abstract: 'Introduction Placing all clients with a positive diagnosis for HIV on

  antiretroviral therapy (ART) has cost implications both for patients and

  health systems, which could, in turn, affect feasibility, sustainability

  and uptake of new services. Patient-incurred costs are recognized

  barriers to healthcare access. Differentiated service delivery (DSD)

  models in general and community-based care in particular, could reduce

  these costs. We aimed to assess patient-incurred costs of a

  community-based DSD intervention (clubs) compared to clinic-based care

  in the Shinyanga region, Tanzania. Methods Cross-sectional survey among

  stable ART patients (n = 390, clinic-based; n = 251, club-based). For

  each group, we collected socio-demographic, income and expenditure data

  between May and August 2019. We estimated direct and indirect

  patient-incurred costs. Direct costs included out-of-pocket

  expenditures. Indirect costs included income loss due to time spent

  during transport, accessing services and off work during illness. Cost

  drivers were assessed in multivariate regression models. Results

  Overall, costs were significantly higher among clinic participants.

  Costs (USD) per year for clinic versus club were as follows: 11.7 versus

  4.17 (p < 0.001) for direct costs, 20.9 versus 8.23 (p < 0.001) for

  indirect costs and 32.2 versus 12.4 (p < 0.001) for total costs. Time

  spent accessing care and time spent in illness (hours/year) were 38.3

  versus 13.8 (p < 0.001) and 16.0 versus 6.69 (p < 0.001) respectively.

  The main cost drivers included transportation (clinic vs. club: 67.7\%

  vs. 44.1\%) for direct costs and income loss due to time spent accessing

  care (clinic vs. club: 60.4\% vs. 56.7\%) for indirect costs. Factors

  associated with higher total costs among patients attending clinic

  services were higher education level (coefficient {[}95\% confidence

  interval]) 20.9 {[}5.47 to 36.3]) and formal employment (44.2 {[}20.0 to

  68.5). Differences in mean total costs remained significantly higher

  with formal employment, rural residence, in addition to more frequent

  visits among clinic participants. The percentage of households

  classified as having had catastrophic expenditures in the last year was

  low but significantly higher among clinic participants (10.8\% vs.

  5.18\%, p = 0.014). Conclusions Costs incurred by patients accessing DSD

  in the community are significantly lower compared to those accessing

  standard clinic-based care. DSD models could improve access, especially

  in resource-limited settings.'
affiliation: 'Okere, NE (Corresponding Author), Amsterdam Inst Global Hlth \& Dev,
  AHTC Tower C4 Paasheuvelweg 25, NL-1105 BP Amsterdam, Netherlands.

  Okere, Nwanneka E., Sanofi Pasteur, Vaccine Epidemiol \& Modelling Dept, Lyon, France.

  Okere, Nwanneka E.; Corball, Lucia; Hermans, Sabine; de Wit, Tobias F. Rinke, Univ
  Amsterdam, Amsterdam UMC, Amsterdam Inst Global Hlth \& Dev, Dept Global Hlth, Amsterdam,
  Netherlands.

  Kereto, Dunia, Bugisi Hlth Ctr, Shinyanga, Tanzania.

  Naniche, Denise, Univ Barcelona, Hosp Clin, ISGLOBAL Barcelona Inst Global Hlth,
  Barcelona, Spain.

  Gomez, Gabriela B., London Sch Hyg \& Trop Med, Dept Global Hlth \& Dev, London,
  England.'
article-number: e25760
author: Okere, Nwanneka E. and Corball, Lucia and Kereto, Dunia and Hermans, Sabine
  and Naniche, Denise and de Wit, Tobias F. Rinke and Gomez, Gabriela B.
author-email: n.okere@aighd.org
author_list:
- family: Okere
  given: Nwanneka E.
- family: Corball
  given: Lucia
- family: Kereto
  given: Dunia
- family: Hermans
  given: Sabine
- family: Naniche
  given: Denise
- family: de Wit
  given: Tobias F. Rinke
- family: Gomez
  given: Gabriela B.
da: '2023-09-28'
doi: 10.1002/jia2.25760
eissn: 1758-2652
files: []
journal: JOURNAL OF THE INTERNATIONAL AIDS SOCIETY
keywords: 'costs; antiretroviral treatment; differentiated service delivery;

  Tanzania; catastrophic costs; patient-incurred costs'
keywords-plus: 'ANTIRETROVIRAL THERAPY; HEALTH FACILITIES; HIV TREATMENT; MODEL;

  DECENTRALIZATION; RETENTION; MALAWI; INCOME'
language: English
month: JUN
number: '6'
number-of-cited-references: '50'
orcid-numbers: 'Gomez, Gabriela B/0000-0002-7409-798X

  Naniche, Denise S/0000-0002-4495-6325

  Okere, Nwanneka/0000-0001-9182-6518'
papis_id: 3f7a32a6e71b141939e870c7fc38ace3
ref: Okere2021patientincurredcosts
researcherid-numbers: 'Gomez, Gabriela B/HSB-1504-2023

  Naniche, Denise S/S-1814-2018

  '
times-cited: '0'
title: Patient-incurred costs in a differentiated service delivery club intervention
  compared to standard clinical care in Northwest Tanzania
type: Article
unique-id: WOS:000667805400005
usage-count-last-180-days: '0'
usage-count-since-2013: '1'
volume: '24'
web-of-science-categories: Immunology; Infectious Diseases
year: '2021'