(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 It is unlikely to be available in published or even unpublished reports.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.

TABLE VCT-1: PER-CLIENT COST OF VCT

Background

This table presents one of the key results of the VCT analysis, the total cost per client who completes VCT and registers for the ARV/substitute feeding interventions. It is presented both for HIV+ clients and for all clients. These are the most important summary statistics for measuring the efficiency of the VCT program. They are determined by variable supply and personnel costs, plus capital and other fixed costs. They also depend on the attrition rate since the denominator is the number of clients who complete VCT. Cost per HIV+ client is extremely sensitive to HIV prevalence (C9). As a measure of VCT operational efficiency, cost for all clients (both HIV+ and HIV-) may therefore be the more meaningful statistic (D9). No data entry required.

C9. VCT cost per HIV+ client only. Total annual expenditures for VCT divided by the number of HIV+ clients who complete VCT and register for the MTCT intervention itself.

D9. VCT cost per client (both HIV+ and HIV-). Total annual expenditures for VCT divided by the total number of clients who complete VCT and register for the MTCT intervention itself.

TABLE VCT-2: “EXTERNAL” COST OF VCT

Background

External cost of VCT refers to the portion of the cost that could be attributed to non-MTCT health benefits. VCT for vertical transmission prevention may also reduce horizontal (adult-adult) transmission. This reduction in horizontal transmission is not captured by the model in its calculation of health benefits to children and is referred to as external. One way to capture or “internalize” the potential horizontal transmission reduction benefits is to reduce the cost of VCT attributable to MTCT. If, for example, we believed that 30% of the total health benefits of VCT take the form of horizontal transmission reduction, we could reduce the cost of VCT by 30%. However, because this “external” benefit of VCT has not been documented, we have set the default value of this parameter to zero.³ This is likely to introduce a conservative bias to the cost-effectiveness results (tending to make results appear less favorable than they really are). The consequences of non-zero values for this external benefit can be assessed by entering other values in cell “VCT” C5.

³ Interested readers can refer to (Wolitski, et al., 1997), and (Zoysa, et al., 1995) for a review of recent studies regarding sexual risk behavioral change following VCT. Studies vary in their findings from significant increase in condom use (Kamenga, et al., 1991) to no benefit from one session (Temmerman, et al., 1990).

Influence on cost-effectiveness: High. The portion of the cost of VCT that is “billed” to horizontal transmission benefits has a major influence on the effective cost of VCT attributed to MTCT and therefore on overall program costs. This is especially true for the less drug intensive regimens such as HIVNET-012 and PETRA-B. VCT’s importance is also greater if substitute feeding interventions are not implemented.

Expected effort of data collection: Low. Estimating VCT’s benefits for horizontal transmission would be a major research undertaking in its own right. We suggest that for the “base case” analysis you use the default value of 0%.

C14. Specifying external cost of VCT. Enter numbers from 0% to 100% to evaluate changes in the value of this parameter. Note that the table in cells “VCT” I18 - “VCT” P29 show the current values of the various cost components of VCT. The left-hand side shows these values assuming no external benefits of VCT and the right-hand side shows these same values assuming the external benefit entered in C5 (and displayed also in P29).

TABLE VCT-3: SUMMARY VCT INFORMATION

Background

This table provides a quick method for estimating VCT costs. It can be unmasked via a macro if you opt to use the summary method of evaluating VCT costs. Enter “S” for “Summary” in cell “VCT” C18. If “D” for “Detailed” in cell “VCT” C18 is selected this table is masked and you may proceed to Table VCT - 3 to enter more detailed information. In that case you may skip this section of the manual and proceed to page 27. This summary method is most appropriate if data are available from projects that focus on VCT for HIV or for projects in which the finances of the non-VCT activities are easily separable from the VCT services.

By dividing total monthly operating expenditures (including capital costs converted to a recurring cost basis), into the number of clients who complete VCT and register for the MTCT intervention, one can directly derive a per-client operating cost. The issues mentioned above such as how to treat research and other adjunct activities; start-up and seasonal effects; patient fees; and the sharing of joint resources apply to this summary costing approach as well. A shortcoming of this approach is that it does not permit differential accounting for the cost of HIV-negative versus HIV-positive clients. This could be useful for predicting cost changes if prevalence in the caseloads changed, or if the VCT program were transferred to an area with a different HIV prevalence. Another disadvantage of the summary costing approach is that, since one cannot document the cost of the various steps in the VCT sequence, it is far less useful for cost control purposes.

