{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,13]],"date-time":"2026-10-13T09:12:06Z","timestamp":1791882726686,"version":"4.3.4"},"reference-count":34,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2020,10,12]],"date-time":"2020-10-12T00:00:00Z","timestamp":1602460800000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2020,10,12]],"date-time":"2020-10-12T00:00:00Z","timestamp":1602460800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/100000002","name":"National Institutes of Health","doi-asserted-by":"crossref","award":["K01MH100994"],"award-info":[{"award-number":["K01MH100994"]}],"id":[{"id":"10.13039\/100000002","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["BMC Health Serv Res"],"published-print":{"date-parts":[[2020,12]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>In recent years, safer conception strategies have been developed to help HIV-serodiscordant couples conceive a child without transmitting HIV to the seronegative partner. The SAFER clinical trial assessed implementation of these strategies in Zimbabwe.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>As a part of the SAFER study, we estimated the costs (in 2017 $US) associated with individual and combination strategies, in the trial setting and real-world practice, from a healthcare system perspective. Safer conception strategies included: 1) ART with frequent viral load testing until achieving undetectable viral load (ART-VL); 2) daily oral pre-exposure prophylaxis (PrEP); 3) semen-washing with intrauterine insemination; and 4) manual self-insemination at home. For costs in the trial, we used a micro-costing approach, including a time and motion study to quantify personnel effort, and estimated the cost per couple for individual and combination strategies for a mean of 6\u2009months of safer services. For real-world practice, we modeled costs for three implementation scenarios, representing differences from the trial in input prices (paid by the Ministry of Health and Child Care [MOHCC]), intervention intensity, and increments to current HIV prevention and treatment practices and guidelines. We used one-way sensitivity analyses to assess the impact of uncertainty in input variables.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Individual strategy costs were $769\u2013$1615 per couple in the trial; $185\u2013$563 if using MOHCC prices. Under the target intervention intensity and using MOHCC prices, individual strategy costs were $73\u2013$360 per couple over and above the cost of current HIV clinical practices. The cost of delivering the most commonly selected combination, ART-VL plus PrEP, ranged from $166\u2013$517 per couple under the three real-world scenarios. Highest costs were for personnel, lab tests, and strategy-specific consumables, in variable proportions by clinical strategy and analysis scenario. Total costs were most affected by uncertainty in the price of PrEP, number of semen-washing attempts, and scale-up of semen-washing capacity.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Safer conception methods have costs that may be affordable in many low-resource settings. These cost data will help implementers and policymakers add safer conception services. Cost-effectiveness analysis is needed to assess value for money for safer conception services overall and for safer strategy combinations.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Trial registration<\/jats:title>\n                    <jats:p>\n                      Registry Name: Clinicaltrials.gov. Trial registration number:\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"uri\" xlink:href=\"https:\/\/clinicaltrials.gov\/ct2\/show\/NCT03049176\">NCT03049176<\/jats:ext-link>\n                      . Registration date: February 9, 2017.