title: Is there scope for cost savings and efficiency gains in HIV services? A systematic review of the evidence from low- and middle-income countries.
abstract: OBJECTIVE
  To synthesize the data available--on costs, efficiency and economies of scale and scope--for the six basic programmes of the UNAIDS Strategic Investment Framework, to inform those planning the scale-up of human immunodeficiency virus (HIV) services in low- and middle-income countries.
  
  
  METHODS
  The relevant peer-reviewed and "grey" literature from low- and middle-income countries was systematically reviewed. Search and analysis followed Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.
  
  
  RESULTS
  Of the 82 empirical costing and efficiency studies identified, nine provided data on economies of scale. Scale explained much of the variation in the costs of several HIV services, particularly those of targeted HIV prevention for key populations and HIV testing and treatment. There is some evidence of economies of scope from integrating HIV counselling and testing services with several other services. Cost efficiency may also be improved by reducing input prices, task shifting and improving client adherence.
  
  
  CONCLUSIONS
  HIV programmes need to optimize the scale of service provision to achieve efficiency. Interventions that may enhance the potential for economies of scale include intensifying demand-creation activities, reducing the costs for service users, expanding existing programmes rather than creating new structures, and reducing attrition of existing service users. Models for integrated service delivery--which is, potentially, more efficient than the implementation of stand-alone services--should be investigated further. Further experimental evidence is required to understand how to best achieve efficiency gains in HIV programmes and assess the cost-effectiveness of each service-delivery model.
authors.affiliation: SaME Modelling and Economics, Department of Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, England .
authors.forename: Mariana
authors.initials: M
authors.lastname: Siapka
authors.affiliation: SaME Modelling and Economics, Department of Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, England .
authors.forename: Michelle
authors.initials: M
authors.lastname: Remme
authors.affiliation: SaME Modelling and Economics, Department of Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, England .
authors.forename: Carol Dayo
authors.initials: CD
authors.lastname: Obure
authors.affiliation: Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland .
authors.forename: Claudia B
authors.initials: CB
authors.lastname: Maier
authors.affiliation: Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland .
authors.forename: Karl L
authors.initials: KL
authors.lastname: Dehne
authors.affiliation: SaME Modelling and Economics, Department of Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, England .
authors.forename: Anna
authors.initials: A
authors.lastname: Vassall
mesh_terms: D017046:Cost Savings; D003362:Cost-Benefit Analysis; D019033:Delivery of Health Care, Integrated / Q000191:economics*; D003906:Developing Countries / Q000191:economics*; D015658:HIV Infections / Q000517:prevention & control*; D006302:Health Services Research; D006801:Humans
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