In cells D23 through F28 of Table VCT-2 you are asked to enter “low”, “best” and “high” estimates for each of six variables that determine total net annual costs of providing VCT to pregnant women in your service area.

Influence on cost-effectiveness: High. VCT costs can constitute up to 75% of total program costs.

Expected effort of data collection: Medium. You have chosen to enter summary estimates in order to reduce the effort of estimating VCT costs in detail. Some loss of accuracy is inevitable. Because VCT costs have such a strong influence on cost-effectiveness, it makes sense to review budget and expenditure documents and to interview relevant project personnel in order to arrive a reasonable data-based estimate.

D23-F23. Number of HIV-positive clients who complete VCT and register for MTCT intervention per year. Enter a low, best and high estimate for the number of HIV positive women you expect will complete VCT and register to receive an MTCT intervention, either ARVs or substitute feeding. Data sources: One way to obtain a quick estimate is to use last year’s figures and adjust them upward or downward to reflect the factors that might make future reality differ from past experience.

D24-F24. Variable costs. Enter a low, best and high estimate for the annual expenditures on items that vary with the number of patients seen. This includes both supply items such as test kits; and personnel items such as wages and benefits for counselors and lab personnel. Since test kits are likely to be a large part of total costs it makes sense to obtain a good estimate of these costs. Data sources: Project expenditure documents.

D25-F25. Fixed costs. Enter a low, best and high estimate for items that tend to remain the same over relatively large changes in program scale. These include administrative costs and rent. Some personnel may have both administrative and direct service duties. If so, divide their compensation expenses appropriately between variable and fixed costs. Data sources: Project expenditure documents.

D26-F26. Capital goods. Enter a low, best and high estimate for annual expenditures on durable items (those lasting over a year) such as furniture and office equipment that are being used for the MTCT-VCT activities. Data sources: Project expenditure documents.

D27-F27. Average life of capital goods. Enter a low, best and high estimate for the average length in years of the useful life of these capital goods. Data sources: None. Use your best judgment based on the current condition of the items and how intensively they will be used.

D28-F28. Patient revenues. Enter a low, best and high estimate for the annual revenues that you expect to receive from VCT clients. This could be in the form of registration and other fees or from voluntary donations. Data sources: Project financial documents.

I18 - P29. Result of VCT cost calculation using the summary approach. If C18 = “S”, this table displays the results of the summary calculation; if C18 = “D” it displays the results of the detailed calculation. In both cases it gives the low, best and high estimates for:

· Variable costs
· Patient revenues
· Net variable costs (variable costs minus patient revenues)
· Fixed costs
· Capital costs
· Total annual costs
· Cost per HIV-positive patient who completes VCT

The left half of the table shows these results assuming that there are no external benefits of VCT. The right side shows the results with whatever the current value in cell C5 is (external benefit of VCT). The figures on the right-hand side are operative in the cost-effectiveness calculation. If you wish to run the analysis assuming no external benefit of VCT, make sure 0% is entered in cell C5.

TABLE VCT-4: DETAILED VCT INFORMATION (VARIABLE COSTS)

Background

“Variable costs” are costs that vary with the volume of service. These are primarily the cost of personnel and disposable supplies. Variable costs are likely to constitute at least 50% of total VCT cost. Using the detailed costing approach, resource consumption is determined by identifying, measuring and valuing all cost elements of the variable cost portion of VCT.

Personnel. This is the amount of staff time required per client for each task. The costing of personnel resources entails calculating the average length of time spent on each VCT activity. This time estimate is then multiplied by the wages of the personnel needed to provide the specified activity. For services provided to groups, such as most pre-test counseling, the personnel costs are divided over the average size of the group. Activities to be costed include: seeking consent for pre-test counseling for the HIV test; entering client’s name and demographic information into project records; administration of the HIV test; pre- and post-test counseling; and laboratory work. Remember, even if the client drops out of the process before the intervention itself, the time staff spends on that client is a real cost. The CET performs the arithmetic entailed in these calculations. The user’s task is to enter reliable information on parameters such as the wage rates, length of time required for each task, and on the proportion of women who drop out of the VCT cohort at each stage of the process.

