In fact, the reported costs are so high for some types of VCT that it may make sense in some programs to attempt to reduce costs (e.g., by offering pre-test counseling in larger groups) if this can be done without seriously compromising quality.

VCT typically includes:

· Registration and pre-test counseling

· Initial HIV test

· Post-test counseling

· Confirmatory test for these who initially test positive for HIV

· Ancillary services such as client transportation that may be needed to maintain the agency’s caseload of VCT clients for MTCT prevention.

In low prevalence areas it may also include an initial screening by interview to eliminate women at low risk of HIV. For purposes of this analysis, VCT does not include other activities such as research projects or maternal health services not directly tied to MTCT-related VCT.

Fixed vs. Variable costs. Many costing approaches distinguish variable costs such as expendable supplies that change as the level of output changes, from fixed costs such as administrative activities that remain constant over a wide range of output levels. Other approaches, such as Cost Analysis in Primary Health Care, distinguish between “recurrent” costs such as personnel compensation, and “capital” costs which occur only once or at long intervals (e.g., buildings, vehicles and other major equipment). We wish to be able to document how costs vary for each step of the VCT process as the number of clients remaining in the sequence varies. We therefore take the approach of distinguishing between fixed costs and variable costs.

Only the cost of services to women should be counted. The cost of services to male partners such as STD testing should not be included as these are not part of the activities needed to prepare mothers to receive the ARV or substitute feeding intervention.

If VCT for MTCT is to be added on to an existing program such as a maternal health program or to an STD clinic, only the incremental resources needed to provide this VCT should be included in the cost assessment.² Here are three related issues that may enter into the cost assessment:

² Incremental simply means additional. For example, incremental costs are the new costs entailed by a program and excludes costs which would have been incurred had there been no new program. Incremental cost-effectiveness analyses compare the additional costs and the additional benefits of one program with another.

Sharing of joint resources. Certain resources such as equipment, space, and overhead costs may be used both for VCT for the MTCT intervention and for other purposes such as STD testing or services to male partners. In evaluating VCT costs, estimate the percentage of the cost of these resources that should be assigned specifically to the MTCT intervention. Base this estimate on the number of full time equivalent staff members assigned to each type of service.

Patient fees. Revenues generated for the project by registration or other fees paid by clients should be separately noted and subtracted from costs, so that costs represent the net cost to the program. Space is provided to do this on the VCT spreadsheet.

Start-up and seasonal effects. Low attendance and relative inefficiency during the start-up period are likely to increase costs during the initial months but will not represent typical project operations. Similarly, during certain seasons of the year the caseload may be much higher or lower than average. Your analysis should be based on a period of time that reflects the average operations of the project.