Cost analysis of HIV outreach to transgender and men having sex with men in Bandung, Indonesia

Transcription

1 Nijmegen International Center for Health Systems Research and Education Cost analysis of HIV outreach to transgender and men having sex with men in Bandung, Indonesia T.E.P. Remers 1,2, A.Y.M. Siregar 2, R. Baltussen 1 1 Department for Health Evidence, Radboud UMC Nijmegen, the Netherlands 2 Faculty of Economics and Business, Padjadjaran University, Bandung, Indonesia Bachelor Internship: March July

2 Cost analysis of HIV outreach to transgender and men having sex with men in Bandung, Indonesia T.E.P. Remers 1,2, A.Y.M. Siregar 2, R. Baltussen 1 1 Department for Health Evidence, Radboud UMC Nijmegen, the Netherlands 2 Faculty of Economics and Business, Padjadjaran University, Bandung, Indonesia Background: Indonesia has one of the fastest growing HIV epidemics in Asia. The prevalence among the general population is low, but HIV is mostly seen in risk groups like men who have sex with men (MSM) and transgender. Outreach is part of the national response against this concentrated epidemic. The aim is to reach out to hidden HIV key populations to reduce risk behaviours. Data on cost-effectiveness of interventions like outreach is necessary for priority setting. Up till now, reliable cost data is however not present. Aim: To discover the societal costs of an outreach program for MSM and transgender in Bandung, Indonesia in Methods: The societal costs of the outreach program in 2016 were collected in Bandung from April 2017 until May Interviews with relevant stakeholders using a micro-costing approach were executed to map health care costs. Non-health care costs were determined by conducting a survey among 16 MSM and 13 transgender. Results: In 2016, the program reached 4710 individuals with total societal costs of US$ 347, The costs of reaching out to one individual during the entire year of 2016 were US$ Costs were largely determined by non-health care costs (56.2%), personnel (32.2%), and transport costs (4.8%). Conclusion: Costs of outreach to MSM and transgender seem high. More research on effectiveness of the intervention is needed to discover the cost-effectiveness. However, stakeholders in Bandung previously determined outreach as priority number one in HIV prevention. A high priority for this intervention, despite the high costs, can therefore be expected. Key words: HIV/aids; men having sex with men/msm; transgender/waria; outreach; cost analysis; MCDA; Indonesia; Bandung 2

3 Content Abstract 2 List of abbreviations 4 1. Introduction HIV/AIDS epidemic in Indonesia National response to the epidemic Priority setting Objectives 6 2. Methods Study setting and study population Data collection and cost estimation Assumptions Sensitivity analysis 8 3. Results Costs Qualitative findings Sensitivity analysis Discussion Limitations Present literature & future research Recommendations Conclusion Acknowledgements 13 References 14 Appendix: Questionnaire 15 3

4 List of abbreviations MSM FSM IDU PMTS STI MTCT NAC TG MCDA NICHE SP NGO Men having sex with men Female sex workers Injecting drug users The prevention of sexual transmission of HIV (PMTS) Sexually transmitted infections Mother to child transmission Indonesian National Aids commission Transgender people Multiple-criteria decision analysis Nijmegen International Center for Health Systems Research and Education Srikandi Pasundan Non-governmental organisation 4

