Cost of integrating non-communicable disease screening into home-based HIV testing and counseling in South Africa

Integrated HIV-non-communicable disease (NCD) services have the potential to avert death and disability, but require data on program costs to assess the impact of integrated services on affordability. We estimated the incremental costs of NCD screening as part of home-based HIV testing and counseling (HTC) and referral to care in KwaZulu-Natal, South Africa. All adults in the households were offered integrated HIV-NCD screening (for HIV, diabetes, hypertension, hypercholesterolemia, obesity, depression, tobacco and alcohol use), counseling, and linkage to care. We conducted comprehensive program micro-costing including ingredient-based and activity-based costing, staff interviews, and time assessment studies. Sensitivity analyses varied cost inputs and screening efficiency. Integrating all-inclusive NCD screening as part of home-based HTC in a high HIV prevalence setting increased program costs by $3.95 (42%) per person screened (from $9.36 to $13.31 per person). Integrated NCD screening, excluding point-of-care cholesterol testing, increased program costs by $2.24 (24%). Further, NCD screening integrated into HTC services reduced the number of persons tested by 15-20% per day. Integrated HIV-NCD screening has the potential to efficiently utilize resources compared with stand-alone services. While all-inclusive NCD screening could increase the incremental cost per person screened for integrated HIV-NCD services over 40%, a less costly lipid assay or targeted screening would result in a modest increase in costs with the potential to avert NCD death and disability. Our analysis highlights the need for implementation science studies to estimate the cost-effectiveness of integrated HIV-NCD screening and linkage per disability-adjusted life year and death averted.