Supplies. The HIV test kit is usually the most important item in this category. This includes the kit for the initial test (e.g., ELISA) and the kits for confirmatory tests, which may be more expensive (e.g., Western blot). These should be costed according to the price the agency actually pays. In most cases this will be a bulk purchase price available through a non-profit agency, not the local retail price for this item. To the bulk price should be added the cost of transporting it to the point of use.

This table provides space for entering detailed information on the items needed to calculate the variable costs. It includes information on each significant cost item and the number of women who receive each item. Several of the information items ask for very specific figures on the percentage of women who drop out of the treatment group at various points in the VCT process. Column E provides figures that convert the percents that you enter into actual numbers of women. In this way you can match the percentages entered in the CET with the actual numbers of women observed in your program.

Double-check cell C5: External benefits of VCT Remember to check the value in cell C5 for external benefit of VCT. This number adjusts the cost of VCT used to calculate cost-effectiveness. We recommend that you use the conservative default value of 0% for the base-case analysis.

Influence on cost-effectiveness: High. Variable costs are likely to be 50% or more of total VCT costs.

Expected effort of data collection: High. Since variable cost estimates have an important influence on cost-effectiveness and because relevant data should be readily available from project documents and personnel this should be considered a high priority.

C35. Prior testing. In cell C35 enter information on the percentage of women who register for VCT who are known to be HIV-positive from previous testing. Only those women who do not require further counseling and testing should be included. Data sources: Document indicating prior positive test results.

C36 and C37. Test characteristics. Enter the false positive rate for the initial and confirmatory tests you plan to use. The false positive rate is 1- specificity. The ELISA test has a specificity of 99.5% (Phillips, 1994). We have entered 0.5% in both C36 and C37 as the default values. Mislabeling of test results and other errors of clerical or lab technician are probably a greater source of error than the technical limits of the tests, this is hard to quantify and will vary from setting to setting. Program managers should in any case conduct periodic assessments to ensure that the error rate is very low.

C40 - C42. Wages per hour including benefits. Enter the average hourly compensation rates for clerical staff, counselors and lab staff. This should include both wages and benefits calculated on an hourly basis. Since pay is usually provided on a monthly basis, the hourly rate can be derived by dividing the average monthly wage by the number of days worked per month multiplied by the average number of hours per day. Other benefits such as health insurance and paid holidays should be added to the monthly wage. The formula for calculating the hourly wage would then be:

(Monthly financial compensation + monthly value of benefits)
divided by
(Average days worked per month x average hours worked per day).

“Clerical” staff here refers to those who assist with managing the paperwork involved in processing the daily caseload. This would be primarily registration and other patient record management and perhaps collecting patient fees, issuing receipts, etc. It would not include higher-level financial, administrative, or supervisory activities. Data sources: Project financial documents.

C45 - C48. Test kits and other cost items. Enter the per-unit cost of the initial test kit; the confirmatory test kit; and blood-draw tubes in cells C45, C46 and C47 respectively. In C48, enter the cost per woman of ancillary service such as transportation and meals if these services are needed to maintain the VCT caseload. Data sources: Project expenditure documents.

C50 - C51. Cost sharing. Enter average per-patient revenues from registration fees or other sources (if any). This figure can be obtained by dividing the monthly cost-sharing revenue by the number of women who register for VCT. Data sources: Project expenditure documents.

C58 - C61. Screening to identify high-risk women. Rather than counsel and test all women some programs may conduct an initial screening to identify high-risk women. The purpose of this screening is to reduce the resources used for pre-test counseling and testing of those who are HIV-negative. This strategy is most sensible in areas with very low prevalence of HIV. Since it inevitably means that some HIV-infected women will be inadvertently screened out, careful planning is required to hold these occurrences to a minimum. If this program does conduct an initial screening enter “Yes” in cell C55. Entering “Yes” unmasks cells C58 through C61.

NOTE: Data entry for cells C58 through C61 is only required if this program conducts an initial screening to identify women at high risk of HIV. This is only indicated if “Yes” is entered in C55. If this program dies not conduct an initial screening enter “No” in C55 and proceed to cell C64.