5 1. Introduction Since the first official reports in 1981(1), a lot has been happening to HIV/AIDS. In fact, the HIV epidemic has become an epidemic affecting 36.7 million people globally in 2015(2). With 5.1 million people suffering from HIV in Asia and the Pacific, this region has the second highest HIV prevalence of all regions worldwide(2). 1.1 HIV/AIDS epidemic in Indonesia In terms of HIV/AIDS, Indonesia is facing an increasing problem as well. The total number of people living with HIV in Indonesia increased from 193,000 in 2007(3), to be 690,000 in 2015(4,5). Besides that, the number of annual new HIV infections in Indonesia makes it one of the fastest growing HIV epidemics in Asia(3). Although the prevalence of HIV among the general population is low (0.27%)(6), the prevalence among HIV risk-groups is much higher, up to 25.8% among men having sex with men (MSM), 5.3% among female sex workers (FSM), 24.8% among transgender people, and 28.8% among injecting drug users (IDU)(7). Due to these high prevalence rates among specific risk groups, the epidemic in Indonesia is known as a concentrated epidemic(8). 1.2 National response to the epidemic The national government of Indonesia focuses on a wide range of programs in order to respond to the growing epidemic(9). The Prevention of Sexual Transmission of HIV (PMTS) program is part of this response, consisting of four key components: mobilisation of stakeholders, improved distribution of condoms and lubricants, and comprehensive management of sexually transmitted infections (STI), which might be supported by providing sex work sites with mobile clinics(10). Furthermore, harm reduction services among risk groups, training of healthcare workers to decrease mother to child transmission (MTCT), and programs to increase coverage of ART treatment are being organized(10). Another community based intervention part of the nationwide program is outreach(10). Outreach focuses on reaching hidden populations of HIV risk groups in order to engage them in the process of reducing HIV risk behaviours(11). Activities consist of finding and contacting individuals by outreach workers in order to disseminate HIV/AIDS related information, change their risky behaviour, and refer them to HIV/AIDS testing and treatment services. Finding new cases is the priority. The Indonesian National Aids Commission (NAC) states that increasing the effectiveness of outreach services is one of the key strategies to prevent and reduce the risk of HIV transmission(10). Outreach programs are performed for all HIV risk groups throughout Indonesia (8). The NAC states that there is however a particular concern about the rising HIV incidence among MSM calling for a significant raise (3-8 times) in outreach activities for this risk group(8). Transgender people (TG) are also reported to have unprotected sex very often making them a vulnerable key population in need of preventive measures like outreach(12). 1.3 Priority setting Obviously, the national HIV/AIDS response consists of many different interventions. In their strategy action plan, the NAC stated that in order to reach their targets set for five years up to 2014, there should be an annual increase in funds supporting all of these interventions(8). In 2014, US$ 208 million would have been necessary while only US$ 97 5

6 million was available resulting in a funding gap of US$ 111 million(8,13). This US$ 111 million funding gap raises important questions about how government money is spent in recourselimited settings and asks for priority setting of HIV/AIDS interventions like outreach(14). Priority setting of health interventions is a process that is often done without careful consideration of multiple criteria(15). Multiple-criteria decision analysis (MCDA) however is a routinely used tool that enables policy makers to take multiple criteria of health interventions into consideration when setting priorities in resource-limited setting. This results in optimal use of available resources(15). In order to set priorities for HIV interventions in Indonesia and aid decisionmaking for the following years to come, MCDA could thus be a helpful tool. In order to perform a MCDA, data on costs of health intervention is needed(15). Cost analysis of many HIV interventions like MSM and TG outreach have been done in the recent past, but are often based on expert opinion and assumptions only. 1.4 Objectives In order to perform MCDA for prioritizing health interventions in Indonesia, a structural and solid approach to cost analysis of a HIV intervention like outreach to MSM and TG is needed. The primary objective of this study will therefore be to discover the costs of an outreach program for MSM and TG in Bandung. This will be done starting from the following research question: What are the total societal costs of outreach to MSM and TG in Bandung, Indonesia in 2016? Besides measuring costs, a secondary objective of this study will be to obtain qualitative data about the performance of the outreach program. This will enable recommendations to be made in order to improve program effectiveness and efficiency. This study is part of and aims at informing the REVISE 2020 research program coordinated by the Nijmegen International Center for Health Systems Research and Education (NICHE). In this program, NICHE aims at transforming the priority setting process in low and middle income countries, and the Netherlands into a evidence-informed deliberative process by 2020(16). 2. Methods 2.1 Study setting and study population This study was conducted in Bandung, the capital of West Java province located at the island of Java, the most densely populated island of Indonesia(17). It is a city with approximately 2.6 million inhabitants(18). The HIV/AIDS epidemic that Bandung is facing is a concentrated epidemic comparable to the nationwide epidemic (17). The outreach to both MSM and TG living in Bandung is conducted by one single organisation: Srikandi Pasundan(SP). SP is a non-governmental organisation (NGO) based in Bandung focusing on several health issues MSM and TG are faced with, including HIV/AIDS. The outreach program of SP is focussing on informing these key populations about HIV/AIDS and referring them to HIV testing facilities. Besides performing outreach, SP is also responsible for some other HIV prevention methods like setting up mobile testing clinics in hotspot areas. The outreach program of SP is a program with both paid workers and volunteers doing outreach 26 times a month. The workers are part of the key population and they perform outreach by visiting HIV hotspots. These hotspots are places where people of the key population gather like malls, parks, gyms or places where individuals from the key 6

