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Lu IJ, Silhol R, d'Elbée M, Boily M, Soni N, Ky‐Zerbo O, Vautier A, Simo Fosto A, Badiane K, Traoré M, Terris‐Prestholt F, Larmarange J, Maheu‐Giroux M. Cost-effectiveness analysis of community-led HIV self-testing among key populations in Côte d'Ivoire, Mali, and Senegal. J Int AIDS Soc 2024; 27:e26334. [PMID: 39034541 PMCID: PMC11260876 DOI: 10.1002/jia2.26334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 06/27/2024] [Indexed: 07/23/2024] Open
Abstract
INTRODUCTION HIV self-testing (HIVST) is a promising strategy to improve diagnosis coverage among key populations (KP). The ATLAS (Auto Test VIH, Libre d'Accéder à la connaissance de son Statut) programme implemented HIVST in three West African countries, distributing over 380,000 kits up between 2019 and 2021, focussing on community-led distribution by KP to their peers and subsequent secondary distribution to their partners and clients. We aim to evaluate the cost-effectiveness of community-led HIVST in Côte d'Ivoire, Mali and Senegal. METHODS An HIV transmission dynamics model was adapted and calibrated to country-specific epidemiological data and used to predict the impact of HIVST. We considered the distribution of HIVST among two KP-female sex workers (FSW), and men who have sex with men (MSM)-and their sexual partners and clients. We compared the cost-effectiveness of two scenarios against a counterfactual without HIVST over a 20-year horizon (2019-2039). The ATLAS-only scenario mimicked the 2-year implemented ATLAS programme, whereas the ATLAS-scale-up scenario achieved 95% coverage of HIVST distribution among FSW and MSM by 2025 onwards. The primary outcome is the number of disability-adjusted life-years (DALY) averted. Scenarios were compared using incremental cost-effectiveness ratios (ICERs). Costing was performed using a healthcare provider's perspective. Costs were discounted at 4%, converted to $USD 2022 and estimated using a cost-function to accommodate economies of scale. RESULTS The ATLAS-only scenario was highly cost-effective over 20 years, even at low willingness-to-pay thresholds. The median ICERs were $126 ($88-$210) per DALY averted in Côte d'Ivoire, $92 ($88-$210) in Mali and 27$ ($88-$210) in Senegal. Scaling-up the ATLAS programme would also be cost-effective, and substantial epidemiological impacts would be achieved. The ICERs for the scale-up scenario were $199 ($122-$338) per DALY averted in Côte d'Ivoire, $224 ($118-$415) in Mali and $61 ($18-$128) in Senegal. CONCLUSIONS Both the implemented and the potential scale-up of community-led HIVST programmes in West Africa, where KP are important to overall transmission dynamics, have the potential to be highly cost-effective, as compared to a scenario without HIVST. These findings support the scale-up of community-led HIVST to reach populations that otherwise may not access conventional testing services.
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Affiliation(s)
- Ingrid Jiayin Lu
- Department of Epidemiology and BiostatisticsSchool of Population and Global HealthFaculty of Medicine and Health SciencesMcGill UniversityMontréalQuébecCanada
| | - Romain Silhol
- Medical Research Council Centre for Global Infectious Disease AnalysisImperial College LondonLondonUK
| | - Marc d'Elbée
- University of BordeauxNational Institute for Health and Medical Research (INSERM) UMR 1219Research Institute for Sustainable Development (IRD) EMR 271Bordeaux Population Health CentreBordeauxFrance
- CepedUniversité Paris CitéIRDInsermParisFrance
| | - Marie‐Claude Boily
- Medical Research Council Centre for Global Infectious Disease AnalysisImperial College LondonLondonUK
| | - Nirali Soni
- Medical Research Council Centre for Global Infectious Disease AnalysisImperial College LondonLondonUK
| | - Odette Ky‐Zerbo
- TransVIHMIUniversité de MontpellierIRDINSERMMontpellierFrance
| | | | - Artlette Simo Fosto
- L'Institut national d’études démographiques (INED)AubervilliersFrance
- Ceped UMR 196, Université Paris CitéResearch Institute for Sustainable Development (IRD)InsermParisFrance
| | | | - Metogara Traoré
- Université LavalQuébec CityQuébecCanada
- VITAM ‐ Centre de recherche en santé durableQuébec CityQuébecCanada
- Centre de recherche du CHU de QuébecQuébec CityQuébecCanada
| | | | | | - Mathieu Maheu‐Giroux
- Department of Epidemiology and BiostatisticsSchool of Population and Global HealthFaculty of Medicine and Health SciencesMcGill UniversityMontréalQuébecCanada
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Shanaube K, Ndubani R, Kelly H, Webb E, Mayaud P, Lamberti O, Fitzpatrick J, Kasese N, Sturt A, Van Lieshout L, Van Dam G, Corstjens PLAM, Kosloff B, Bond V, Hayes R, Terris-Prestholt F, Webster B, Vwalika B, Hansingo I, Ayles H, Bustinduy AL. Zipime-Weka-Schista study protocol: a longitudinal cohort study and economic evaluation of an integrated home-based approach for genital multipathogen screening in women, including female genital schistosomiasis, human papillomavirus, Trichomonas and HIV in Zambia. BMJ Open 2024; 14:e080395. [PMID: 38858160 PMCID: PMC11168163 DOI: 10.1136/bmjopen-2023-080395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 05/27/2024] [Indexed: 06/12/2024] Open
Abstract
INTRODUCTION Multiplathogen home-based self-sampling offers an opportunity to increase access to screening and treatment in endemic settings with high coinfection prevalence of sexually transmitted (HIV, Trichomonas vaginalis (Tv), human papillomavirus (HPV)) and non-sexually transmitted pathogens (Schistosoma haematobium (Sh)). Chronic coinfections may lead to disability (female genital schistosomiasis) and death (cervical cancer). The Zipime-Weka-Schista (Do self-testing sister!) study aims to evaluate the validity, acceptability, uptake, impact and cost-effectiveness of multipathogen self-sampling for genital infections among women in Zambia. METHODS AND ANALYSIS This is a longitudinal cohort study aiming to enrol 2500 non-pregnant, sexually active and non-menstruating women aged 15-50 years from two districts in Zambia with 2-year follow-up. During home visits, community health workers offer HIV and Tv self-testing and cervicovaginal self-swabs for (1) HPV by GeneXpert and, (2) Sh DNA detection by conventional (PCR)and isothermal (recombinase polymerase assay) molecular methods. Schistosoma ova and circulating anodic antigen are detected in urine. At a clinic follow-up, midwives perform the same procedures and obtain hand-held colposcopic images. High-risk HPV positive women are referred for a two-quadrant cervical biopsy according to age and HIV status. A cost-effectiveness analysis is conducted in parallel. ETHICS AND DISSEMINATION The University of Zambia Biomedical Research Ethics Committee (UNZABREC) (reference: 1858-2021), the London School of Hygiene and Tropical Medicine (reference: 25258), Ministry of Health and local superintendents approved the study in September 2021.Written informed consent was obtained from all participants prior to enrolment. Identifiable data collected are stored securely and their confidentiality is protected in accordance with the Data Protection Act 1998.
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Affiliation(s)
| | | | - Helen Kelly
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Emily Webb
- Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Philippe Mayaud
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Olimpia Lamberti
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Amy Sturt
- Department of Infectious Diseases, Veterans Affairs Health Care System, Palo Alto, UK
| | | | - Govert Van Dam
- Leiden University Medical Center, Leiden, The Netherlands
| | - Paul L A M Corstjens
- Department of Cell and Chemical Biology, Leiden University Medical Center, Leiden, The Netherlands
| | - Barry Kosloff
- Zambart, Lusaka, Zambia
- Longhorn Vaccines & Diagnostics, Bethesda, Maryland, USA
| | - Virginia Bond
- Zambart, Lusaka, Zambia
- London School of Hygiene & Tropical Medicine Centre of Global Change and Health, London, UK
| | - Richard Hayes
- Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Bellington Vwalika
- Department of Obstetrics & Gynaecology, University of Zambia School of Medicine, Lusaka, Zambia
| | - Isaiah Hansingo
- Gynecology, Livingstone Central Hospital, Livingstone, Zambia
| | - Helen Ayles
- Zambart, Lusaka, Zambia
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Amaya L Bustinduy
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
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Huang S, Baker K, Ibinaiye T, Oresanya O, Nnaji C, Richardson S. Predictors of accessing seasonal malaria chemoprevention medicines through non-door-to-door distribution in Nigeria. Malar J 2024; 23:131. [PMID: 38702672 PMCID: PMC11067122 DOI: 10.1186/s12936-024-04964-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 04/25/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND In Nigeria, seasonal malaria chemoprevention (SMC) is typically administered door-to-door to children under five by community medicine distributors during high transmission seasons. While door-to-door distribution (DDD) is exclusively employed in Nigeria as part of standard operating procedures of SMC programmes, some households access SMC through non-DDD channels, such as fixed-point distributions, health facilities, and private purchase. However, analysis of access to SMC medicines through non-DDD has been limited, with little evidence of its outcomes on adherence to the three-day complete course of SMC medicines and caregiver actions in the event of adverse reactions to SMC medicines. METHODS Data were obtained from SMC end-of-round coverage surveys conducted in Nigeria in 2021 and 2022, including 25,278 households for the analysis. The proportion of households accessing SMC medicine through non-DDD and the distribution of various non-DDD sources of SMC medicines were described. Multivariate random-effects logistic regression models were performed to identify predictors of accessing SMC medicines through non-DDD. The associations between non-DDD, and caregiver-reporting of adherence to complete administration of SMC medicines and caregiver actions in the event of adverse reactions to SMC medicines were also assessed. RESULTS Less than 2% (314/24003) of households accessed SMC medicines through non-DDD in the states surveyed. Over 60% of non-DDD access was via health facility personnel and community medicine distributors from different locations. Variables associated with non-DDD access included heads of household being born in the local state (OR = 0.68, 95% CI 0.47 to 0.90), households residing in the study state since the first cycle of the SMC round (OR = 0.39, 95% CI 0.17 to 0.88), households with high wealth index (OR = 1.36, 95% CI 1.01 to 1.82), and caregivers hearing about date of SMC delivery in the previous cycle (OR = 0.18, 95%CI 0.14 to 0.24). Furthermore, non-DDD was associated with reduced SMC adherence and higher caregiver non-reporting of adverse reactions to SMC medicines in children compared with DDD. CONCLUSION This study provides evidence on the characteristics of households accessing SMC medicines through non-DDD and its potential negative outcomes on adherence to SMC medicine and adverse reaction reporting, underscoring potential implementation issues that may arise if non-DDD delivery models are adopted in SMC, particularly in places where DDD had been firstly used.
