Estimated costs for the delivery of safer conception strategies for HIV-discordant couples in Zimbabwe: a cost analysis

BMC Health Serv Res. 2020 Oct 12;20(1):940. doi: 10.1186/s12913-020-05784-4.


Background: 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.

Methods: 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 months 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.

Results: Individual strategy costs were $769-$1615 per couple in the trial; $185-$563 if using MOHCC prices. Under the target intervention intensity and using MOHCC prices, individual strategy costs were $73-$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-$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.

Conclusions: 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.

Trial registration: Registry Name:

Trial registration number: NCT03049176 . Registration date: February 9, 2017.

Keywords: ART; Conception; Cost; Discordant; HIV; PrEP; Semen-washing.

Publication types

  • Clinical Trial

MeSH terms

  • Adult
  • Anti-HIV Agents / economics
  • Anti-HIV Agents / therapeutic use
  • Contraception / adverse effects
  • Contraception / economics*
  • Contraception / methods
  • Cost-Benefit Analysis
  • Family Characteristics*
  • Female
  • HIV Infections / epidemiology
  • HIV Infections / prevention & control*
  • HIV Seronegativity*
  • HIV Seropositivity*
  • Humans
  • Male
  • Middle Aged
  • Pre-Exposure Prophylaxis / economics
  • Semen / virology
  • Young Adult
  • Zimbabwe / epidemiology


  • Anti-HIV Agents

Associated data