7 populations live. SP has six regions in Bandung and every region has at least five paid workers responsible for the outreach in that region. Despite having a clear purpose of educating people about HIV, the meeting itself is just about the outreach worker having a chat with the individuals. This results in a bond between the individual and the outreach worker so that the recommended HIV prevention measures are more likely to be executed by the individuals as well. It might also encourage people to attend outreach meetings regularly. An outreach meeting can consist of several activities at once, depending on the situation and time available. First of all, outreach workers could get in contact with new MSM and TG. In this case, they hand them an information package containing a leaflet, a sticker, condoms, and lubricant and provide them with any further information the individual would like to know. After this initial contact, the newly reached person is referred to a HIV testing facility to get tested. Secondly, people that have already been reached have the opportunity to meet the workers again during their regular visit to the hotspot. In this case, what happens largely depends on the individual from the key population. They can ask the outreach worker for more information or they can ask for condoms or lubricants. People that have already been reached are referred to the HIV facility once every three months. 2.2 Data collection and cost estimation The annual costs of SP outreach to MSM and TG were assessed from societal perspective. The cost analysis was performed from April until May 2017 based on the guidelines mentioned in the WHO training manual on cost analysis in primary healthcare(19). Costs were collected in Indonesian Rupiah (IDR) and converted to US$ using the official 2016 annual conversion rate (13). Costs were divided into health care costs (costs generated by utilization of resources in the health care system) and non-health care costs (costs paid for by patient caused by seeking and receiving care). All calculations and additional analyses of data were done using Microsoft Office Excel Health care costs were calculated based on the frequency of outreach and the costs of delivering outreach. The frequency of outreach was determined by interviewing SP staff and consulting SP records on frequency of outreach. In order to obtain costs of delivering outreach, a micro costing approach was used(20). SP management staff was interviewed and financial records were consulted to map all health care cost components of the outreach program. Shared allocation of cost items with other programs was estimated based on expert opinion and taken into account in any further calculations. Classification of costs was done by inputs; meaning costs were grouped based on having similar characteristics. Additionally, recourses were divided into capital costs and recurrent costs. Capital costs included all items used during the program that were paid for once and last for more than one year including building costs, furniture costs, and equipment costs. Building costs were calculated based on annual renting prices of the buildings. Equipment and furniture costs were determined based on local market prices of similar goods, expert opinion of prices, and the amount of goods used for the outreach program. Costs were annualized using a useful working life generally accepted for that type of capital item combined with a discount rate of 3%(20). Recurrent costs included all costs of items that were used up in the course of a year and were therefore purchased at least once a year. Personnel costs were estimated based on SP 7