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Affiliation(s)
- Sikai Huang
- Vanke School of Public Health, Tsinghua University, Beijing, 100083, China
| | - Kevin Baker
- Malaria Consortium UK, The Green House, 244-254 Cambridge Heath Road, London, E2 9DA, UK
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
| | - Taiwo Ibinaiye
- Malaria Consortium Nigeria, 33 Pope John Paul Street, Maitama, Abuja-FCT, Nigeria
| | - Olusola Oresanya
- Malaria Consortium Nigeria, 33 Pope John Paul Street, Maitama, Abuja-FCT, Nigeria
| | - Chuks Nnaji
- Malaria Consortium UK, The Green House, 244-254 Cambridge Heath Road, London, E2 9DA, UK
| | - Sol Richardson
- Vanke School of Public Health, Tsinghua University, Beijing, 100083, China.
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McGee K, d'Elbée M, Dekova R, Sande LA, Dube L, Masuku S, Dlamini M, Mangenah C, Mwenge L, Johnson C, Hatzold K, Neuman M, Meyer-Rath G, Terris-Prestholt F. Costs of distributing HIV self-testing kits in Eswatini through community and workplace models. BMC Infect Dis 2024; 22:976. [PMID: 38424538 PMCID: PMC10902928 DOI: 10.1186/s12879-023-08694-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 10/10/2023] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND This study evaluates the implementation and running costs of an HIV self-testing (HIVST) distribution program in Eswatini. HIVST kits were delivered through community-based and workplace models using primary and secondary distribution. Primary clients could self-test onsite or offsite. This study presents total running economic costs of kit distribution per model between April 2019 and March 2020, and estimates average cost per HIVST kit distributed, per client self-tested, per client self-tested reactive, per client confirmed positive, and per client initiating antiretroviral therapy (ART). METHODS Distribution data and follow-up phone interviews were analysed to estimate implementation outcomes. Results were presented for each step of the care cascade using best-case and worst-case scenarios. A top-down incremental cost-analysis was conducted from the provider perspective using project expenditures. Sensitivity and scenario analyses explored effects of economic and epidemiological parameters on average costs. RESULTS Nineteen thousand one hundred fifty-five HIVST kits were distributed to 13,031 individuals over a 12-month period, averaging 1.5 kits per recipient. 83% and 17% of kits were distributed via the community and workplace models, respectively. Clients reached via the workplace model were less likely to opt for onsite testing than clients in the community model (8% vs 29%). 6% of onsite workplace testers tested reactive compared to 2% of onsite community testers. Best-case scenario estimated 17,458 (91%) clients self-tested, 633 (4%) received reactive-test results, 606 (96%) linked to confirmatory testing, and 505 (83%) initiated ART. Personnel and HIVST kits represented 60% and 32% of total costs, respectively. Average costs were: per kit distributed US$17.23, per client tested US$18.91, per client with a reactive test US$521.54, per client confirmed positive US$550.83, and per client initiating ART US$708.60. Lower rates for testing, reactivity, and linkage to care in the worst-case scenario resulted in higher average costs along the treatment cascade. CONCLUSION This study fills a significant evidence gap regarding costs of HIVST provision along the client care cascade in Eswatini. Workplace and community-based distribution of HIVST accompanied with effective linkage to care strategies can support countries to reach cascade objectives.
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Affiliation(s)
- Kathleen McGee
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
| | - Marc d'Elbée
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Linda A Sande
- Malawi Liverpool Wellcome Trust Research Programme, Blantyre, Malawi
| | | | - Sanele Masuku
- Population Services International, Mbabane, Eswatini
| | | | - Collin Mangenah
- Centre for Sexual Health and HIV/AIDS Research, Harare, Zimbabwe
| | | | - Cheryl Johnson
- World Health Organisation, Global HIV, Hepatitis and STI Programmes, Geneva, Switzerland
| | - Karin Hatzold
- Population Services International, Cape Town, South Africa
| | - Melissa Neuman
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Gesine Meyer-Rath
- Center for Global Heath and Development, Boston University School of Public Health, Boston, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Fern Terris-Prestholt
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Mangenah C, Sibanda EL, Maringwa G, Sithole J, Gudukeya S, Mugurungi O, Hatzold K, Terris-Prestholt F, Maheswaran H, Thirumurthy H, Cowan FM. Provider and female client economic costs of integrated sexual and reproductive health and HIV services in Zimbabwe. PLoS One 2024; 19:e0291082. [PMID: 38346046 PMCID: PMC10861069 DOI: 10.1371/journal.pone.0291082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 08/22/2023] [Indexed: 02/15/2024] Open
Abstract
A retrospective facility-based costing study was undertaken to estimate the comparative cost per visit of five integrated sexual and reproductive health and HIV (human immuno-deficiency virus) services (provider perspective) within five clinic sites. These five clinics were part of four service delivery models: Non-governmental-organisation (NGO) directly managed model (Chitungwiza and New Africa House sites), NGO partner managed site (Mutare site), private-public-partnership (PPP) model (Chitungwiza Profam Clinic), and NGO directly managed outreach (operating from New Africa House site. In addition client cost exit interviews (client perspective) were conducted among 856 female clients exiting integrated services at three of the sites. Our costing approach involved first a facility bottom-up costing exercise (February to April 2015), conducted to quantify and value each resource input required to provide individual SRH and HIV services. Secondly overhead financial expenditures were allocated top-down from central office to sites and then respective integrated service based on pre-defined allocation factors derived from both the site facility observations and programme data for the prior 12 months. Costs were assessed in 2015 United States dollars (USD). Costs were assessed for HIV testing and counselling, screening and treatment of sexually transmitted infections, tuberculosis screening with smear microscopy, family planning, and cervical cancer screening and treatment employing visual inspection with acetic acid and cervicography and cryotherapy. Variability in costs per visit was evident across the models being highest for cervical cancer screening and cryotherapy (range: US$6.98-US$49.66). HIV testing and counselling showed least variability (range; US$10.96-US$16.28). In general the PPP model offered integrated services at the lowest unit costs whereas the partner managed site was highest. Significant client costs remain despite availability of integrated sexual and reproductive health and HIV services free of charge in our Zimbabwe study setting. Situating services closer to communities, incentives, transport reimbursements, reducing waiting times and co-location of sexual and reproductive health and HIV services may help minimise impact of client costs.
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Affiliation(s)
- Collin Mangenah
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR), Harare, Zimbabwe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Euphemia L. Sibanda
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR), Harare, Zimbabwe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Galven Maringwa
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR), Harare, Zimbabwe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | | | | | | | - Karin Hatzold
- Population Services International, Washington DC, United States of America
| | | | | | - Harsha Thirumurthy
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Frances M. Cowan
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR), Harare, Zimbabwe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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Putri WCWS, Ulandari LPS, Valerie IC, Prabowo BR, Hardiawan D, Sihaloho ED, Relaksana R, Wardhani BDK, Harjana NPA, Nugrahani NW, Siregar AYM, Januraga PP. Costs and scale-up costs of community-based Oral HIV Self-Testing for female sex workers and men who have sex with men in Jakarta and Bali, Indonesia. BMC Health Serv Res 2024; 24:114. [PMID: 38254186 PMCID: PMC10802071 DOI: 10.1186/s12913-024-10577-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 01/08/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND The proportion of individuals who know their HIV status in Indonesia (66% in 2021) still remains far below the first 95% of UNAIDS 2030 target and were much lower in certain Key Populations (KPs) particularly Female Sex Workers (FSW) and Male having Sex with Male (MSM). Indonesia has implemented Oral HIV Self-testing (oral HIVST) through Community-based screening (HIV CBS) in addition to other testing modalities aimed at hard-to-reach KPs, but the implementation cost is still not analysed. This study provides the cost and scale up cost estimation of HIV CBS in Jakarta and Bali, Indonesia. METHODS We estimated the societal cost of HIV CBS that was implemented through NGOs. The HIV CBS's total and unit cost were estimated from HIV CBS outcome, health care system cost and client costs. Cost data were presented by input, KPs and areas. Health care system cost inputs were categorized into capital and recurrent cost both in start-up and implementation phases. Client costs were categorized as direct medical, direct non-medical cost and indirect costs. Sensitivity and scenario analyses for scale up were performed. RESULTS In total, 5350 and 1401 oral HIVST test kits were distributed for HIV CBS in Jakarta and Bali, respectively. Average total client cost for HIV CBS Self testing process ranged from US$1.9 to US$12.2 for 1 day and US$2.02 to US$33.61 for 2 days process. Average total client cost for HIV CBS confirmation test ranged from US$2.83 to US$18.01. From Societal Perspective, the cost per HIVST kit distributed were US$98.59 and US$40.37 for FSW and MSM in Jakarta andUS$35.26 and US$43.31 for FSW and MSM in Bali. CONCLUSIONS CBS using oral HIVST approach varied widely along with characteristics of HIV CBS volume and cost. HIV CBS was most costly among FSW in Jakarta, attributed to the low HIV CBS volume, high personnel salary cost and client cost. Future approaches to minimize cost and/or maximize testing coverage could include unpaid community led distribution to reach end-users, integrating HIVST into routine clinical services via direct or secondary distribution and using social media network.