C58. Percent who decline initial high-risk screening and therefore drop out of VCT cohort. This is the attrition (“drop-out” rate) of women who refuse the high-risk screening and are therefore no longer in the counseling and testing cohort. Data sources: By examining patient records, project staff can tabulate the number of women who reported for antenatal services and received a referral for the initial high-risk screening for MTCT. The percent who decline the screening is then calculated by comparing this figure (number of women available) with the number who actually registered for the screening. This comparison should be carried out over five randomly selected days in order to ensure an adequately precise estimate.

C59. Minutes per woman needed to conduct the initial screening. If the screening is conducted in a group, this would be the length of time required to process each group divided by the average number of women per group. Data sources: Direct observation on three randomly-selected days.

C60. Percentage of women who were in fact found to be at high risk. This is the portion of women of all women screened who are determined by the screening criteria to be high risk. Only these women would then proceed to VCT. Estimates should be based on staff observation of the average number of minutes required for each high-risk screening session and the average number of women in each session. Data sources: Direct observation on three randomly-selected days.

C61. Number of women who were in fact HIV-infected but were excluded by the initial screening. The proportion of undetected positives inadvertently screened out of treatment in each program can be determined by periodic sampling of those screened out and offering to test them. In general, as the value in cell C60 goes down (screening criteria more stringent and higher proportion of positives in cohort screened in for services), the value in cell C61 goes up (more undetected positives screened out of services). Apart from its value in calculating cost-effectiveness, this figure is very important in ensuring that the screening process is not screening out an unacceptably large number of HIV-infected women. Data sources: Estimating this input requires periodic random sampling of those screened out and offering to test them to determine how many are in fact HIV-infected. Since this is an important parameter for reasons additional to the cost-effectiveness analysis, we recommend that this check should be carried out on an ongoing basis on one randomly selected day each month. Ten women should be randomly chosen on each of these days.

Cell C64 - C67. Registering for VCT. What appears in these cell range varies according to whether initial screening (C55) is offered or not. Please follow the instructions that correspond with your situation. Use the instructions in the first box “Registering for VCT-I” (below) if no initial screening for high-risk women is offered and the second box “Registering for VCT-II” on page 32 if initial screening is provided.

Registering for VCT - I Complete only if no initial screening is offered (If C55 = “No”) C64. Percent of those known to be HIV-infected but who decline to register. Another point of possible attrition, this is the proportion of women known to be positive from previous testing who arrived at the clinic for the MTCT intervention but who then declined to register. We expect that this number would be very small, particularly since, being already documented as HIV-infected, they would not have to be tested again. Using patient registry data, calculate the percentage of women referred for VCT who (1) are known from previous tests to be HIV-infected, but who (2) decline, for whatever reason, to register for VCT. Data sources: This information is probably available from client registry data. Since the number of women with known HIV+ status is likely to be small, a sample of 50 known HIV-infected women who received antenatal services should be adequate. If possible, this sample should be dawn from two or more time periods separated by 1-2 months. C65. Percent of those of unknown HIV status who decline to register. Another point of possible attrition. Data sources: See “Percent of those known to be HIV+ who decline to register” (above) but considering only women of unknown HIV status. Because there are far more women with unknown HIV status, 100 should be a reasonable sample. C66. Time in minutes required to register women of known HIV+ status for the MTCT intervention. Data sources: Observe patient flow directly to record the time required for each woman to register. A sample of 10-15 women of known HIV-positive status is adequate. C67. Time in minutes required to register women of unknown HIV status for VCT. Data sources: As in C66, observe patient flow directly. A sample of 15-20 women is adequate.

Registering for VCT - II Complete only if initial screening is offered (C55 = “Yes”) C64. Masked. C65. Percent of those who complete initial screening for high risk who decline to register for VCT. Another point of possible attrition. Data sources: Over 5 randomly-selected days, record the number of clients who complete the screening for high-risk and are found to be at “high risk” but who then do not register for VCT. Divide the average figure for these five days this into the total found to be “high risk”. The recording of this information should be as unobtrusive as possible, so that women’s decisions are not affected by their awareness of being monitored. C66. Masked. C67. Minutes required to register each ‘high risk’ woman for VCT. Data sources: Time the actual length of time required to register “high risk” women on three randomly selected days and take the average of all three days. C70. Percent of women receiving ancillary services. Percent of women who register for VCT who received ancillary services. If no ancillary services are provided, set this to 0%. This is the default value. Data sources: Review project records of the number of clients who receive ancillary services in a month. If family members of a client receive ancillary services such as transportation this should also be counted as services to that client. Calculate the percentage of all clients seen during that month that this constitutes. Since ancillary services may vary by time of year, collect this information during different seasons if possible. Average the results over the number of months that you collected data. A total sample of 100 clients should be adequate.