8 financial records of wages and expert opinion of the amount of workers. Transport costs were calculated based on expert opinion of the distance travelled every day and the type of transport used combined with the general cost of using a certain type of transport. Supply costs were calculated by using SP data on supplies used up in 2016, local market prices of all supplies, and expert opinion of the distance workers needed to travel to pick up supplies. Recurrent building costs, recurrent training costs, and recurrent consultancy costs were all based on expert opinion. Additionally, financial reports from the NAC Bandung were used to map the costs of an additional training SP workers participated in. Non-health care costs were determined by conducting a survey among 16 MSM and 13 TG while they visited an outreach meeting. The survey was conducted using a questionnaire aiming at giving insight in people s income and time spent on outreach. Questions focussing on their monthly income, monthly expenses, travel time to- and time spent at the outreach location and several other things (see appendix: questionnaire) were included in the questionnaire. Besides this, SP data and expert opinion were used to measure the amount of visitors a year and estimate the average duration of meetings respectively. The questionnaire also contained some simple qualitative questions regarding the clarity of outreach, skills of workers, accessibility, positive points and improvements of the outreach program. 2.3 Assumptions There have been some assumptions made during the cost analysis of the SP outreach program. First of all, the opinion of the SP outreach coordinator about numbers and prices was seen as the truth. Experts estimates on prices of equipment were checked with local market prices if possible. Besides that, if the expert stated that a certain value was within a range of several numbers, the average of these numbers was taken and used for further analysis. Furthermore, it was assumed that workers of the SP outreach program did not buy a vehicle specifically for the outreach program. Capital vehicle costs where therefore assumed to be non-existent. Travel costs of outreach clients were always included regardless of the fact that people might come to the outreach location without outreach being their primary purpose of visiting. Because the primary purpose of visit is hard to measure or predict for all visitors during 2016, travel costs were included for all visitors in order to prevent underestimations. Finally, it was assumed that the 16 MSM and 13 transgender being interviewed reflected the entire population of MSM and transgender reached by SP in Results from their questionnaires were therefore extrapolated to this entire population. 2.4 Sensitivity analysis Due to assumptions done during the collection and estimation of costs, the final costs per receiving unit might deviate from the real costs. In order to assess the reliability of the estimated costs and the influence of assumption made on these costs, a sensitivity analysis was performed. The variables included in this sensitivity analysis were based on the largest costs components. Included were: duration of meetings, number of people referred by volunteers, and kilometres travelled by outreach workers every day. The effects on costs of a 15% over- and underestimation of these variables were determined. 8

9 Table 1: All cost inputs and corresponding costs in US$ of the Srikandi Pasundan outreach program in A distinction is made between health care and non-health care costs and costs are grouped based on origin of recourses. Input Personal costs (US$)* Sponsored costs (US$)* 2 Patient costs (US$) Societal Cost (US$) HEALTH CARE COSTS Capital 1, Building and furniture - 1, , Equipment Recurrent 150, Personnel - 111, , Supplies - 12, , Transport 2, , , Building recurrent - 1, , Recurrent training - 6, , Short-term consultancies - 2, , Subtotal health care costs 152, NON-HEALTH CARE COSTS Travel costs MSM 1 24, , Travel costs TG 2 8, , Productivity loss MSM 1 145, , Productivity loss TG 2 16, , Subtotal non-health care costs 195, Total 347, Men having sex with men 2 Transgender people *Costs that are not paid for by any organization or donor but are the result of volunteers paying their own transport. * 2 All sponsored costs are covered by GlobalFund. 3. Results In 2016, the SP outreach program reached 4500 MSM and 210 TG resulting in a total number of 4710 people being reached. These people were reached on average once a week with 45 minutes spent per meeting for MSM and 90 minutes spent per meeting for TG. 3.1 Costs Table 1 shows all cost inputs and their corresponding costs of the SP outreach program in Shown is that the total societal costs of the program in 2016 were US$ 347, (Table 1). All sponsored costs were covered by GlobalFund. The biggest cost input was productivity loss of MSM being US$ 145, or 42% followed by personnel with US$ 111, or 32% of total costs. Total societal costs divided by the number of persons being reached resulted in a cost of US$ for reaching out to one individual every week during the entire year of Figure 1 shows the contribution of individual cost components to the total health care and non-health care costs of the SP outreach program in Shown is that health care costs were largely determined by personnel (73%), transport (11%), and supplies (9%). Non-health care costs were mostly determined by the biggest cost component of the entire program as mentioned above: productivity loss of MSM (75%). 9