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Affiliation(s)
- Wayan Citra Wulan Sucipta Putri
- Department of Public Health and Preventive Medicine, Faculty of Medicine, Udayana University, Jl. P. B. Sudirman, Denpasar, Bali, 80232, Indonesia.
| | - Luh Putu Sinthya Ulandari
- Department of Public Health and Preventive Medicine, Faculty of Medicine, Udayana University, Jl. P. B. Sudirman, Denpasar, Bali, 80232, Indonesia
| | - Ivy Cerelia Valerie
- Center for Public Health Innovation (CPHI), Udayana University, Denpasar, Bali, Indonesia
| | | | - Donny Hardiawan
- Center for Economics and Development Studies (CEDS), Department of Economics, Faculty of Economics and Business, Universitas Padjadjaran, Bandung, West Java, Indonesia
| | - Estro Dariatno Sihaloho
- Center for Economics and Development Studies (CEDS), Department of Economics, Faculty of Economics and Business, Universitas Padjadjaran, Bandung, West Java, Indonesia
| | - Riki Relaksana
- Center for Economics and Development Studies (CEDS), Department of Economics, Faculty of Economics and Business, Universitas Padjadjaran, Bandung, West Java, Indonesia
| | | | | | - Nur Wulan Nugrahani
- Center for Public Health Innovation (CPHI), Udayana University, Denpasar, Bali, Indonesia
| | - Adiatma Yudistira Manogar Siregar
- Center for Economics and Development Studies (CEDS), Department of Economics, Faculty of Economics and Business, Universitas Padjadjaran, Bandung, West Java, Indonesia
| | - Pande Putu Januraga
- Center for Public Health Innovation (CPHI), Udayana University, Denpasar, Bali, Indonesia
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Nhamo D, Mangenah C, Chapwanya G, Mamvuto T, Mahaka I, Sri-Pathmanathan C, Ferrand RA, Kranzer K, Terris-Prestholt F, Marks M, Tucker JD. Feasibility and economic costs of syphilis self-testing to expand test uptake among gay, bisexual and transgender men: results from a randomised controlled trial in Zimbabwe. Sex Health 2023; 20:514-522. [PMID: 37666490 DOI: 10.1071/sh23038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 08/10/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Access to syphilis testing and treatment is frequently limited for men who have sex with men (MSM). A two-armed randomised controlled trial compared feasibility and costs of facility-based syphilis testing with self-testing among MSM in Zimbabwe. METHODS This randomised controlled trial was conducted in Harare, with participants randomised 1:1. Syphilis self-testing was offered in community-based settings. The primary outcome was the relative proportion of individuals taking up testing. Total incremental economic provider and user costs, and cost per client tested, diagnosed and treated were assessed using ingredients-based costing in 2020US$. RESULTS A total of 100 men were enrolled. The two groups were similar in demographics. The mean age was 26years. Overall, 58% (29/50) and 74% (37/50) of facility- and self-testing arm participants, respectively, completed syphilis testing. A total of 28% of facility arm participants had a reactive test, with 50% of them returning for confirmatory testing yielding 28% reactivity. In the self-testing arm, 67% returned for confirmatory testing, with a reactivity of 16%. Total provider costs were US$859 and US$736, and cost per test US$30 and US$15 for respective arms. Cost per reactive test was US$107 and US$123, and per client treated US$215 and US$184, respectively. The syphilis test kit was the largest cost component. Total user cost per client per visit was US$9. CONCLUSION Syphilis self-testing may increase test uptake among MSM in Zimbabwe. However, some barriers limit uptake including lack of self-testing and poor service access. Bringing syphilis testing services to communities, simplifying service delivery and increasing self-testing access through community-based organisations are useful strategies to promote health-seeking behaviours among MSM.
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Affiliation(s)
- Definate Nhamo
- Pangaea Zimbabwe AIDS Trust (PZAT), Harare, Zimbabwe; and Department of Nursing and Public Health, University of KwaZulu Natal (UKZN), Durban, South Africa
| | - Collin Mangenah
- Centre for Sexual Health and HIV Research (CeSHHAR), Harare, Zimbabwe; and Department of International Global Public Health, Liverpool School of Tropical Medicine (LSTM), Liverpool, UK
| | | | | | - Imelda Mahaka
- Pangaea Zimbabwe AIDS Trust (PZAT), Harare, Zimbabwe
| | | | - Rashida A Ferrand
- Department of Clinical Research, London School of Hygiene and Tropical Medicine (LSHTM), London, UK; and Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Katharina Kranzer
- Department of Clinical Research, London School of Hygiene and Tropical Medicine (LSHTM), London, UK; and Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Fern Terris-Prestholt
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine (LSHTM), London, UK; and UNAIDS, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland
| | - Michael Marks
- Department of Clinical Research, London School of Hygiene and Tropical Medicine (LSHTM), London, UK
| | - Joseph D Tucker
- Department of Clinical Research, London School of Hygiene and Tropical Medicine (LSHTM), London, UK; and Institute of Global Health and Infectious Diseases, University of North Carolina at Chapel Hill (UNC), Chapel Hill, NC, USA
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Empringham B, Karellis A, Kashkary A, D’Silva O, Carmona S, Suarez MF, Addae A, Pai NP, Zwerling AA. How much does HIV self-testing cost in low and middle income countries? A systematic review of evidence from economic studies. Front Public Health 2023; 11:1135425. [PMID: 38026397 PMCID: PMC10679730 DOI: 10.3389/fpubh.2023.1135425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 09/27/2023] [Indexed: 12/01/2023] Open
Abstract
Objectives HIV self-testing (HIVST) has been proposed as an innovative strategy to diagnose human immunodeficiency virus (HIV). While HIVST offers the potential to broaden accessibility of early HIV diagnosis and treatment initiation, this testing strategy incurs additional cost and requires confirmatory testing and treatment. We have conducted the first systematic review to summarize the current economic literature for HIVST in low- and middle-income countries (LMICs). Design A search strategy was developed including key terms for HIV, self-testing and cost-effectiveness and was conducted in Medline and Embase databases. Studies were included that reported costs per outcome and included both cost-effectiveness and cost-utility outcome measures. The search strategy identified publications up until August 15, 2023 were included. Abstract and full text screening was conducted and a standardized data abstraction form was used for included studies. Costs are reported in USD, 2020. Results Our search strategy identified 536 total titles from the search strategy, which were screened down to 25 relevant studies that provided both cost and outcome data on HIVST. There was significant heterogeneity in the HIVST intervention, study population, costs and outcomes reported among included studies. Cost per person tested ranged from $1.09-155. Cost per case diagnosed ranged from $20-1,277. Cost-utility estimates ranged from cost-saving to $1846 per DALY averted. Higher cost-effectiveness estimates were associated with more expensive testing algorithms with increased support for linkage to care and post-test counseling. Conclusion All studies considered HIVST cost-effective although major drivers were identified included underlying HIV prevalence, testing cost and linkage to care. HIVST is likely to be cost-effective in a LMIC context, however policy makers should be aware of the drivers of cost-effectiveness when implementing HIVST programs as these underlying factors can impact the overall cost-effectiveness of HIVST.
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Affiliation(s)
- Brianna Empringham
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Angela Karellis
- Division of Clinical Epidemiology & Experimental Medicine, McGill University, Montreal, QC, Canada
| | - Abdulhameed Kashkary
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Public Health Authority, Riyadh, Saudi Arabia
| | - Olivia D’Silva
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Sergio Carmona
- Foundation for Innovative New Diagnostics, Geneva, Switzerland
| | | | - Angelina Addae
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Nitika Pant Pai
- Division of Clinical Epidemiology & Experimental Medicine, McGill University, Montreal, QC, Canada
| | - Alice Anne Zwerling
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
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Zishiri V, Conserve DF, Haile ZT, Corbett E, Hatzold K, Meyer-Rath G, Matsimela K, Sande L, d’Elbee M, Terris-Prestholt F, Johnson CC, Chidarikire T, Venter F, Majam M. Secondary distribution of HIV self-test kits by HIV index and antenatal care clients: implementation and costing results from the STAR Initiative in South Africa. BMC Infect Dis 2023; 22:971. [PMID: 37264343 PMCID: PMC10234581 DOI: 10.1186/s12879-023-08324-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 05/11/2023] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND Partner-delivered HIV self-testing kits has previously been highlighted as a safe, acceptable and effective approach to reach men. However, less is known about its real-world implementation in reaching partners of people living with HIV. We evaluated programmatic implementation of partner-delivered self-testing through antenatal care (ANC) attendees and people newly diagnosed with HIV by assessing use, positivity, linkage and cost per kit distributed. METHODS Between April 2018 and December 2019, antenatal care (ANC) clinic attendees and people or those newly diagnosed with HIV clients across twelve clinics in three cities in South Africa were given HIVST kits (OraQuick Rapid HIV-1/2 Antibody Test, OraSure Technologies) to distribute to their sexual partners. A follow-up telephonic survey was administered to all prior consenting clients who were successfully reached by telephone to assess primary outcomes. Incremental economic costs of the implementation were estimated from the provider's perspective. RESULTS Fourteen thousand four hundred seventy-three HIVST kits were distributed - 10,319 (71%) to ANC clients for their male partner and 29% to people newly diagnosed with HIV for their partners. Of the 4,235 ANC clients successfully followed-up, 82.1% (3,475) reportedly offered HIVST kits to their male partner with 98.1% (3,409) accepting and 97.6% (3,328) using the kit. Among ANC partners self-testing, 159 (4.8%) reported reactive HIVST results, of which 127 (79.9%) received further testing; 116 (91.3%) were diagnosed with HIV and 114 (98.3%) initiated antiretroviral therapy (ART). Of the 1,649 people newly diagnosed with HIV successfully followed-up; 1,312 (79.6%) reportedly offered HIVST kits to their partners with 95.8% (1,257) of the partners accepting and 95.9% (1,206) reported that their partners used the kit. Among these index partners, 297 (24.6%) reported reactive HIVST results of which 261 (87.9%) received further testing; 260 (99.6%) were diagnosed with HIV and 258 (99.2%) initiated ART. The average cost per HIVST distributed in the three cities was US$7.90, US$11.98, and US$14.81, respectively. CONCLUSIONS Partner-delivered HIVST in real world implementation was able to affordably reach many male partners of ANC attendees and index partners of people newly diagnosed with HIV in South Africa. Given recent COVID-19 related restrictions, partner-delivered HIVST provides an important strategy to maintain essential testing services.
