Discussion
PWH
In our implementation of three different modes of booster session delivery within a counseling-based alcohol intervention for PWH in Uganda, we found that the intervention including twice weekly booster sessions using automated technology systems cost 2.5-3 times more per participant than that of the intervention using phone calls from a live counselor every 3 weeks. This result was consistent over four different implementation scenarios for programs with 1000 participants. The differences in costs between the intervention delivery types were driven overall by significant differences between the technology and non-technology (live call) arms for capital and training costs. For example, there were several initial investments for locally developed software. In addition, associated recurring costs (i.e., recurring connectivity and technology support costs) were increased for the technology boosters compared to the live call arms. For the live call booster-based intervention arm, the observed costs per participant were higher than the costs reported for a very similar brief intervention tested in a study in Vietnam. However, the differences were due to costs used for counselor salaries; sensitivity analysis using MOH counselor salaries showed estimated costs that were quite similar to those observed in Vietnam ($38.60-$40.60 for hypothetical programs implemented for 1000 persons at MOH facilities, compared to $39 reported for the study in Vietnam) [As technology use grows, however, these costs may decline over time. Based on these costs, for technology-based interventions (either SMS or IVR) to be considered cost-effective, the efficacy of an intervention (i.e., decreased drinking and/or other health improvements) using these technologies will need to be significantly greater for IVR- or SMS- based booster session delivery compared to an intervention that relies on live calls from counsellors for booster delivery if the program includes fewer than 1000 participants. It is notable that when participants in the SOC arm were offered the intervention after 9 months, the vast majority (87%) chose the live call option over the two technology-based options, suggesting the live call option was preferable in addition to being lowest per participant cost.