10 Figure 1: The contribution of individual cost inputs to the total health care and non-health care costs of the SP outreach program in Qualitative findings MSM marked the clarity of outreach with an 8.2 whereas clarity among TG received a 7.9. Skills of outreach workers received a score of 8.5 among MSM and an 8.0 among TG. MSM awarded the accessibility of outreach with an 8.5 and TG marked this with an 8.2. The positive aspect of the outreach program that was mentioned the most was: I got more knowledge and insights in HIV (mentioned eighteen times). In addition, three TG reported to have gained more information about how to access HIV/AIDS health services. Suggestions for improvement of the program included the increase of outreach intensity, setting up collaborations between HIV and tuberculosis programs, and provision of more condoms and lubricants. 3.3 Sensitivity analysis Table 2 shows the results of the sensitivity analysis being performed. As seen in table 2, a 15% over- and underestimation of the duration of outreach meetings resulted in a 7% difference in costs per reached person compared to the original price. Besides that, table 2 shows that both a 15% over- and underestimation of people referred by volunteers and kilometres travelled by outreach workers resulted in a deviation <1% from original costs. Table 2: Sensitivity analysis on the duration of meetings, number of people referred by volunteers, and kilometres travelled by outreach workers every day. The effects on original costs are determined using a 15% over- and underestimation of these variables. Input category Assumption Societal costs per person with over- and underestimation (US$) Non-health care costs Personnel costs MSM 1 meetings always take 45 minutes, TG 2 meetings 90 minutes Volunteers always refer 8 people to testing facilities Transport costs Workers always travel 12.5 kilometres a day for outreach 1 Men having sex with men 2 Transgender people Difference from original cost per person (%) -15% +15% -15% +15%

11 4. Discussion This study examined the total societal costs of outreach to MSM and TG in Bandung, Indonesia in The total societal costs of the Srikandi Pasundan outreach program were US$ 347, $73.72 was paid to reach out to one individual once a week for an entire year in Health care costs formed 43.8% of total costs and were largely determined by recurrent costs. Capital costs only included building costs and a small amount of capital items like computers and printers. Personnel cost was by far the biggest cost component of recurrent costs. The biggest contribution to personnel costs came from the salary of 35 outreach workers. Despite being a big cost item of the SP outreach program, saving on personnel costs should be done with caution. Outreach relies on the special bond between workers and receivers. If there are less staff members, time spent on individual outreach meetings will decrease, outreach might become less of a friendly interaction because of a lack of time and the special bond might be affected. In the end, saving money by cutting personnel might therefore result in a less effective outreach program and is therefore probably not desirable. Transport costs could be a more suitable category for cutting costs. It is the second biggest health care cost component and is mostly determined by transportation fees given to outreach workers and volunteers. Outreach workers are compensated for the travelling they do. This compensation is performance based meaning that the amount of people referred to the HIV testing facility determines the amount of money received by workers. Every referral results in US$ 1.88 with a maximum of sixteen referrals or US$ and an $11.27 bonus for referring three extra people. It seems reasonable to compensate workers for their travel costs, but most of the workers receive way more money than they have likely spent. In fact, 90% of workers use their own motorcycle and receive on average more than six times more money than they spent. Adjusting this system of transportation fees in a way that fees approximate an amount close to the money spent on outreach seems therefore a reasonable way of cutting costs of the SP outreach program. Non-health care cost formed the remaining 56.2% of total societal costs. 74.8% of these costs were caused by productivity loss of MSM. This might indicate that MSM outreach meetings cause a lot of productivity loss for each individual attending a meeting. This is however not the case. MSM outreach meetings last two times shorter than TG meetings, but the fact that 4500 MSM attended in 2016 makes it the single biggest cost component of the entire program. As said before, decreasing the duration of meetings seems not preferable and therefore both productivity loss of MSM and TG are not likely to be cost components eligible for decreasing SP outreach program costs. Travel costs of both MSM and TG are relatively small cost items and results from questionnaires indicate that individual travel costs do not seem to be a holdback for people to attend a meeting. Qualitative results indicate that both MSM and TG are very satisfied with all aspects of the program included in the questionnaire. Overall, MSM rated the program slightly better than TG. The reasons behind this are unclear. The most commonly mentioned positive aspect of the program was I got more knowledge and insights in HIV indicating that the outreach reached its goal of providing people with basic HIV/AIDS related information. The fact that three TG reported to have learned more about how to access HIV/AIDS health services also shows that outreach could play an important role in affecting health seeking behaviour within 11