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Affiliation(s)
- Vincent Zishiri
- Ezintsha, a Sub-Division of Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
| | - Donaldson F. Conserve
- Department of Prevention and Community Health, Milken Institute of Public Health, George Washington University, District of Columbia, USA
| | - Zelalem T. Haile
- Department of Social Medicine, Ohio University Heritage College of Osteopathic Medicine, Dublin, USA
| | | | | | - Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Centre for Global Health and Development, Boston University, Boston, USA
| | - Katleho Matsimela
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Linda Sande
- London School of Hygiene and Tropical Medicine, London, UK
| | - Marc d’Elbee
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Cheryl C. Johnson
- London School of Hygiene and Tropical Medicine, London, UK
- Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | | | - Francois Venter
- Ezintsha, a Sub-Division of Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
| | - Mohammed Majam
- Ezintsha, a Sub-Division of Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
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10
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Walker JG, Ivanova E, Jamil MS, Ong JJ, Easterbrook P, Fajardo E, Johnson CC, Luhmann N, Terris-Prestholt F, Vickerman P, Shilton S. Cost-effectiveness of Hepatitis C virus self-testing in four settings. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001667. [PMID: 37018166 PMCID: PMC10075433 DOI: 10.1371/journal.pgph.0001667] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 02/20/2023] [Indexed: 04/06/2023]
Abstract
Globally, there are approximately 58 million people with chronic hepatitis C virus infection (HCV) but only 20% have been diagnosed. HCV self-testing (HCVST) could reach those who have never been tested and increase uptake of HCV testing services. We compared cost per HCV viraemic diagnosis or cure for HCVST versus facility-based HCV testing services. We used a decision analysis model with a one-year time horizon to examine the key drivers of economic cost per diagnosis or cure following the introduction of HCVST in China (men who have sex with men), Georgia (men 40-49 years), Viet Nam (people who inject drugs, PWID), and Kenya (PWID). HCV antibody (HCVAb) prevalence ranged from 1%-60% across settings. Model parameters in each setting were informed by HCV testing and treatment programmes, HIV self-testing programmes, and expert opinion. In the base case, we assume a reactive HCVST is followed by a facility-based rapid diagnostic test (RDT) and then nucleic acid testing (NAT). We assumed oral-fluid HCVST costs of $5.63/unit ($0.87-$21.43 for facility-based RDT), 62% increase in testing following HCVST introduction, 65% linkage following HCVST, and 10% replacement of facility-based testing with HCVST based on HIV studies. Parameters were varied in sensitivity analysis. Cost per HCV viraemic diagnosis without HCVST ranged from $35 2019 US dollars (Viet Nam) to $361 (Kenya). With HCVST, diagnosis increased resulting in incremental cost per diagnosis of $104 in Viet Nam, $163 in Georgia, $587 in Kenya, and $2,647 in China. Differences were driven by HCVAb prevalence. Switching to blood-based HCVST ($2.25/test), increasing uptake of HCVST and linkage to facility-based care and NAT testing, or proceeding directly to NAT testing following HCVST, reduced the cost per diagnosis. The baseline incremental cost per cure was lowest in Georgia ($1,418), similar in Viet Nam ($2,033), and Kenya ($2,566), and highest in China ($4,956). HCVST increased the number of people tested, diagnosed, and cured, but at higher cost. Introducing HCVST is more cost-effective in populations with high prevalence.
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Affiliation(s)
- Josephine G. Walker
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Elena Ivanova
- FIND, The Global Alliance for Diagnostics, Geneva, Switzerland
| | - Muhammad S. Jamil
- Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Jason J. Ong
- London School of Hygiene & Tropical Medicine, London, United Kingdom
- Central Clinical School, Monash University, Melbourne, Australia
| | - Philippa Easterbrook
- Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Emmanuel Fajardo
- FIND, The Global Alliance for Diagnostics, Geneva, Switzerland
- Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Cheryl Case Johnson
- Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Niklas Luhmann
- Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | | | - Peter Vickerman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
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11
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Ma S, Manabe YC. Highlighting and addressing barriers to widespread adaptation of HIV self-testing in the United States. Expert Rev Mol Diagn 2023; 23:191-198. [PMID: 36891583 PMCID: PMC10119889 DOI: 10.1080/14737159.2023.2187291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 03/01/2023] [Indexed: 03/10/2023]
Abstract
INTRODUCTION HIV self-testing (HIVST), whereby an individual performs and interprets their own rapid screening test at home, is another tool to increase the proportion of at-risk individuals who know their status. Globally, HIVST has rapidly been adopted through global partnerships to ensure equitable access to tests in low- and middle-income countries (LMIC). AREA COVERED This review discusses the regulatory burdens of HIV self-testing within the United States while examining the use of HIV self-tests on a global scale. While the United States only has one approved HIV self-test, numerous tests have been prequalified by the WHO. EXPERT OPINION Despite the US Food and Drug Administration (FDA) clearance of the first and only self-test in 2012, there have been no other tests that have undergone FDA consideration due to regulatory barriers. This, in turn, has stifled market competition. Despite existing evidence that such programs are an innovative approach to testing hesitant or hard-to-reach populations, high individual test cost and bulky packaging make large-scale, mail-out, and HIV self-testing programs expensive. COVID-19 pandemic has accelerated the public demand for self-testing - HIV self-test programs should capitalize on this to increase the proportion of at-risk people who know their status and are linked to care to contribute to ending the HIV epidemic.
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Affiliation(s)
- Stephany Ma
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Yukari C. Manabe
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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12
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Lapsley R, Beima-Sofie K, Moraa H, Manyeki V, Mung’ala C, Kohler PK, Simoni JM, Farquhar C, Inwani I, McClelland RS, Otiso L, Masyuko S, Bukusi D, Wilson KS. "They have given you the morale and confidence:" adolescents and young adults want more community-based oral HIV self-testing options in Kenya. AIDS Care 2023; 35:392-398. [PMID: 35468010 PMCID: PMC9592677 DOI: 10.1080/09540121.2022.2067315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 04/13/2022] [Indexed: 10/18/2022]
Abstract
Community-based delivery of oral HIV self-testing (HIVST) may expand access to testing among adolescents and young adults (AYA). Eliciting youth perspectives can help to optimize these services. We conducted nine focus group discussions (FGDs) with HIV negative AYA aged 15-24 who had completed oral HIVST following community-based distribution through homes, pharmacies, and bars. FGDs were stratified by distribution point and age (15-17, 18-24). Participants valued HIVST because it promoted greater autonomy and convenience compared to traditional clinic-based testing. AYA noted how HIVST could encourage positive behavior change, including using condoms to remain HIV negative. Participants recommended that future testing strategies include individualized, ongoing support during and after testing. Support examples included access to trained peer educators, multiple community-based distribution points, and post-test support via phones and websites. Multiple distribution points and trained peer educators' involvement in all steps of distribution, testing, and follow-up can enhance future community-based HIVST programs.
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Affiliation(s)
- Robert Lapsley
- Department of Global Health, University of Washington, Seattle, USA
| | | | - Hellen Moraa
- University of Nairobi/Kenyatta National Hospital, Nairobi, Kenya
| | - Vivianne Manyeki
- University of Nairobi/Kenyatta National Hospital, Nairobi, Kenya
| | - Carol Mung’ala
- University of Nairobi/Kenyatta National Hospital, Nairobi, Kenya
| | - Pamela K. Kohler
- Department of Global Health, University of Washington, Seattle, USA
- Department of Child, Family, and Population Health, Nursing, University of Washington, Seattle, USA
| | - Jane M. Simoni
- Department of Global Health, University of Washington, Seattle, USA
- Department of Psychology, University of Washington, Seattle, USA
| | - Carey Farquhar
- Department of Global Health, University of Washington, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
| | | | - R. Scott McClelland
- Department of Global Health, University of Washington, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
| | | | - Sarah Masyuko
- National AIDS and STI Control Program (NASCOP), Nairobi, Kenya
| | | | - Kate S. Wilson
- Department of Global Health, University of Washington, Seattle, USA
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13
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Phiri M, Lemba M, Chomba C, Kanyamuna V. Examining differentials in HIV transmission risk behaviour and its associated factors among men in Southern African countries. HUMANITIES & SOCIAL SCIENCES COMMUNICATIONS 2022; 9:295. [PMID: 36060615 PMCID: PMC9419142 DOI: 10.1057/s41599-022-01312-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 08/15/2022] [Indexed: 06/15/2023]
Abstract
Sub-Saharan Africa (SSA), particularly Southern and East Africa, has the highest AIDS deaths and HIV-infected people in the world. Even though considerable effort has been made over the years to study HIV transmission risk behaviours of different population groups in SSA, there is little evidence of studies that have looked at pooled effects of associated HIV risk factors among men, particularly in Southern Africa. Thus, this study sought to fill this gap in knowledge by investigating the variations in HIV risk behaviours among men in the region. The study analysed cross-sectional data based on the most recent country Demographic and Health Survey (DHS) for six countries, namely Lesotho, Mozambique, Namibia, South Africa, Zambia and Zimbabwe. The study employed multivariate logistic regression models on a pooled dataset and individual country data to examine the relative risk of education and other factors on HIV risk behaviour indicators. It considered: (i) condom use during high risk-sex, (ii) multiple sexual partnerships, and (iii) HIV testing among men aged 15-59 years. Findings show that the proportion of men who engaged in HIV transmission risk behaviour was high in Southern Africa. Two-thirds of men reported non-use of a condom during last sex with most recent partners while 22% engaged in multiple sexual partnerships. The percentage of men who used condoms during sex with most recent partners ranged from 18% in Mozambique to 58% in Namibia. Age, residence, marital status and household wealth status were associated with HIV risk factors in the region. The study has established country variations in terms of how individual factors influence HIV transmission risk behaviour among men. Results show that the level of education was associated with increased use of condoms, only in Zambia and Mozambique. Delay in starting a sexual debut was associated with reduced odds of having multiple sexual partnerships in the region. Suggesting the need to strengthen comprehensive sexuality education among young men in school, to promote social behaviour change during adolescence age. The study presents important results to inform direct health policy, programme and government action to address HIV prevalence in the Southern region of Africa.
