The Cost of Implementing Hiv Drug Resistance Testing in Kenya: a Case Study of a Service Delivery Site at Kenyatta National Hospital

Abstract

World health organization (WHO) recommends the inclusion of HIV drug resistance (HIVDR) testing in management of Human Immunodeficiency Virus (HIV) patients on treatment to mitigate the rising cases of HIVDR. However, despite this recommendation, there is paucity of information related to the cost of HIVDR testing in Kenya. This study aimed at estimating the unit cost of HIVDR testing, identifying the cost drivers for the HIVDR test, exploring opportunities for cost saving and documenting challenges and lessons learnt in implementation of HIVDR testing. To achieve these objectives, the cost analysis was performed at Molecular and Infectious Diseases Research (MIDR) Laboratory, a KNH/UON-CoEHM project initiative situated at the University of Nairobi Tropical and Infectious Diseases Institute (UNITID). The study utilized a mixed costing approach in quantification and valuation of the cost categories from the provider’s perspective. Data collection involved time and motion study of the laboratory procedures for HIVDR testing and interviewing the Laboratory personnel and the operations manager. As one of the cost saving opportunities adopted by the laboratory, we evaluated the cost of reagent volume reduction at amplification and sequencing processes intervention. Data entry and analysis was done in Microsoft excel and costs converted to US dollar (2019). The estimated unit cost for a HIVDR test was $271.78 per test. The main cost drivers for the HIVDR test included capital cost ($102.42, 37.68%) and reagent cost (101.50, 37.35%). The other costs included, personnel ($46.81, 17.22%), utilities ($14.69, 5.41%), maintenance cost of equipments ($2.37, 0.87%) and quality assurance program ($4, 1.47%). Costs in relation to laboratory processes were, sample collection ($2.41, 0.89%), RNA extraction ($22.79, 8.38%), amplification ($56.14, 20.66%), gel electrophoresis ($10.34, 3.80%), sequencing ($160.94, 59.22%) and sequence analysis ($19.16, 7.05%). Halving reagents volume at amplification and sequencing processes reduced the cost for HIVDR test to $247.30. All the test performance characteristics for the modified assay were within acceptable ranges. The challenges experienced included, high staff turnover, insufficiencies in the supply chain and lack of a functional laboratory network for sample-referral mechanisms leading to sub-optimal utilization of the facility. Furthermore, uncertainty in donor funding raises concerns on the sustainability of such capital intensive endeavors.