\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s12913-020-05784-4","type":"journal-article","created":{"date-parts":[[2020,10,12]],"date-time":"2020-10-12T09:02:56Z","timestamp":1602493376000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":10,"title":["Estimated costs for the delivery of safer conception strategies for HIV-discordant couples in Zimbabwe: a cost analysis"],"prefix":"10.1186","volume":"20","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8216-7634","authenticated-orcid":false,"given":"Carolyn Smith","family":"Hughes","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joelle","family":"Brown","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Caroline","family":"Murombedzi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thandiwe","family":"Chirenda","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gift","family":"Chareka","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Felix","family":"Mhlanga","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bismark","family":"Mateveke","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Serah","family":"Gitome","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tinei","family":"Makurumure","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Allen","family":"Matubu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nyaradzo","family":"Mgodi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zvavahera","family":"Chirenje","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"James G.","family":"Kahn","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2020,10,12]]},"reference":[{"key":"5784_CR1","unstructured":"Ministry of Health and Child Care (MOHCC), Zimbabwe. Zimbabwe Population-based HIV Impact Assessment (ZIMPHIA) 2015\u20132016: Final Report. August 2019, Harare: MOHCC."},{"key":"5784_CR2","doi-asserted-by":"publisher","unstructured":"Asfaw HM, Gashe FE. Fertility intentions among HIV positive women aged 18\u201349 years in Addis Ababa Ethiopia: a cross sectional study. Reprod Health. 2014;11(36). https:\/\/doi.org\/10.1186\/1742-4755-11-36.","DOI":"10.1186\/1742-4755-11-36"},{"issue":"6","key":"5784_CR3","doi-asserted-by":"publisher","first-page":"e0198798","DOI":"10.1371\/journal.pone.0198798","volume":"13","author":"JW Krashin","year":"2018","unstructured":"Krashin JW, Haddad LB, Tweya H, et al. Factors associated with desired fertility among HIV-positive women and men attending two urban clinics in Lilongwe, Malawi. PLoS One. 2018;13(6):e0198798. https:\/\/doi.org\/10.1371\/journal.pone.0198798.","journal-title":"PLoS One"},{"issue":"1","key":"5784_CR4","doi-asserted-by":"publisher","first-page":"69","DOI":"10.1007\/s10461-011-9981-3","volume":"16","author":"SR Schwartz","year":"2012","unstructured":"Schwartz SR, Mehta SH, Taha TE, Rees HV, Venter F, Black V. High pregnancy intentions and missed opportunities for patient-provider communication about fertility in a south African cohort of HIV-positive women on antiretroviral therapy. AIDS Behav. 2012;16(1):69\u201378.","journal-title":"AIDS Behav"},{"key":"5784_CR5","doi-asserted-by":"publisher","unstructured":"Tweya H, Feldacker C, Breeze E, et al. Incidence of pregnancy among women accessing antiretroviral therapy in urban Malawi: A retrospective cohort study. AIDS Behav. 2013;17:471. doi.org\/https:\/\/doi.org\/10.1007\/s10461-012-0150-0.","DOI":"10.1007\/s10461-012-0150-0"},{"issue":"6","key":"5784_CR6","doi-asserted-by":"publisher","first-page":"1713","DOI":"10.1007\/s10461-017-1777-7","volume":"22","author":"LT Matthews","year":"2018","unstructured":"Matthews LT, Beyeza-Kashesya J, Cooke I, Davies N, Heffron R, Kaida A, et al. Consensus statement: supporting safer conception and pregnancy for men and women living with and affected by HIV. AIDS Behav. 