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Voluntary medical male circumcision (VMMC) is effective in reducing the risk of human immunodeficiency virus (HIV). However, countries like Tanzania have high HIV prevalence but low uptake of VMMC. We conducted a discrete-choice experiment to evaluate the preferences for VMMC service attributes in a random sample of 325 men aged 18 years or older from the general population in 2 Tanzanian districts, Njombe and Tabora. We examined the preference for financial incentives in the form of a lottery ticket or receiving a guaranteed transport voucher for attendance at a VMMC service. We created a random-parameters logit model to account for individual preference heterogeneity and a latent class analysis model for identifying groups of men with similar preferences to test the hypothesis that men who reported sexually risky behaviors (i.e., multiple partners and any condomless sex in the past 12 months) may have a preference for participation in a lottery-based incentive. Most men preferred a transport voucher (84%) over a lottery ticket. We also found that offering a lottery-based financial incentive may not differentially attract those with greater sexual risk. Our study highlights the importance of gathering local data to understand preference heterogeneity, particularly regarding assumptions around risk behaviors.

Background: Antenatal care (ANC) is provided for free in Tanzania in all public health facilities. Yet surveys suggested that long distances to the facilities limit women from accessing these services. Mobile health clinics (MHC) were introduced to address this problem; however, little is known about the client cost and time associated with utilizing ANC at MHC and whether these costs deter women from using the provided services. Methods: Client-exit interviews were conducted by interviewing 293 pregnant women who visited the MHC in rural Tanzania. Two subgroups were created, one with women who travelled more than 1.5 h to the MHC, and the other with women who travelled within 1.5 h. For each subgroup we estimated the direct cost in US$ and time in hours for utilizing services and they hinder service utilization. The Wilcoxon-Mann-Whitney rank sum test was performed to compare the differences between the estimated mean values in the two groups. Result: Total direct cost per visit was: US$2.27 (SD = 0.90) for overall, US$2.29 (SD = 1.03) for those women who travelled less than 1.5 h and US$2.53 (SD = 0.63) for those who travelled more than 1.5 h (p = 0.08). Laboratory and medicine cost accounted for 70 and 16% of the total direct cost and were similar across the groups. Total time cost per visit (in hours) was: 3.75 (SD = 1.83), 2.88 (SD = 1.27) for those women who travelled less than 1.5 h and 5.02 (SD = 1.81) for those who travelled more than 1.5 h (p < 0.01). The major contributor of time cost was waiting time; 1.89 (SD = 1.29) for overall, 1.68 (SD = 1.02) for those women who travelled less than 1.5 h and 2.17 (SD = 1.57) for those who travelled more than 1.5 h (p = 0.07). Participants reported having missed their scheduled visit due to lack of money (15%) and time (9%). Conclusion: Women receiving nominally free ANC incur considerable time and direct cost, which may result in an unsteady use of maternal care. Improving availability of essential medicine and supplies at health facilities, as well as focusing on efficient utilization of community health workers may reduce these costs. CA Neke

Introduction: Geographical access to antenatal intervention is a growing problem in sub-Saharan Africa (SSA). Countries in the regions have for more than 40 years deployed mobile health clinics (MHC) to address that problem, yet, their feasibility, costs, and effectiveness of are poorly known. Methods: A qualitative case study in chapter three using key informant interviews to explore the feasibility of using MHC to deliver maternal health care was conducted. Thematic analysis was done using NVivo software for Mac version 10.5.8. In chapter four exit interviews were conducted to estimate client time and direct costs incurred by clients when they use services. Data were entered in EpiData software version 3.1 and analysed in STATA version 12. In chapter five, a systematic review and meta-analysis of randomised control trial were conducted to synthesis effectiveness data used in the cost-effectiveness analysis (CEA). In chapter six a CEA was conducted from the provider perspective. DALYs lost due to malaria, and severe anaemia was calculated based on recommended guidelines. Cost data were collected from the public district hospital that oversees the MHC. The activity-based costing methodology was adopted to identify measure and value resource used. The Markov decision model was used to compare the cost-effectiveness of using MHC to scale up the provision of IPTp-SP3 and a "wait to treat" strategy. The model was built in Microsoft Excel version 15.37. Probabilistic sensitivity analyses with 10,000 simulations were used to test the robustness of model results. In chapter seven-a, stratified analysis and a net health benefits analysis was conducted to explore the impact of heterogeneity on the estimates when considering parity and HIV status as focus subgroups. Results: Policymakers perceive MHC as an important mode of service delivery to scale up essential interventions in areas that lack static health facilities. Yet, this approach is challenged by scarce resource, poor road infrastructure, and a weak health information system. MHC indicates to have reduced client travel time; however, women incur direct costs due to out of pocket payments driven by out of stock of medicine. The cost of IPTp-SP3 per pregnancy was estimated to be US$ 12.87. The model predicted the total cost to roll out the intervention to 1,000 women to be US$ 20,185 compared to US$ 12,283 if the "wait to treat" strategy is adopted. The strategy was predicted to be more cost-effective than waiting to treat, with an incremental cost-effectiveness ratio (ICER) of US$ 40 per DALY averted. The strategy was also associated with lower costs of the consequences as compared to wait to treat strategy (US$6 086 versus US$12 365). Additionally, more net health benefits (NHB) were predicted when the intervention was provided to low parity and HIV positive women alone. Conclusions: Using MHC to scale up IPTp-SP3 in Tanzania is worth the cost with more NHB predicted for low parity and HIV positive women. Although the presented evidence may help guide decision in scaling up essential health intervention, yet more evidence is needed on the impact of this mode of service delivery on a budget of the ministry of health and social welfare. Dissertation, Universität Duisburg-Essen, 2018

We compared macronutrient intake, food insecurity, and anthropometrics in breastfeeding women: 40 HIV-positive women not yet on antiretroviral therapy and 40 HIV-negative women. Calculated deficits at 2 weeks were 517 kcal per day for HIV-positive women vs 87 kcal per day surplus for HIV-negative women (P = 0.01) and 29 g protein per day for HIV-positive women vs 16 g protein per day for HIV-negative women (P = 0.04). Food insecurity scores were 11.3 for HIV-positive women vs 7.8 for HIV-negative women (P0.01). Enhanced dietary education together with macronutrient supplementation may be required to improve health outcomes in HIV-positive women and their infants.