12 these risk groups. Increase of outreach intensity, setting up collaborations between HIV and tuberculosis programs, and provision of more condoms and lubricants were the most commonly mentioned suggestions to improve the program. Both provision of more condoms and lubricants and setting up a collaboration between HIV and tuberculosis seem improvements that can help the program to become even more effective and are therefore worth considering. Increase of intensity could have the same effect as cutting on personnel costs and is therefore something that has to be done with caution. It might result in lower productivity loss cost of attendees, but it can also affect the special bond between worker and receiver resulting in a less effective program as mentioned before. 4.1 Limitations Despite adherence to strict guidelines on how to perform a cost analysis(19), this study has some limitations. First of all, some cost components are solely based on expert opinion. A micro costing approach(20) was used to calculate all cost components and expert opinion was the only way of calculating costs if data on some aspects of cost components were not available. Prices that were the result from expert opinion were however checked with local market prices if possible. Prices mentioned by the expert during previous interviews were also checked during follow-up interviews if there was any doubt about the validity of these prices. Secondly, this cost analysis was conducted within one organisation in Bandung meaning conclusions on costs can only be drawn for this single organisation. Generalizing results to other similar programs is thus not possible due to possible differences in set-up of programs. It is however expected that the way outreach activities are undertaken is not totally different in other regions. The results of this study might therefore be seen as a rough cost estimate of other MSM and TG outreach programs in Indonesia. Thirdly, assumptions needed to be made in order to complete the cost analysis. This might cause a deviation from the true costs if assumptions were not in line with reality. Assumptions were however based on expert opinion and sensitivity analysis shows that influence of over- or underestimations of several assumptions made are small. Lastly, the non-health care costs of the SP outreach program were only based on questionnaires filled in by 16 MSM and 13 TG. This might have caused a deviation from the real costs because this small population might not reflect the entire population reached by the SP outreach program. People interviewed were however recruited from 5 different outreach meetings and visited the meetings regularly like most of the people reached by SP. These people were therefore assumed to be a good reflection of the entire population reached. 4.2 Present literature & future research No other studies on this particular topic have been done so far. Studies about the effects or costs of HIV outreach to risk groups have been done in the recent past(11,21,22), but research settings are different, key populations differ, and none of these studies focuses on an outreach program similar like the program investigated in this study. More research therefore needs to be done on costs of outreach programs for MSM and TG in Indonesia. The content of programs needs to be similar to the SP program and the same approach as used in this study needs to be applied to the cost analysis of these studies. Results of different studies need to be compared in order to determine the validity of results. 12