2018;22(6):1713\u201324.","journal-title":"AIDS Behav"},{"key":"5784_CR7","doi-asserted-by":"publisher","first-page":"524","DOI":"10.1521\/aeap.2016.28.6.524","volume":"28","author":"JM Brown","year":"2016","unstructured":"Brown JM, Njoroge B, Akama E, Breitnauer B, Leddy A, Darbes L, et al. A novel safer conception counseling toolkit for the prevention of HIV: a mixed methods evaluation in Kisumu, Kenya. AIDS Educ Prev. 2016;28:524\u201338.","journal-title":"AIDS Educ Prev"},{"key":"5784_CR8","volume-title":"Supplement to the 2016 consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection","author":"Updated recommendations on first-line and second-line antiretroviral regimens and post-exposure prophylaxis and recommendations on early infant diagnosis of HIV: interim guidelines","year":"2018","unstructured":"Updated recommendations on first-line and second-line antiretroviral regimens and post-exposure prophylaxis and recommendations on early infant diagnosis of HIV: interim guidelines. Supplement to the 2016 consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. Geneva: World Health Organization; 2018."},{"key":"5784_CR9","volume-title":"Recommendations for a public health approach","author":"World Health Organization","year":"2016","unstructured":"World Health Organization. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. In: Recommendations for a public health approach. Second ed. Geneva: World Health Organization; 2016.","edition":"Second"},{"key":"5784_CR10","unstructured":"World Health Organization. Guideline\u00a0on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV. Geneva: World Health Organization; 2015."},{"key":"5784_CR11","volume-title":"PrEP Guidelines","author":"Zimbabwe Ministry of Health and Child Care","year":"2016","unstructured":"Zimbabwe Ministry of Health and Child Care. PrEP Guidelines. Harare: MOHCC; 2016."},{"key":"5784_CR12","volume-title":"Guidelines for Antiretroviral Therapy for the Prevention and Treatment of HIV in Zimbabwe","author":"Zimbabwe Ministry of Health and Child Care","year":"2016","unstructured":"Zimbabwe Ministry of Health and Child Care. Guidelines for Antiretroviral Therapy for the Prevention and Treatment of HIV in Zimbabwe. Harare: MOHCC; 2016."},{"key":"5784_CR13","volume-title":"Methods for the economic evaluation of health care programmes. 2nd ed. Oxford","author":"M Drummond","year":"1997","unstructured":"Drummond M. Methods for the economic evaluation of health care programmes. 2nd ed. Oxford. New York: Oxford University Press; 1997."},{"key":"5784_CR14","doi-asserted-by":"publisher","first-page":"e51993","DOI":"10.1371\/journal.pone.0051993","volume":"7","author":"E Marseille","year":"2012","unstructured":"Marseille E, Giganti MJ, Mwango A, et al. Taking ART to scale: determinants of the cost and cost-effectiveness of antiretroviral therapy in 45 clinical sites in Zambia. PLoS One. 2012;7:e51993.","journal-title":"PLoS One"},{"key":"5784_CR15","unstructured":"Webb K, Maclean R, Engelsmann B, et al. Optimizing Zimbabwe\u2019s National PMTCT Program: Cost-effectiveness of a planned village health worker (VHW)-based intervention to improve linkage to postnatal care. Vancouver: Poster presented at: 8th International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention; 2015."},{"issue":"16","key":"5784_CR16","doi-asserted-by":"publisher","first-page":"2005","DOI":"10.1097\/QAD.0b013e32834a36d0","volume":"25","author":"PL Vernazza","year":"2011","unstructured":"Vernazza PL, Graf I, Sonnenberg-Schwan U, Geit M, Meurer A. Preexposure prophylaxis and timed intercourse for HIV-discordant couples willing to conceive a child. AIDS. 2011;25(16):2005\u20138.","journal-title":"AIDS"},{"issue":"5","key":"5784_CR17","doi-asserted-by":"publisher","first-page":"289","DOI":"10.1136\/oem.54.5.289","volume":"54","author":"M Joffe","year":"1997","unstructured":"Joffe M. Time to pregnancy: a measure of reproductive function in either sex. Asclepios project. Occup Environ Med. 1997;54(5):289\u201395.","journal-title":"Occup Environ Med"},{"key":"5784_CR18","unstructured":"Health Transition Fund A Multi-donor Pooled Transition Fund for Health in Zimbabwe. 