Objective: Evidence-based models for
integrated family planning and HIV services have been called for by
international stakeholders. The objective of this study was to evaluate the cost-effectiveness of an
integrated program focusing on couple involvement in HIV testing and family planning counseling.

Methods: In this
implementation study, community health workers and personnel in
government health facilities promoted and delivered integrated couples’
voluntary HIV counseling and testing and family planning counseling (the
‘integrated program’) with long-acting reversible contraception (copper
intrauterine device or hormonal implant) provision. From March 2013-September
2015, the integrated program was offered in 55 government facilities in seven
Zambian cities.

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Results: Program cost for training and service
delivery was $3,582,187 (United States Dollars). Over 82,000 couples received the
integrated program and 56,409 long-acting reversible contraception insertions
were performed (10% intrauterine device, 90% implant). Cost-per-couple tested
ranged from $19-29 and cost-per-long-acting reversible contraception inserted ranged
from $7-28. The integrated program averted an estimated 7,165 HIV infections
and 62,275 unintended pregnancies (assuming three years of long-acting
reversible contraception use). Estimated cost-effectiveness outcomes were: $280-445
per HIV infection averted; $3-51 per quality-adjusted life year saved; and assuming
three years of long-acting reversible contraception use, $5-21 per unintended pregnancy
averted and $618-5,453 per perinatal infection averted. In the final six months
of the program when integrated services and mutual referrals were mature, 21%
of integrated service couples reported prior long-acting reversible contraception
insertion and 54% of women requesting long-acting reversible contraception methods
reported prior integrated service use.

Conclusions: An
integrated program delivery model focused on couples and long-acting reversible
contraception was feasible, acceptable, and highly cost-effective in preventing
HIV and unintended pregnancy. This is one of very few studies to provide
cost-effectiveness evidence in support of such an integrated program. This
model is highly adaptable to other settings in sub-Saharan Africa. 


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