13 4.3 Recommendations The SP outreach program seems to be a very effective program in reducing HIV risk behaviour of MSM and TG. Despite the high costs of US$ per person reached, it is recommended to continue the program in its current form. This is shown by both the fact that the stakeholder panel conducting the MCDA in Bandung rated outreach by peer educator as priority number one in HIV prevention and the finding that both MSM and TG are very satisfied with the program. There are however some opportunities to save costs. First of all, the system of performance based transportation fee for outreach workers needs a critical examination and a possible revision. This reduces the amount of workers receiving more fee than costs made for transport which happens in the present situation and therefore reduces the total amount of transport costs. Both cutting personnel costs and increasing intensity are also a ways of achieving a significant reduction of the SP outreach program costs. Despite their opportunity to save a significant amount of money, saving on personnel costs or increase of intensity is however not recommended. An increase in condoms and lubricants distributed might help the program to be more effective, but it also results in more costs. It therefore has to be investigated if TG and MSM experience a shortage of condoms and lubricants before implementing this. Lastly, a collaboration between HIV and tuberculosis is worth considering. Not only did outreach receivers ask for this, but working together also results in MSM and TG being better informed about a very relevant health topic when dealing with HIV. Finally, it is advised that SP keeps looking for additional funding of the outreach program. GlobalFund is currently the only funder of SP and therefore pays for all aspects of the program. SP has to apply for funding at GlobalFund once in a while meaning there is a chance of not receiving funding anymore within a couple of years. An additional donor would therefore be a way of diminishing insecurity about funds which ensures the continued existence of the program. 5. Conclusion This study mapped the societal costs of outreach to MSM and TG conducted by the NGO Srikandi Pasundan in Shown is that one individual can be reached every week during an entire year for $ Revision of the performance based transportation fee system is presented as an acceptable way to cut costs without affecting program efficiency. Lastly, both MSM and TG have shown to be satisfied with the program. Data from this study can be used to set priorities for HIV interventions in Indonesia and aid decisionmaking for the following years using MCDA. This will result in the most optimal way of government spending in a resource-limited setting. 6. Acknowledgements My gratitude goes out to all Srikandi Pasundan staff that was always willing to help and made it possible for me to attend outreach meetings. I would also like to express my appreciation for the PRISMA team in Bandung and a special thanks to Muhammad Putra Hutama for helping me with all the practicalities. Finally, I would like to thank dr. A.Y.M. Siregar and Prof. dr. Rob Baltussen for their supervision and coordination during my research. 13

14 References 1. AIDS.gov. A TIMELINE OF HIV/AIDS 2011 updated 2016.; Available from: 2. UNAIDS. GLOBAL AIDS UPDATE National Aids Commission Indonesia. Country report on the Follow up to the Declaration of Commitment On HIV/AIDS UNAIDS. HIV and AIDS estimates 2015; Available from: 5. AIDSdatahub. Indonesia Country Profile ; Available from: 6. World Health Organisation. Indonesia: WHO statistical profile UNAIDS. Aidsinfo; Available from: 8. Ministry of Health Indonesia. National HIV and AIDS Strategy and Action Plan Siregar AY, Tromp N, Komarudin D, Wisaksana R, van Crevel R, van der Ven A, et al. Costs of HIV/AIDS treatment in Indonesia by time of treatment and stage of disease. BMC health services research. 2015;15: National Aids Commission Indonesia. Indonesia Country Progress Report Needle RH, Burrows D, Friedman SR, Dorabjee J, Touzé G, Badrieva L, et al. Effectiveness of community-based outreach in preventing HIV/AIDS among injecting drug users. International Journal of Drug Policy. 2005;16: Prabawanti C, Dijkstra A, Riono P, Hartana G. A survey on HIV-related health-seeking behaviors among transgender individuals in Jakarta, based on the theory of planned behavior. BMC public health. 2015;15: World Bank. Official exchange rate (LCU per US$, period average); Available from: Dieleman JL, Haakenstad A. The complexity of resource allocation for health. The Lancet Global health. 2015;3(1):e Baltussen R, Niessen L. Priority setting of health interventions: the need for multi-criteria decision analysis. Cost effectiveness and resource allocation : C/E. 2006;4: Nijmegen International Center for Health Systems Research and Education N. REVISE Rethinking the Valuation of Interventions to improve priority SEtting 2016; Available from: prove_priority_setting. 17. Tromp N. Priority Setting in HIV/AIDS Control - the use of multi criteria decision analysis in Indonesia and South Africa Department of Economic and Social Affairs. The World s Cities in 2016 Data Booklet. United Nations; Creese A, Parker D. Cost Analysis in Primary Health Care. A Training Manual for Programme Managers: ERIC; Drummond MF. Methods for the Economic Evaluation of Health Care Programmes: Oxford University Press; George A, Blankenship KM. Peer outreach work as economic activity: implications for HIV prevention interventions among female sex workers. PloS one. 2015;10(3):e Kasymova N, Johns B, Sharipova B. The costs of a sexually transmitted infection outreach and treatment programme targeting most at risk youth in Tajikistan. Cost effectiveness and resource allocation : C/E. 2009;7:19.