Cell C73 - C79. Pre-test counseling.

C73. Percent registered for VCT but who do not accept pre-test counseling. Data sources: Requires direct observation of the number of clients who drop out before pre-test counseling. Compare the number of registrations in a given day with a count of those who complete pre-test counseling. Completing this count over five randomly selected days would give a reasonable estimate. In most cases this number will be quite small and zero is the default.

C74. The number of women who receive pre-test counseling in one session. For individual counseling this will of course be “1”; but usually group counseling will be employed and the number should reflect the average size of the pre-test counseling group. In most cases we expect that a maximum number is set by policy. However, if patient flow is lower than expected, sessions may be conducted with less than this maximum. Data sources: Counting the actual number in each session over five randomly-selected days would provide an adequate basis on which to take an average. This may be an input that is sensitive to seasonal fluctuations. If possible, repeat this exercise during normal, low and high caseload seasons.

C75. Minutes required for pre-test counseling session. Data sources: Whether it is individual or group, time the actual length of the counseling sessions on five randomly selected days and take the average of all sessions.

C76. Percent of women who completed pre-test counseling but do not accept blood draw for initial HIV test. Another point of possible attrition. Data sources: This input can be calculated by asking staff to count the women who accept blood draw over the course of a randomly selected day and comparing this with the number who completed pre-test counseling on that day. Repeating this exercise over five randomly selected days should be an adequate basis on which to take an average percentage.

C77. Minutes required for blood draw. Data sources: Direct observation of 10-15 clients who are having their blood drawn on two randomly selected days should give an adequate estimate.

C78. Number of initial tests processed in a batch. There may be a maximum determined by the type of equipment in the lab, but depending on patient flow the number actually processed in a batch could be lower. Data sources: The lab staff can count the number per batch over five randomly selected days. If seasonal variation in patient flow is an issue, the sampled days should include days in different seasons.

C79. Minutes of lab technicians’ time for each batch of initial tests. Data sources:

Project staff should time the number of person-minutes needed to process each batch of initial tests. This should include the time between delivery of samples to the lab and delivery of the results to the counselors. Observations should cover a full day on two randomly-selected days.

Cell C82 - C85. Confirmatory test

C83. Percent of women who test positive on initial test who do not take the confirmatory test. If no confirmatory tests are provided, enter “No”. The remaining data entry cells in this section are then masked. In the vast majority of cases however, VCT programs will provide confirmatory tests to those who tested positive on the first test. Data sources: Over five randomly-selected days, staff should compare the number of women who test positive with the number who take the confirmatory test. Because women may return for the confirmatory test either before or after they are asked to return, staff should keep track of those who return by name or ID number over a two week**(?) period. This will ensure that results include all who return, not only those who return at the appointed time.

C84. Number of confirmatory tests processed in a batch. See explanation for C78 above.

C85. Number of minutes of lab technicians’ time for each batch of confirmatory tests. See explanation for C79 above.

C89 - C92. Post-test counseling. Different lengths of time for post-test counseling and different sized groups can be entered for HIV-negative versus HIV-positive women. The default assumption is that HIV-negative women will be counseled in the same sized groups at post-test as at pre-test but that HIV-positive women will be counseled on an individual basis at post-test.

C89. Number of women HIV-negative women who receive post-test counseling in one session. For individual counseling this will of course be “1”. Data sources: If the number per session is variable, counting the actual number over five randomly-selected days would be provide an adequate basis on which to take an average. This may be an input that is sensitive to seasonal fluctuations. If possible, repeat this exercise during normal, low and high caseload seasons.

C90. Minutes required for post-test counseling session for HIV-negative women. See explanation for C75 above.

C91. Number of women HIV-infected women who receive post-test counseling in one session. See explanation for C89 above

C92. Minutes required for post-test counseling session for HIV+ women. See explanation for C75 above.