2011. https:\/\/www.unicef.org\/zimbabwe\/ZIM_resources_htfoutline.pdf. Accessed March 23, 2017."},{"issue":"12","key":"5784_CR19","doi-asserted-by":"publisher","first-page":"e0143433","DOI":"10.1371\/journal.pone.0143433","volume":"10","author":"V Jain","year":"2015","unstructured":"Jain V, Chang W, Byonanebye DM, et al. Estimated costs for delivery of HIV antiretroviral therapy to individuals with CD4+ T-cell counts >350 cells\/uL in rural Uganda. PLoS One. 2015;10(12):e0143433. https:\/\/doi.org\/10.1371\/journal.pone.0143433.","journal-title":"PLoS One"},{"key":"5784_CR20","unstructured":"Clinton Health Access Initiative. ARV market report: the state of the antiretroviral drug market in low- and middle-income countries. 2016. http:\/\/www.clintonhealthaccess.org\/content\/uploads\/2016\/10\/CHAI-ARV-Market-Report-2016-.pdf. Accessed June 19, 2017."},{"key":"5784_CR21","unstructured":"2016 ANTIRETROVIRAL (ARV) CHAI REFERENCE PRICE LIST. ARV Ref Price List 2016. http:\/\/www.clintonhealthaccess.org\/content\/uploads\/2016\/11\/2016-CHAI-ARV-Reference-Price-List_FINAL.pdf. Accessed June 19, 2017."},{"key":"5784_CR22","unstructured":"Clinton Health Access Initiative. CHAI supports South Africa and global partners to achieve landmark HIV viral load access program.\u00a0Case Study; 2015. https:\/\/diagnostics.roche.com\/content\/dam\/diagnostics\/Blueprint\/en\/pdf\/rmd\/Case-Study_Viral-Load-Access_CHAIPublication.pdf. Accessed 19 June 2017."},{"key":"5784_CR23","unstructured":"Roche Molecular Systems. Global Access Initiative Country List. July 2015. https:\/\/molecular.roche.com\/app\/uploads\/2016\/07\/GAP_Country_List_15July2015_v2.pdf. Accessed June 19, 2017."},{"key":"5784_CR24","doi-asserted-by":"publisher","first-page":"346","DOI":"10.1186\/1472-6963-11-346","volume":"11","author":"JG Kahn","year":"2011","unstructured":"Kahn JG, Harris B, Mermin J, et al. Cost of community integrated prevention campaign for malaria, HIV, and diarrhea in rural Kenya. BMC Health Serv Res. 2011;11:346.","journal-title":"BMC Health Serv Res"},{"key":"5784_CR25","doi-asserted-by":"publisher","first-page":"19157","DOI":"10.7448\/IAS.17.3.19157","volume":"17","author":"N Mack","year":"2014","unstructured":"Mack N, Evens EM, Tolley EE, et al. The importance of choice in the rollout of ARV-based prevention to user groups in Kenya and South Africa: a qualitative study. J Int AIDS Soc. 2014;17:19157.","journal-title":"J Int AIDS Soc"},{"key":"5784_CR26","unstructured":"Gray A, Smit J, Manzini N, Beksinska M. Systematic review of contraceptive medicines. \u201cDoes choice make a difference?\u201d University of Witwatersrand, Johannesberg. 2006."},{"issue":"3","key":"5784_CR27","doi-asserted-by":"publisher","first-page":"340","DOI":"10.1097\/QAI.0000000000000172","volume":"66","author":"D Donnell","year":"2014","unstructured":"Donnell D, Baeten JM, Bumpus NN, et al. HIV protective efficacy and correlates of tenofovir blood concentrations in a clinical trial of PrEP for HIV prevention. J Acquir Immune Defic Syndr. 2014;66(3):340\u20138. https:\/\/doi.org\/10.1097\/QAI.0000000000000172.","journal-title":"J Acquir Immune Defic Syndr"},{"issue":"4","key":"5784_CR28","doi-asserted-by":"publisher","first-page":"CD009153","DOI":"10.1002\/14651858.CD009153.pub3","volume":"4","author":"A Anglemyer","year":"2013","unstructured":"Anglemyer A, Rutherford GW, Horvath T, Baggaley RC, Egger M, Siegfried N. Antiretroviral therapy for prevention of HIV transmission in HIV-discordant couples. Cochrane Database Syst Rev. 2013;4(4):CD009153. Published 2013 Apr 30. https:\/\/doi.org\/10.1002\/14651858.CD009153.pub3.","journal-title":"Cochrane Database Syst