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Affiliation(s)
- Million Phiri
- Department of Population Studies, School of Humanities and Social Sciences, University of Zambia, Lusaka, Zambia
- Department of Demography and Population Studies, Schools of Public Health and Social Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Musonda Lemba
- Department of Population Studies, School of Humanities and Social Sciences, University of Zambia, Lusaka, Zambia
| | - Chrispin Chomba
- Department of Community and Family Medicine, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Vincent Kanyamuna
- Department of Development Studies, School of Humanities and Social Sciences, University of Zambia, Lusaka, Zambia
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14
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Expanding syphilis test uptake using rapid dual self-testing for syphilis and HIV among men who have sex with men in China: A multiarm randomized controlled trial. PLoS Med 2022; 19:e1003930. [PMID: 35235573 PMCID: PMC8890628 DOI: 10.1371/journal.pmed.1003930] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 01/25/2022] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Low syphilis testing uptake is a major public health issue among men who have sex with men (MSM) in many low- and middle-income countries. Syphilis self-testing (SST) may complement and extend facility-based testing. We aimed to evaluate the effectiveness and costs of providing SST on increasing syphilis testing uptake among MSM in China. METHODS AND FINDINGS An open-label, parallel 3-arm randomized controlled trial (RCT) was conducted between January 7, 2020 and July 17, 2020. Men who were at least 18 years of age, had condomless anal sex with men in the past year, reported not testing for syphilis in the last 6 months, and had a stable residence with mailing addresses were recruited from 124 cities in 26 Chinese provinces. Using block randomization with blocks of size 12, enrolled participants were randomly assigned (1:1:1) into 3 arms: standard of care arm, standard SST arm, and lottery incentivized SST arm (1 in 10 chance to win US$15 if they had a syphilis test). The primary outcome was the proportion of participants who tested for syphilis during the trial period and confirmed with photo verification and between arm comparisons were estimated with risk differences (RDs). Analyses were performed on a modified intention-to-treat basis: Participants were included in the complete case analysis if they had initiated at least 1 follow-up survey. The Syphilis/HIV Duo rapid test kit was used. A total of 451 men were enrolled. In total, 136 (90·7%, 136/150) in the standard of care arm, 142 (94·0%, 142/151) in the standard of SST arm, and 137 (91·3%, 137/150) in the lottery incentivized SST arm were included in the final analysis. The proportion of men who had at least 1 syphilis test during the trial period was 63.4% (95% confidence interval [CI]: 55.5% to 71.3%, p = 0.001) in the standard SST arm, 65.7% (95% CI: 57.7% to 73.6%, p = 0.0002) in the lottery incentivized SST arm, and 14.7% (95% CI: 8.8% to 20.7%, p < 0.001) in the standard of care arm. The estimated RD between the standard SST and standard of care arm was 48.7% (95% CI: 37.8% to 58.4%, p < 0.001). The majority (78.5%, 95% CI: 72.7% to 84.4%, p < 0.001) of syphilis self-testers reported never testing for syphilis. The cost per person tested was US$26.55 for standard SST, US$28.09 for the lottery incentivized SST, and US$66.19 for the standard of care. No study-related adverse events were reported during the study duration. Limitation was that the impact of the Coronavirus Disease 2019 (COVID-19) restrictions may have accentuated demand for decentralized testing. CONCLUSIONS Compared to standard of care, providing SST significantly increased the proportion of MSM testing for syphilis in China and was cheaper (per person tested). TRIAL REGISTRATION Chinese Clinical Trial Registry: ChiCTR1900022409.
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Mangenah C, Nhamo D, Gudukeya S, Gwavava E, Gavi C, Chiwawa P, Chidawanyika S, Muleya P, Taruberekera N, Madidi N, Ncube G, Bara H, Napierala S, Dunbar M, Hoke T, Kripke K, Cowan FM, Torjesen K, Terris-Prestholt F. Efficiency in PrEP Delivery: Estimating the Annual Costs of Oral PrEP in Zimbabwe. AIDS Behav 2022; 26:161-170. [PMID: 34453240 PMCID: PMC8786759 DOI: 10.1007/s10461-021-03367-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2021] [Indexed: 11/19/2022]
Abstract
Although oral PrEP is highly effective at preventing HIV acquisition, optimizing continuation among beneficiaries is challenging in many settings. We estimated the costs of delivering oral PrEP to populations at risk of HIV in seven clinics in Zimbabwe. Full annual economic costs of oral PrEP initiations and continuation visits were estimated from the providers’ perspective for a six-clinic NGO network and one government SGBV clinic in Zimbabwe (January–December 2018). Disaggregating costs of full initiation and incremental follow-up visits enabled modeling of the impact of duration of continuation on the cost per person-year ($pPY) on PrEP. 4677 people initiated oral PrEP, averaging 2.7 follow-up visits per person. Average cost per person initiated was $238 ($183–$302 across the NGO clinics; $86 in the government facility). The full cost per initiation visit, including central and direct costs, was $178, and the incremental cost per follow-up visit, capturing only additional resources used directly in the follow up visits, was $22. The average duration of continuation was 3.0 months, generating an average $pPY of $943, ranging from $839 among adolescent girls and young women to $1219 in men. Oral PrEP delivery costs varied substantially by scale of initiations and by duration of continuation and type of clinic. Extending the average oral PrEP continuation from 2.7 to 5 visits (about 6 months) would greatly improve service efficiency, cutting the $pPY by more than half.
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Traore MM, Badiane K, Vautier A, Simo Fotso A, Kanku Kabemba O, Rouveau N, Maheu-Giroux M, Boily MC, Larmarange J, Terris-Prestholt F, d'Elbée M. Economic Analysis of Low Volume Interventions Using Real-World Data: Costs of HIV Self-Testing Distribution and HIV Testing Services in West Africa From the ATLAS Project. FRONTIERS IN HEALTH SERVICES 2022; 2:886513. [PMID: 36925821 PMCID: PMC10012764 DOI: 10.3389/frhs.2022.886513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/23/2022] [Indexed: 11/13/2022]
Abstract
Achieving the first 95 of the UNAIDS targets requires the implementation of innovative approaches to knowing one's HIV status. Among these innovations is the provision of HIV self-testing (HIVST) kits in west Africa by the international partner organization Solthis (IPO). In order to provide guidance for the optimal use of financial resources, this study aims to estimate the program and site level costs of dispensing HIVST as well as HIV testing services (HTS)-excluding HIVST-in health facilities in Côte d'Ivoire, Mali and Senegal as part of the ATLAS project. We estimated from the provider's perspective, HIVST and HTS incremental costs using top-down and bottom-up costing approaches and conducted a time and motion study. We identified costs at the program level for HIVST (including IPO central costs) and at the site level for HIVST and HTS. The economic costs of distributing HIVST kits were assessed in 37 health facilities between July 2019 and March 2021 (21 months). Sensitivity analyses were also performed on unit costs to examine the robustness of our estimates related to key assumptions. In total, 16,001 HIVST kits were dispensed for 32,194 HTS sessions carried out. Program level HIVST average costs ranged $12-286, whereas site level costs ranged $4-26 across distribution channels and countries. Site level HTS costs ranged $7-8 per testing session, and ranged $72-705 per HIV diagnosis. Across countries and channels, HIVST costs were driven by personnel (27-68%) and HIVST kits (32-73%) costs. The drivers of HTS costs were personnel costs ranging between 65 and 71% of total costs across distribution channels and countries, followed by supplies costs between 21 and 30%. While program level HIVST average costs were high, site level HIVST average costs remained comparable to HTS costs in all countries. Health facility-based distribution channels operating at low volume exhibit high proportion of central costs which should be considered carefully for financial planning when run alongside high volumes mobile outreach distribution channels. HIVST can diversify the HIV testing offer at health facilities, thus improving access to screening for target populations not reached by HTS services.
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Affiliation(s)
| | - Kéba Badiane
- Solidarité Thérapeutique et Initiative pour la Santé, Dakar, Senegal
| | - Anthony Vautier
- Solidarité Thérapeutique et Initiative pour la Santé, Dakar, Senegal
| | - Arlette Simo Fotso
- Centre Population et Développement (Ceped), Institut de Recherche pour le Développement (IRD), Université de Paris, Inserm, Paris, France
| | | | - Nicolas Rouveau
- Centre Population et Développement (Ceped), Institut de Recherche pour le Développement (IRD), Université de Paris, Inserm, Paris, France
| | - Mathieu Maheu-Giroux
- Department of Epidemiology, Biostatistics, and Occupational Health, School of Population and Global Health, McGill University, Montréal, QC, Canada
| | - Marie-Claude Boily
- Department of Infectious Disease Epidemiology, Medical Research Council Centre for Global Infectious Disease Analysis, Imperial College London, London, United Kingdom
| | - Joseph Larmarange
- Centre Population et Développement (Ceped), Institut de Recherche pour le Développement (IRD), Université de Paris, Inserm, Paris, France
| | - Fern Terris-Prestholt
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Marc d'Elbée
- Department of Global Health in the Global South, Bordeaux Population Health, Institut National de la Santé et de la Recherche Médicale (Inserm), University of Bordeaux, Bordeaux, France
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Pai N, Esmail A, Saha Chaudhuri P, Oelofse S, Pretorius M, Marathe G, Daher J, Smallwood M, Karatzas N, Fadul M, de Waal A, Engel N, Zwerling AA, Dheda K. Impact of a personalised, digital, HIV self-testing app-based program on linkages and new infections in the township populations of South Africa. BMJ Glob Health 2021; 6:bmjgh-2021-006032. [PMID: 34475026 PMCID: PMC8413877 DOI: 10.1136/bmjgh-2021-006032] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 08/15/2021] [Indexed: 11/08/2022] Open
Abstract
Introduction Implementation data for digital unsupervised HIV self-testing (HIVST) are sparse. We evaluated the impact of an app-based, personalised, oral HIVST program offered by healthcare workers in Western Cape, South Africa. Methods In a quasirandomised study (n=3095), we recruited consenting adults with undiagnosed HIV infection from township clinics. To the HIVST arm participants (n=1535), we offered a choice of an offsite (home, office or kiosk based), unsupervised digital HIVST program (n=962), or an onsite, clinic-based, supervised digital HIVST program (n=573) with 24/7 linkages services. With propensity score analyses, we compared outcomes (ie, linkages, new HIV infections and test referrals) with conventional HIV testing (ConvHT) arm participants (n=1560), recruited randomly from geographically separated clinics. Results In both arms, participants were young (HIVST vs ConvHT) (mean age: 28.2 years vs 29.2 years), female (65.0% vs 76.0%) and had monthly income <3000 rand (80.8% vs 75%). Participants chose unsupervised HIVST (62.7%) versus supervised HIVST and reported multiple sex partners (10.88% vs 8.7%), exposure to sex workers (1.4% vs 0.2%) and fewer comorbidities (0.9% vs 1.9%). Almost all HIVST participants were linked (unsupervised HIVST (99.7%), supervised HIVST (99.8%) vs ConvHT (98.5%)) (adj RR 1.012; 95% CI 1.005 to 1.018) with new HIV infections: overall HIVST (9%); supervised HIVST (10.9%) and unsupervised HIVST (7.6%) versus ConvHT (6.79%) (adj RR 1.305; 95% CI 1.023 to 1.665); test referrals: 16.7% HIVST versus 3.1% ConvHT (adj RR 5.435; 95% CI 4.024 to 7.340). Conclusions Our flexible, personalised, app-based HIVST program, offered by healthcare workers, successfully linked almost all HIV self-testers, detected new infections and increased referrals to self-test. Data are relevant for digital HIVST initiatives worldwide.