C95 - C96. Registration for MTCT intervention. These cells record the number who may drop out at the final point of possible attrition, namely at the time of registration for the MTCT intervention itself. We assume that registration for MTCT is part of post-test counseling in the case of those women with previously unknown HIV status.

Registration for MTCT Intervention - I If initial screening is not provided (C55 = “No”) C95. Percent of women of previously unknown HIV status who completed post-test counseling who do NOT register for MTCT intervention. Final point of attrition. Data sources: This can be calculated by comparing the number of women who complete VCT and are referred to the MTCT intervention(s), with the number who actually register. This input, which determines the uptake rate for the interventions, can have an important effect on cost-effectiveness. We suggest you take the average percentage over 10-15 randomly selected days. Care needs to be taken only to include women who were not known to be positive from previous testing. This could perhaps be done by designating a space in the registration books and forms that record whether each client arrived at the facility with known HIV+ status from a previous test. C96. Percent of women of previously known HIV-positive status who completed post-test counseling who do NOT register for MTCT intervention. See explanation for C95 above.

Registration for MTCT Intervention - II If initial screening is provided (C55 = “Yes”) C95. Percent of women who complete post-test counseling who do NOT register for MTCT intervention. The final point of attrition. The sheet is now set to reflect the provision of an initial screening to identify high-risk women (C55= “Yes”). All women who register for MTCT therefore completed this initial screening. We assume that in the low prevalence settings where initial screening for high risk make sense, very few women will have known HIV-positive status, and we do not track them separately. C96. Masked.

D101 - F102. Total annual variable costs: Result and ranges. The blue cells E101 and E102 contain the results of the calculation of variable costs based on the data you have provided. (For more detail on how these results were derived, see the calculations in cells I45 - V62). In cells D101 and D102 you are asked to enter low-end estimates for supply and for personnel costs respectively. Cells F101 and F102 require high-end estimates for these same variable. These ranges will be used to define the lower and upper end of the ranges used in the sensitivity analyses to examine how cost-effectiveness varies with the cost of VCT.

C107 - F107. Annual number of women who complete VCT. Given the number of women who give birth in this service area; the portion of these women reachable by the program; HIV prevalence; and the number of women who drop out of the VCT process at various stages, cells C107, D107 and E107 display the number of HIV+, HIV-, and combined HIV+/HIV- women who complete VCT and register for the ARV/substitute feeding intervention. F107 shows the percentage of all women who register for VCT who do not complete the VCT sequence and register for the MTCT intervention itself.

TABLE VCT- 5: DETAILED VCT INFORMATION: (FIXED COSTS EXCLUDING CAPITAL COSTS)

Background

Fixed costs are expenditure items that do not vary with short-term changes in the caseload. Good examples of fixed costs include rent, telecommunications and administrative expenses. They do not include the wages of personnel who provide direct services. This table provides a template for entering detailed information on the fixed cost expenditures required by the VCT program.

Influence on cost-effectiveness: Medium. Fixed costs can constitute over half the cost of running a VCT program, and VCT can be the dominant cost of an MTCT program.

Expected effort of data collection: Low-medium. This may be an area in which it possible to get a reasonable estimate fairly quickly by focusing on the large expenditure items which are likely to include rent, administrative costs and possibly vehicle fuel and maintenance. The increased precision obtained by tracking down the exact cost of low-cost items may be small.

C117 - C137. Monthly expenditures for fixed cost items. For each cost item, you are asked to enter a monthly expenditure figure and the percentage of that amount spent on the MTCT program. In the first few lines some typical cost items are supplied such as “accounting”, and “telecommunications”. You may alter these as you wish and can enter up to 11 additional items that are not currently listed. Finally, in cells C137 and D137 you may record the combined expenditures for all other items not specifically listed in the rows above. Data sources: Project expenditure reports are the best sources of information on fixed costs. If these are not available, budget documents can also be used though they are less desirable since they reflect planned rather than actual outlays.