Rev"},{"issue":"6","key":"5784_CR29","doi-asserted-by":"publisher","first-page":"493","DOI":"10.1056\/NEJMoa1105243","volume":"365","author":"MS Cohen","year":"2011","unstructured":"Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365(6):493\u2013505. https:\/\/doi.org\/10.1056\/NEJMoa1105243.","journal-title":"N Engl J Med"},{"issue":"1","key":"5784_CR30","doi-asserted-by":"publisher","first-page":"21579","DOI":"10.7448\/IAS.20.1.21579","volume":"20","author":"SE Rutstein","year":"2017","unstructured":"Rutstein SE, Ananworanich J, Fidler S, et al. Clinical and public health implications of acute and early HIV detection and treatment: a scoping review. J Int AIDS Soc. 2017;20(1):21579. https:\/\/doi.org\/10.7448\/IAS.20.1.21579.","journal-title":"J Int AIDS Soc"},{"key":"5784_CR31","doi-asserted-by":"publisher","first-page":"S145","DOI":"10.1097\/QAI.0000000000001063","volume":"72","author":"JT Price","year":"2016","unstructured":"Price JT, Wheeler SB, Stranix-Chibanda L, et al. Cost-effectiveness of pre-exposure HIV prophylaxis during pregnancy and breastfeeding in sub-Saharan Africa. J Acquir Immune Defic Syndr. 2016;72:S145\u201353.","journal-title":"J Acquir Immune Defic Syndr"},{"key":"5784_CR32","doi-asserted-by":"publisher","unstructured":"Cremin I, Hallett TB. Estimating the range of potential epidemiological impact of preexposure prophylaxis: run-away success or run-away failure? AIDS. 2015;29(6): 733\u2013738. https:\/\/doi.org\/https:\/\/doi.org\/10.1097\/qad.0000000000000591.","DOI":"10.1097\/qad.0000000000000591"},{"key":"5784_CR33","doi-asserted-by":"publisher","first-page":"1523","DOI":"10.1093\/infdis\/jiv523","volume":"213","author":"RP Walensky","year":"2016","unstructured":"Walensky RP, Jacobsen MM, Bekker L-G, et al. Potential clinical and economic value of long-acting Preexposure prophylaxis for south African women at high-risk for HIV infection. J Infect Dis. 2016;213:1523\u201331.","journal-title":"J Infect Dis"},{"issue":"2","key":"5784_CR34","first-page":"91","volume":"5","author":"C Huyser","year":"2013","unstructured":"Huyser C, Boyd L. ART in South Africa: the price to pay. Facts Views Vis Obgyn. 2013;5(2):91\u20139.","journal-title":"Facts Views Vis Obgyn"}],"container-title":["BMC Health Services Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12913-020-05784-4.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s12913-020-05784-4\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12913-020-05784-4.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,10,12]],"date-time":"2021-10-12T00:45:22Z","timestamp":1633999522000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmchealthservres.biomedcentral.com\/articles\/10.1186\/s12913-020-05784-4"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,10,12]]},"references-count":34,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2020,12]]}},"alternative-id":["5784"],"URL":"https:\/\/doi.org\/10.1186\/s12913-020-05784-4","relation":{"has-preprint":[{"id-type":"doi","id":"10.21203\/rs.3.rs-34096\/v2","asserted-by":"object"},{"id-type":"doi","id":"10.21203\/rs.3.rs-34096\/v1","asserted-by":"object"},{"id-type":"doi","id":"10.21203\/rs.3.rs-34096\/v3","asserted-by":"object"}]},"ISSN":["1472-6963"],"issn-type":[{"value":"1472-6963","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,10,12]]},"assertion":[{"value":"5 June 2020","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"30 September 2020","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"12 October 2020","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"The SAFER Study was approved by the Medical Research Council of Zimbabwe and University of California, San Francisco ethical review boards. Written informed consent was obtained from all study participants.","order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"There are no competing interests to report.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"940"}}