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Affiliation(s)
- Nitika Pai
- Department of Medicine, McGill University, Montreal, Québec, Canada .,Research Institute of McGill University, Montreal, Québec, Canada
| | - Aliasgar Esmail
- South African MRC Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa.,Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Paramita Saha Chaudhuri
- Department of Epidemiology, Biostatistics & Occupational Health, McGill University, Montreal, Québec, Canada
| | - Suzette Oelofse
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Marietjie Pretorius
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Gayatri Marathe
- Department of Epidemiology, Biostatistics & Occupational Health, McGill University, Montreal, Québec, Canada
| | - Jana Daher
- Research Institute of McGill University, Montreal, Québec, Canada
| | - Megan Smallwood
- Research Institute of McGill University, Montreal, Québec, Canada.,Department of Epidemiology, Biostatistics & Occupational Health, McGill University, Montreal, Québec, Canada
| | - Nicolaos Karatzas
- Department of Experimental Medicine, McGill University, Montreal, Québec, Canada
| | - Mohammed Fadul
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Anna de Waal
- Research Institute of McGill University, Montreal, Québec, Canada.,Department of Epidemiology, Biostatistics & Occupational Health, McGill University, Montreal, Québec, Canada
| | - Nora Engel
- Department of Health, Ethics & Society/CAPHRI, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Alice Anne Zwerling
- School of Epidemiology & Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Keertan Dheda
- South African MRC Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa.,Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute, University of Cape Town, Cape Town, South Africa.,Faculty of Infectious and Tropical Diseases, Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, UK
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18
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Jamieson L, Johnson LF, Matsimela K, Sande LA, d'Elbée M, Majam M, Johnson C, Chidarikire T, Hatzold K, Terris-Prestholt F, Nichols B, Meyer-Rath G. The cost effectiveness and optimal configuration of HIV self-test distribution in South Africa: a model analysis. BMJ Glob Health 2021; 6:bmjgh-2021-005598. [PMID: 34275876 PMCID: PMC8287627 DOI: 10.1136/bmjgh-2021-005598] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 06/24/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND HIV self-testing (HIVST) has been shown to be acceptable, feasible and effective in increasing HIV testing uptake. Novel testing strategies are critical to achieving the UNAIDS target of 95% HIV-positive diagnosis by 2025 in South Africa and globally. METHODS We modelled the impact of six HIVST kit distribution modalities (community fixed-point, taxi ranks, workplace, partners of primary healthcare (PHC) antiretroviral therapy (ART) patients), partners of pregnant women, primary PHC distribution) in South Africa over 20 years (2020-2039), using data collected alongside the Self-Testing AfRica Initiative. We modelled two annual distribution scenarios: (A) 1 million HIVST kits (current) or (B) up to 6.7 million kits. Incremental economic costs (2019 US$) were estimated from the provider perspective; assumptions on uptake and screening positivity were based on surveys of a subset of kit recipients and modelled using the Thembisa model. Cost-effectiveness of each distribution modality compared with the status-quo distribution configuration was estimated as cost per life year saved (estimated from life years lost due to AIDS) and optimised using a fractional factorial design. RESULTS The largest impact resulted from secondary HIVST distribution to partners of ART patients at PHC (life years saved (LYS): 119 000 (scenario A); 393 000 (scenario B)). However, it was one of the least cost-effective modalities (A: $1394/LYS; B: $4162/LYS). Workplace distribution was cost-saving ($52-$76 million) and predicted to have a moderate epidemic impact (A: 40 000 LYS; B: 156 000 LYS). An optimised scale-up to 6.7 million tests would result in an almost threefold increase in LYS compared with a scale-up of status-quo distribution (216 000 vs 75 000 LYS). CONCLUSION Optimisation-informed distribution has the potential to vastly improve the impact of HIVST. Using this approach, HIVST can play a key role in improving the long-term health impact of investment in HIVST.
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Affiliation(s)
- Lise Jamieson
- Department of Internal Medicine, Health Economics and Epidemiology Research Office, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, Gauteng, South Africa
| | - Leigh F Johnson
- Centre of Infectious Disease Epidemiology and Research (CIDER), University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Katleho Matsimela
- Department of Internal Medicine, Health Economics and Epidemiology Research Office, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, Gauteng, South Africa
| | - Linda Alinafe Sande
- Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Marc d'Elbée
- Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Mohammed Majam
- Ezintsha, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
| | - Cheryl Johnson
- Global HIV, Hepatitis, STI programmes, World Health Organization, Geneve, Switzerland
| | - Thato Chidarikire
- HIV Prevention Programmes, National Department of Health, Pretoria, South Africa, Pretoria, South Africa
| | - Karin Hatzold
- Population Services International, Johannesburg, South Africa
| | - Fern Terris-Prestholt
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneve, Switzerland
| | - Brooke Nichols
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts, USA.,Department of Medical Microbiology, Amsterdam University Medical Centres, Duivendrecht, Noord-Holland, The Netherlands
| | - Gesine Meyer-Rath
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts, USA.,Department of Internal Medicine, Health Economics and Epidemiology Research Office, University of the Witwatersrand School of Clinical Medicine, Johannesburg, Gauteng, South Africa
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19
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Adawiyah RA, Saweri OPM, Boettiger DC, Applegate TL, Probandari A, Guy R, Guinness L, Wiseman V. The costs of scaling up HIV and syphilis testing in low- and middle-income countries: a systematic review. Health Policy Plan 2021; 36:939-954. [PMID: 33693731 PMCID: PMC8227996 DOI: 10.1093/heapol/czab030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2021] [Indexed: 12/18/2022] Open
Abstract
Around two-thirds of all new HIV infections and 90% of syphilis cases occur in low- and middle-income countries (LMICs). Testing is a key strategy for the prevention and treatment of HIV and syphilis. Decision-makers in LMICs face considerable uncertainties about the costs of scaling up HIV and syphilis testing. This paper synthesizes economic evidence on the costs of scaling up HIV and syphilis testing interventions in LMICs and evidence on how costs change with the scale of delivery. We systematically searched multiple databases (Medline, Econlit, Embase, EMCARE, CINAHL, Global Health and the NHS Economic Evaluation Database) for peer-reviewed studies examining the costs of scaling up HIV and syphilis testing in LMICs. Thirty-five eligible studies were identified from 4869 unique citations. Most studies were conducted in Sub-Saharan Africa (N = 17) and most explored the costs of rapid HIV in facilities targeted the general population (N = 19). Only two studies focused on syphilis testing. Seventeen studies were cost analyses, 17 were cost-effectiveness analyses and 1 was cost-benefit analysis of HIV or syphilis testing. Most studies took a modelling approach (N = 25) and assumed costs increased linearly with scale. Ten studies examined cost efficiencies associated with scale, most reporting short-run economies of scale. Important drivers of the costs of scaling up included testing uptake and the price of test kits. The 'true' cost of scaling up testing is likely to be masked by the use of short-term decision frameworks, linear unit-cost projections (i.e. multiplying an average cost by a factor reflecting activity at a larger scale) and availability of health system capacity and infrastructure to supervise and support scale up. Cost data need to be routinely collected alongside other monitoring indicators as HIV and syphilis testing continues to be scaled up in LMICs.
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Affiliation(s)
- Rabiah Al Adawiyah
- The Kirby Institute, University New South Wales, High St, Kensington 2052, New South Wales, Australia
| | - Olga P M Saweri
- The Kirby Institute, University New South Wales, High St, Kensington 2052, New South Wales, Australia.,Population Health and Demography, Papua New Guinea Institute of Medical Research, PO Box 60 Homate Street, Goroka, Papua New Guinea
| | - David C Boettiger
- The Kirby Institute, University New South Wales, High St, Kensington 2052, New South Wales, Australia
| | - Tanya L Applegate
- The Kirby Institute, University New South Wales, High St, Kensington 2052, New South Wales, Australia
| | - Ari Probandari
- Department of Public Health, Faculty of Medicine, Universitas Sebelas Maret, Jl. Ir. Sutami 36A. Surakarta, 57126, Indonesia
| | - Rebecca Guy
- The Kirby Institute, University New South Wales, High St, Kensington 2052, New South Wales, Australia
| | - Lorna Guinness
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK.,Centre for Global DevelopmentEurope, Great Peter House, Great College St, London SW1P 3SE, UK
| | - Virginia Wiseman
- The Kirby Institute, University New South Wales, High St, Kensington 2052, New South Wales, Australia.,London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
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20
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Mangenah C, Mavhu W, Garcia DC, Gavi C, Mleya P, Chiwawa P, Chidawanyika S, Ncube G, Xaba S, Mugurungi O, Taruberekera N, Madidi N, Fielding KL, Johnson C, Hatzold K, Terris-Prestholt F, Cowan FM, Bautista-Arredondo S. Relative efficiency of demand creation strategies to increase voluntary medical male circumcision uptake: a study conducted as part of a randomised controlled trial in Zimbabwe. BMJ Glob Health 2021; 6:bmjgh-2021-004983. [PMID: 34275870 PMCID: PMC8287601 DOI: 10.1136/bmjgh-2021-004983] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 05/01/2021] [Accepted: 05/03/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Supply and demand-side factors continue to undermine voluntary medical male circumcision (VMMC) uptake. We assessed relative economic costs of four VMMC demand creation/service-delivery modalities as part of a randomised controlled trial in Zimbabwe. METHODS Interpersonal communication agents were trained and incentivised to generate VMMC demand across five districts using four demand creation modalities (standard demand creation (SDC), demand creation plus offer of HIV self-testing (HIVST), human-centred design (HCD)-informed approach, HCD-informed demand creation approach plus offer of HIVST). Annual provider financial expenditure analysis and activity-based-costing including time-and-motion analysis across 15 purposively selected sites accounted for financial expenditures and donated inputs from other programmes and funders. Sites represented three models of VMMC service-delivery: static (fixed) model offering VMMC continuously to walk-in clients at district hospitals and serving as a district hub for integrated mobile and outreach services, (2) integrated (mobile) modelwhere staff move from the district static (fixed) site with their commodities to supplement existing services or to recently capacitated health facilities, intermittently and (3) mobile/outreach model offering VMMC through mobile clinic services in more remote sites. RESULTS Total programme cost was $752 585 including VMMC service-delivery costs and average cost per client reached and cost per circumcision were $58 and $174, respectively. Highest costs per client reached were in the HCD arm-$68 and lowest costs in standard demand creation ($52) and HIVST ($55) arms, respectively. Highest cost per client circumcised was observed in the arm where HIVST and HCD were combined ($226) and the lowest in the HCD alone arm ($160). Across the three VMMC service-delivery models, unit cost was lowest in static (fixed) model ($54) and highest in integrated mobile model ($63). Overall, economies of scale were evident with unit costs lower in sites with higher numbers of clients reached and circumcised. CONCLUSIONS There was high variability in unit costs across arms and sites suggesting opportunities for cost reductions. Highest costs were observed in the HCD+HIVST arm when combined with an integrated service-delivery setting. Mobilisation programmes that intensively target higher conversion rates as exhibited in the SDC and HCD arms provide greater scope for efficiency by spreading costs. TRIAL REGISTRATION NUMBER PACTR201804003064160.