15 Appendix: Questionnaire Questionnaire Please answer the following questions by writing down your answers, or by ticking ( ) the appropriate box ( ). If you have trouble in answering a question, do not hesitate to ask the enumerator. A. RESPONDENT PROFILE 1. ID : 2. Place of stay : 3. Sex: Male 1 Female 2 Transgender 3 4. Age : year 5. Last degree of completed education: 1. Not going to school 2. Primary School 3. Junior High School 4. Senior High School 5. Diploma 6. Bachelor Degree 7. Master Degree 8. Doctoral Degree 6. Current marital status: not yet married 0 married 1 divorced 2 widowed 3 7. Number of children B OCCUPATION AND INCOME 8. What is your current occupation (may give more than one answer, proceed no 12 it non paid job) What is your average monthly income? (if you have more than one occupation, please state the total income) Rp. 10. How many hours do you work per day? hours 11. How many days do you work per week? days 15

16 12. To fulfill your own monthly needs, do you also receive money from other people? Please state in the following table as well as the amount. No areceive money from blast month amount 1 Parents Rp.. 2 Siblings Rp.. 3 Other relatives Rp.. 4 Children Rp.. 5 Friends Rp.. 6 Selling own goods Rp.. 7 Borrow from. Rp.. 8 Others, please state. Rp Please state and detail your own monthly expenses No aexpenses blast month amount 1 House rent/mortgage Rp 2 Electricity, water, telephone Rp 3 Water Rp 4 Telephone Rp 5 Transport/gasoline Rp 6 Cellphone credit Rp 7 Food at home Rp 8 Food out of home Rp 9 Entertainment (i.e. snacks, cinema) Rp 10 Cigarettes Rp 11 Health/doctor fee Rp 12 Medication Rp 13 Savings Rp 14 Others, please state Rp.. 16

17 14. Who is currently staying with you? To fill the following tabel: - Please circle the number of the person who is currently living with you, if he/she is not on the list, please state on number Please state the occupation of the person (including housewife, students, or unemployed) and his/her income A. Family member/ accompanying person B. Occupation C. Monthly income D. Does this person accompany you to the health facility? 1 Father... Rp... 2 Mother... Rp... 3 Older sibling... Rp... 4 Younger sibling... Rp... 5 Spouse... Rp... 6 Child... Rp Rp Rp Rp Rp How do you reach the outreach location? 1. On foot 2. Bicycle 3. Motorcycle 4. Motorcycle taxi 6. Public transport (car) 7. Taxi 8. Public transport (bus) 9. Others, please state 5. Car 16. How long is your travel time to reach the outreach location? minutes 17. On your visit to the facility, how much do you spent in average for: a. Two way transport for yourself Rp... b. Two way transport for person(s) accompanying you Rp... c. Registration Rp... d. Outreach meeting Rp... e. Materials received during meeting Rp... f. Rp How much time do you spent at the outreach location? (including waiting time)..minutes 17

18 19 Was this the first time you visited an outreach meeting? Yes No IF NO, how often do you visit an outreach meeting? *Please write down the total number of visits a week, month or year What mark ranging from 1 up to 10 would you give the outreach meeting in terms of clarity of the information that was give to you? Please explain What mark ranging from 1 up to 10 would you give the outreach meeting in terms of the skills of the outreach worker that conducts the outreach? Please explain What mark ranging from 1 up to 10 would you give the outreach meeting in terms of accessibility of the outreach meeting? Please explain Was the information that was given to you during the outreach meeting sufficient to know where to look at in terms of HIV/AIDS prevention and treatment? Yes No IF NO, what else would you have liked to learn about this during the meeting? What are positive aspects of the outreach meeting? What are things that can be improved about the outreach meeting?