D117 - D137. Percent of fixed costs expenditures that are for MTCT-related VCT. Throughout this cost analysis we seek to separate items that are strictly for VCT associated with MTCT prevention from other costs. In some cases this may be challenging. For example, consider the case in which VCT for MTCT is carried out at a clinic that also provides VCT in conjunction with STD services for men. It is likely that these services will be housed in the same building and share administrative staff and other fixed expenses. The problem then is to make a reasonable allocation of costs to these two distinct activities. Data sources: Project managers may have a good sense of how staff time and other resources are allocated among activities and in some cases the information that they are able to provide will be sufficient. In other cases it will be worthwhile to undertake a more formal accounting either by observing how staff and equipment is used (time and motion studies) or by interviewing key staff members to learn how they allocate their time.

D143 - F143. Total annual fixed costs: Result and ranges. The blue cell E143 contains the results of the calculation of fixed costs based on the data you have provided. In cells D143 and F143 please enter low-end and high-end estimates for fixed costs. As was the case with variable costs, these ranges will be used to define the lower and upper end of the ranges used in the sensitivity analyses to examine how cost-effectiveness varies with the cost of VCT.

TABLE VCT-6: DETAILED VCT INFORMATION: CAPITAL COSTS

Background

Capital goods refer to physical goods with a useful life longer than the annual budget cycle. Examples include furniture, lab equipment and computer hardware and software. Expenditure documents supported by receipts are the best sources of information on capital costs. Capital costs require special accounting methods because they can vary greatly from year to year. Typically a program must make a large capital goods outlay during its start-up period. These expenses then drop dramatically as additional outlays are only made to replace worn-out equipment. There are a number of accounting methods, some of them quite sophisticated, for depreciating capital goods over their expected lives so that the “lumpy” capital costs can be smoothed out and put on the same annual basis as other costs. We have adopted a simple “straight-line” approach that amortizes the cost of an item evenly over its expected life.

As is true for every cost estimate in the CET, only consider the additional (or “incremental”) costs needed for this intervention. If, for example, a desk is purchased for use by the project administrator, and only 50% of her time is devoted to VCT, only 50% of the cost of that desk should be attributed to the program. Column “F” cells F151 - F168 labeled “% of use for VCT” allows you to make the appropriate allocation of cost.

Influence on cost-effectiveness: Depends. VCT is not a capital-intensive activity in general. However, capital costs could be important in some projects, (e.g., if the project purchased new computers for record keeping, particularly in countries that place high import duties on such items).

Expected effort of data collection: Depends. The level of precision to seek depends upon how large overall capital expediters are likely to be.

C151- F168. Capital goods. For each capital item this range of cells requires estimates of the quantity, cost, months of expected useful life and percent of use devoted to VCT for MTCT prevention. These data are then used to calculate the total monthly cost of that item to the VCT activity. As with fixed costs, some suggested items with hypothetical cost figures are provided to help get you started. Data sources: Project financial documents.

D170 - F170. All remaining items. Here you may enter combined cost data on any capital items not included in the list above. It may make sense to use these cells if you have numerous small items that would be tedious to itemize and which constitute only a small portion of total capital goods. We suggest that you limit the use of these cells because combining cost items and estimating an average useful life for all of them is likely to introduce inaccuracy into the calculation. Data sources: Project financial documents.

D175 - F175. Total annual capital costs: Result and ranges. E175 displays the “Best estimate” of total annual capital costs. Enter a low and high estimate in cells D175 and F175 respectively.

TABLE VCT-7: VARIABLE COST OF VCT BY TASK

Background

This table shows the personnel and supply costs entailed in each step of the VCT process and may be particularly useful for cost analysis purposes. The percent that each task constitutes of total variable costs shown in column M shows where the most money is spent and where, therefore, the greatest potential for improved economy may lie. Notice that the large number of women who receive services at early stages in the process such as registration and testing itself, may drive costs more than services provided in later stages such as post-test counseling which involves relatively few women.

B180 - M197. VCT cost analysis. All values in this table are derived from data entered elsewhere. Based on the attrition data entered in Table VCT-3, column C shows the number of women remaining in the VCT cohort at various stages of the process. Columns E through G detail personnel costs for each task. These are calculated by multiplying wage rates by minutes spent per client per task. Columns H through K treat supply costs and show unit costs, number of units used based on the number of clients receiving each item, and unit costs. Column L sums personnel and supply costs for each task and totals the annual costs net of revenues in “VCT” L197. Column M shows the percent that each task constitutes of the total.