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Affiliation(s)
- Collin Mangenah
- Centre for Sexual Health and HIV/AIDS Research Zimbabwe, Harare, Zimbabwe .,Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Webster Mavhu
- Centre for Sexual Health and HIV/AIDS Research Zimbabwe, Harare, Zimbabwe,Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Diego Cerecero Garcia
- Division of Health Economics and Health Systems Innovations, Instituto Nacional de Salud Publica, Cuernavaca, Mexico
| | - Chiedza Gavi
- Centre for Sexual Health and HIV/AIDS Research Zimbabwe, Harare, Zimbabwe
| | - Polite Mleya
- Centre for Sexual Health and HIV/AIDS Research Zimbabwe, Harare, Zimbabwe
| | - Progress Chiwawa
- Centre for Sexual Health and HIV/AIDS Research Zimbabwe, Harare, Zimbabwe
| | | | | | | | | | | | | | - Katherine L Fielding
- Faculty of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Karin Hatzold
- Population Services International, Washington, District of Columbia, USA
| | - Fern Terris-Prestholt
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Frances M Cowan
- Centre for Sexual Health and HIV/AIDS Research Zimbabwe, Harare, Zimbabwe,Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Sergio Bautista-Arredondo
- Division of Health Economics and Health Systems Innovations, Instituto Nacional de Salud Publica, Cuernavaca, Mexico
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21
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Matsimela K, Sande LA, Mostert C, Majam M, Phiri J, Zishiri V, Madondo C, Khama S, Chidarikire T, d'Elbée M, Hatzold K, Johnson C, Terris-Prestholt F, Meyer-Rath G. The cost and intermediary cost-effectiveness of oral HIV self-test kit distribution across 11 distribution models in South Africa. BMJ Glob Health 2021; 6:bmjgh-2021-005019. [PMID: 34275873 PMCID: PMC8287621 DOI: 10.1136/bmjgh-2021-005019] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 03/29/2021] [Accepted: 03/31/2021] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Countries around the world seek innovative ways of closing their remaining gaps towards the target of 95% of people living with HIV (PLHIV) knowing their status by 2030. Offering kits allowing HIV self-testing (HIVST) in private might help close these gaps. METHODS We analysed the cost, use and linkage to onward care of 11 HIVST kit distribution models alongside the Self-Testing AfRica Initiative's distribution of 2.2 million HIVST kits in South Africa in 2018/2019. Outcomes were based on telephonic surveys of 4% of recipients; costs on a combination of micro-costing, time-and-motion and expenditure analysis. Costs were calculated from the provider perspective in 2019 US$, as incremental costs in integrated and full costs in standalone models. RESULTS HIV positivity among kit recipients was 4%-23%, with most models achieving 5%-6%. Linkage to confirmatory testing and antiretroviral therapy (ART) initiation for those screening positive was 19%-78% and 2%-72% across models. Average costs per HIVST kit distributed varied between $4.87 (sex worker model) and $18.07 (mobile integration model), with differences largely driven by kit volumes. HIVST kit costs (at $2.88 per kit) and personnel costs were the largest cost items throughout. Average costs per outcome increased along the care cascade, with the sex worker network model being the most cost-effective model across metrics used (cost per kit distributed/recipient screening positive/confirmed positive/initiating ART). Cost per person confirmed positive for HIVST was higher than standard HIV testing. CONCLUSION HIV self-test distribution models in South Africa varied widely along four characteristics: distribution volume, HIV positivity, linkage to care and cost. Volume was highest in models that targeted public spaces with high footfall (flexible community, fixed point and transport hub distribution), followed by workplace models. Transport hub, workplace and sex worker models distributed kits in the least costly way. Distribution via index cases at facility as well as sex worker network distribution identified the highest number of PLHIV at lowest cost.
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Affiliation(s)
- Katleho Matsimela
- Health Economics and Epidemiology Research Office (HE1RO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Linda Alinafe Sande
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK,Department of HIV/AIDS and TB, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Cyprian Mostert
- Wits Reproductive Health and HIV Research Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mohammed Majam
- Ezintsha, Wits Reproductive Health and HIV Research Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Jane Phiri
- Ezintsha, Wits Reproductive Health and HIV Research Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Vincent Zishiri
- Ezintsha, Wits Reproductive Health and HIV Research Institute, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Stephen Khama
- Society for Family Health, Johannesburg, South Africa
| | - Thato Chidarikire
- HIV Prevention Programmes, National Department of Health, Pretoria, South Africa
| | - Marc d'Elbée
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK
| | - Karin Hatzold
- Population Services International, Cape Town, South Africa
| | - Cheryl Johnson
- HIV Department, World Health Organization, Geneva, Switzerland
| | - Fern Terris-Prestholt
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK,Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland
| | - Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office (HERO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa .,Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts, USA
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22
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Madut DB, Manavalan P, Mtalo A, Peter TA, Ostermann J, Njau B, Thielman NM. Increasing the Uptake of HIV Testing among Men in Tanzania: A Novel Intervention for Bar Patrons. AIDS Behav 2021; 25:2014-2022. [PMID: 33389376 DOI: 10.1007/s10461-020-03131-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2020] [Indexed: 11/29/2022]
Abstract
We investigated a novel community-based HIV testing and counseling (HTC) strategy by recruiting men from bars in northern Tanzania in order to identify new HIV infections. All bars in the town of Boma Ng'ombe were identified and male patrons were systematically invited to participate in a health study. HIV testing was offered to all enrolled participants. Outputs included HIV test yield, cost per diagnosis, and comparison of our observed test yield to that among male patients contemporaneously tested at five local facility-based HTC. We enrolled 366 participants and identified 17 new infections - providing a test yield of 5.3% (95% Confidence interval [CI] 3.3-8.4). The test yield among men contemporaneously tested at five local HTC centers was 2.1% (95% CI 1.6-2.8). The cost-per-diagnosis was $634. Our results suggest that recruiting male bar patrons for HIV testing is efficient for identifying new HIV infections. The scalability of this intervention warrants further evaluation.
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Affiliation(s)
- Deng B Madut
- Department of Medicine, Duke University, 315 Trent Drive, Durham, NC, 27710, USA.
- Duke Global Health Institute, Durham, NC, USA.
| | - Preeti Manavalan
- Department of Medicine, Duke University, 315 Trent Drive, Durham, NC, 27710, USA
- Duke Global Health Institute, Durham, NC, USA
| | - Antipas Mtalo
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | | | - Jan Ostermann
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Bernard Njau
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Nathan M Thielman
- Department of Medicine, Duke University, 315 Trent Drive, Durham, NC, 27710, USA
- Duke Global Health Institute, Durham, NC, USA
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23
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Indravudh PP, Fielding K, Sande LA, Maheswaran H, Mphande S, Kumwenda MK, Chilongosi R, Nyirenda R, Johnson CC, Hatzold K, Corbett EL, Terris-Prestholt F. Pragmatic economic evaluation of community-led delivery of HIV self-testing in Malawi. BMJ Glob Health 2021; 6:e004593. [PMID: 34275869 PMCID: PMC8287609 DOI: 10.1136/bmjgh-2020-004593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/27/2021] [Accepted: 04/16/2021] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Community-based strategies can extend coverage of HIV testing and diagnose HIV at earlier stages of infection but can be costly to implement. We evaluated the costs and effects of community-led delivery of HIV self-testing (HIVST) in Mangochi District, Malawi. METHODS This economic evaluation was based within a pragmatic cluster-randomised trial of 30 group village heads and their catchment areas comparing the community-led HIVST intervention in addition to the standard of care (SOC) versus the SOC alone. The intervention involved mobilising community health groups to lead 7-day HIVST campaigns including distribution of HIVST kits. The SOC included facility-based HIV testing services. Primary costings estimated economic costs of the intervention and SOC from the provider perspective, with costs annualised and measured in 2018 US$. A postintervention survey captured individual-level data on HIV testing events, which were combined with unit costs from primary costings, and outcomes. The incremental cost per person tested HIV-positive and associated uncertainty were estimated. RESULTS Overall, the community-led HIVST intervention costed $138 624 or $5.70 per HIVST kit distributed, with test kits and personnel the main contributing costs. The SOC costed $263 400 or $4.57 per person tested. Individual-level provider costs were higher in the community-led HIVST arm than the SOC arm (adjusted mean difference $3.77, 95% CI $2.44 to $5.10; p<0.001), while the intervention effect on HIV positivity varied based on adjustment for previous diagnosis. The incremental cost per person tested HIV positive was $324 but increased to $1312 and $985 when adjusting for previously diagnosed self-testers or self-testers on treatment, respectively. Community-led HIVST demonstrated low probability of being cost-effective against plausible willingness-to-pay values, with HIV positivity a key determinant. CONCLUSION Community-led HIVST can provide HIV testing at a low additional unit cost. However, adding community-led HIVST to the SOC was not likely to be cost-effective, especially in contexts with low prevalence of undiagnosed HIV. TRIAL REGISTRATION NUMBER NCT03541382.
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Affiliation(s)
- Pitchaya P Indravudh
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Katherine Fielding
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Linda A Sande
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - Saviour Mphande
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Moses K Kumwenda
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - Rose Nyirenda
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - Cheryl C Johnson
- Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, WHO, Geneva, Switzerland
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Karin Hatzold
- Population Services International, Washington, DC, USA
| | - Elizabeth L Corbett
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Fern Terris-Prestholt
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
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Indravudh PP, Fielding K, Chilongosi R, Nzawa R, Neuman M, Kumwenda MK, Nyirenda R, Johnson CC, Taegtmeyer M, Desmond N, Hatzold K, Corbett EL. Effect of door-to-door distribution of HIV self-testing kits on HIV testing and antiretroviral therapy initiation: a cluster randomised trial in Malawi. BMJ Glob Health 2021; 6:bmjgh-2020-004269. [PMID: 34275866 PMCID: PMC8287599 DOI: 10.1136/bmjgh-2020-004269] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 01/19/2021] [Accepted: 02/10/2021] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Reaching high coverage of HIV testing remains essential for HIV diagnosis, treatment and prevention. We evaluated the effectiveness and safety of door-to-door distribution of HIV self-testing (HIVST) kits in rural Malawi. METHODS This cluster randomised trial, conducted between September 2016 and January 2018, used restricted 1:1 randomisation to allocate 22 health facilities and their defined areas to door-to-door HIVST alongside the standard of care (SOC) or the SOC alone. The study population included residents (≥16 years). HIVST kits were provided door-to-door by community-based distribution agents (CBDAs) for at least 12 months. The primary outcome was recent HIV testing (in the last 12 months) measured through an endline survey. Secondary outcomes were lifetime HIV testing and cumulative 16-month antiretroviral therapy (ART) initiations, which were captured at health facilities. Social harms were reported through community reporting systems. Analysis compared cluster-level outcomes by arm. RESULTS Overall, 203 CBDAs distributed 273 729 HIVST kits. The endline survey included 2582 participants in 11 HIVST clusters and 2908 participants in 11 SOC clusters. Recent testing was higher in the HIVST arm (68.5%, 1768/2582) than the SOC arm (48.9%, 1422/2908), with adjusted risk difference (RD) of 16.1% (95% CI 6.5% to 25.7%). Lifetime testing was also higher in the HIVST arm (86.9%, 2243/2582) compared with the SOC arm (78.5%, 2283/2908; adjusted RD 6.3%, 95% CI 2.3% to 10.3%). Differences were most pronounced for adolescents aged 16-19 years (adjusted RD 18.6%, 95% CI 7.3% to 29.9%) and men (adjusted RD 10.2%, 95% CI 3.1% to 17.2%). Cumulative incidence of ART initiation was 1187.2 and 909.0 per 100 000 population in the HIVST and SOC arms, respectively (adjusted RD 309.1, 95% CI -95.5 to 713.7). Self-reported HIVST use was 42.5% (1097/2582), with minimal social harms reported. CONCLUSION Door-to-door HIVST increased recent and lifetime testing at population level and showed high safety, underscoring potential for HIVST to contribute to HIV elimination goals in priority settings. TRIAL REGISTRATION NUMBER NCT02718274.
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Affiliation(s)
- Pitchaya P Indravudh
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK .,Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Katherine Fielding
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK.,School of Public Health, University of the Witwatersrand, Johannesburg-Braamfontein, Gauteng, South Africa
| | | | - Rebecca Nzawa
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Melissa Neuman
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Moses K Kumwenda
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Rose Nyirenda
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - Cheryl C Johnson
- Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organization, Geneve, Switzerland.,Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK.,Tropical Infectious Diseases Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Nicola Desmond
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Karin Hatzold
- Population Services International, Washington, DC, USA
| | - Elizabeth L Corbett
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
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Sande LA, Matsimela K, Mwenge L, Mangenah C, Choko AT, d'Elbée M, Majam M, Mostert C, Matamwandi I, Sibanda EL, Johnson C, Hatzold K, Ayles H, Cowan FM, Corbett EL, Neuman M, Maheswaran H, Meyer-Rath G, Terris-Prestholt F. Costs of integrating HIV self-testing in public health facilities in Malawi, South Africa, Zambia and Zimbabwe. BMJ Glob Health 2021; 6:bmjgh-2021-005191. [PMID: 34275874 PMCID: PMC8287606 DOI: 10.1136/bmjgh-2021-005191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 04/19/2021] [Accepted: 04/27/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION As countries approach the UNAIDS 95-95-95 targets, there is a need for innovative and cost-saving HIV testing approaches that can increase testing coverage in hard-to-reach populations. The HIV Self-Testing Africa-Initiative distributed HIV self-test (HIVST) kits using unincentivised HIV testing counsellors across 31 public facilities in Malawi, South Africa, Zambia and Zimbabwe. HIVST was distributed either through secondary (partner's use) distribution alone or primary (own use) and secondary distribution approaches. METHODS We evaluated the costs of adding HIVST to existing HIV testing from the providers' perspective in the 31 public health facilities across the four countries between 2018 and 2019. We combined expenditure analysis and bottom-up costing approaches. We also carried out time-and-motion studies on the counsellors to estimate the human resource costs of introducing and demonstrating how to use HIVST for primary and secondary use. RESULTS A total of 41 720 kits were distributed during the analysis period, ranging from 1254 in Zimbabwe to 27 678 in Zambia. The cost per kit distributed through the primary distribution approach was $4.27 in Zambia and $9.24 in Zimbabwe. The cost per kit distributed through the secondary distribution approach ranged from $6.46 in Zambia to $13.42 in South Africa, with a wider variation in the average cost at facility-level. From the time-and-motion observations, the counsellors spent between 20% and 44% of the observed workday on HIVST. Overall, personnel and test kit costs were the main cost drivers. CONCLUSION The average costs of distributing HIVST kits were comparable across the four countries in our analysis despite wide cost variability within countries. We recommend context-specific exploration of potential efficiency gains from these facility-level cost variations and demand creation activities to ensure continued affordability at scale.
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Affiliation(s)
- Linda Alinafe Sande
- Faculty of Public Health and Policy, Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
- Public Health Group, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Katleho Matsimela
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Health Economics and Epidemiology Research Office, Johannesburg, South Africa
| | | | - Collin Mangenah
- Centre for Sexual Health, HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe
| | - Augustine Talumba Choko
- Public Health Group, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Marc d'Elbée
- Faculty of Public Health and Policy, Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Mohammed Majam
- University of the Witwatersrand, Ezintsha, Johannesburg, South Africa
| | - Cyprian Mostert
- Faculty of Health Sciences, University of the Witwatersrand, Wits Reproductive Health and HIV Institute, Johannesburg, South Africa
| | | | | | | | - Karin Hatzold
- Population Services International, Cape Town, South Africa
| | | | - Frances M Cowan
- Centre for Sexual Health HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Elizabeth Lucy Corbett
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Melissa Neuman
- MRC International Statistics and Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Gesine Meyer-Rath
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Health Economics and Epidemiology Research Office, Johannesburg, South Africa
- Center for Global Health and Development, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Fern Terris-Prestholt
- Department of Global Health & Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
- Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland
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d'Elbée M, Gomez GB, Sande LA, Mwenge L, Mangenah C, Johnson C, Medley GF, Neuman M, Hatzold K, Corbett EL, Meyer-Rath G, Terris-Prestholt F. Modelling costs of community-based HIV self-testing programmes in Southern Africa at scale: an econometric cost function analysis across five countries. BMJ Glob Health 2021; 6:e005554. [PMID: 34275875 PMCID: PMC8287624 DOI: 10.1136/bmjgh-2021-005554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 05/25/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Following success demonstrated with the HIV Self-Testing AfRica Initiative, HIV self-testing (HIVST) is being added to national HIV testing strategies in Southern Africa. An analysis of the costs of scaling up HIVST is needed to inform national plans, but there is a dearth of evidence on methods for forecasting costs at scale from pilot projects. Econometric cost functions (ECFs) apply statistical inference to predict costs; however, we often do not have the luxury of collecting large amounts of location-specific data. We fit an ECF to identify key drivers of costs, then use a simpler model to guide cost projections at scale. METHODS We estimated the full economic costs of community-based HIVST distribution in 92 locales across Malawi, Zambia, Zimbabwe, South Africa and Lesotho between June 2016 and June 2019. We fitted a cost function with determinants related to scale, locales organisational and environmental characteristics, target populations, and per capita Growth Domestic Product (GDP). We used models differing in data intensity to predict costs at scale. We compared predicted estimates with scale-up costs in Lesotho observed over a 2-year period. RESULTS The scale of distribution, type of community-based intervention, percentage of kits distributed to men, distance from implementer's warehouse and per capita GDP predicted average costs per HIVST kit distributed. Our model simplification approach showed that a parsimonious model could predict costs without losing accuracy. Overall, ECF showed a good predictive capacity, that is, forecast costs were close to observed costs. However, at larger scale, variations of programme efficiency over time (number of kits distributed per agent monthly) could potentially influence cost predictions. DISCUSSION Our empirical cost function can inform community-based HIVST scale-up in Southern African countries. Our findings suggest that a parsimonious ECF can be used to forecast costs at scale in the context of financial planning and budgeting.
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Affiliation(s)
- Marc d'Elbée
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Gabriela B Gomez
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Linda Alinafe Sande
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
- Department of HIV/AIDS & TB, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - Collin Mangenah
- Department of Health Economics, Centre for Sexual Health HIV/AIDS Research, Harare, Zimbabwe
| | - Cheryl Johnson
- Global HIV, Hepatitis and STI Programme, World Health Organisation, Geneva, Switzerland
| | - Graham F Medley
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Melissa Neuman
- MRC International Statistics and Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Karin Hatzold
- Population Services International, Washington, DC, USA
| | - Elizabeth Lucy Corbett
- Department of HIV/AIDS & TB, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Gesine Meyer-Rath
- Department of Internal Medicine, Health Economics and Epidemiology Research Office (HE2RO) - University of the Witwatersrand, Johannesburg, South Africa
- Center for Global Health and Development, Boston University, Boston, Massachusetts, USA
| | - Fern Terris-Prestholt
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
- Department of Global Health & Development, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland
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Sibanda EL, Mangenah C, Neuman M, Tumushime M, Watadzaushe C, Mutseta MN, Maringwa G, Dirawo J, Fielding KL, Johnson C, Ncube G, Taegtmeyer M, Hatzold K, Corbett EL, Terris-Prestholt F, Cowan FM. Comparison of community-led distribution of HIV self-tests kits with distribution by paid distributors: a cluster randomised trial in rural Zimbabwean communities. BMJ Glob Health 2021; 6:e005000. [PMID: 34275872 PMCID: PMC8287604 DOI: 10.1136/bmjgh-2021-005000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 06/18/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND We compared community-led versus an established community-based HIV self-testing (HIVST) model in rural Zimbabwe using a cluster-randomised trial. METHODS Forty village groups were randomised 1:1 using restricted randomisation to community-led HIVST, where communities planned and implemented HIVST distribution for 4 weeks, or paid distribution (PD), where distributors were paid US$50 to distribute kits door-to-door over 4 weeks. Individual level primary outcomes compared household survey responses by arm 4 months post-intervention for: (1) newly diagnosed HIV during/within 4 months following HIVST distribution, (2) linkage to confirmatory testing, pre-exposure prophylaxis or voluntary medical male circumcision during/within 4 months following HIVST distribution. Participants were not masked to allocation; analysis used masked data. Trial analysis used random-effects logistic regression.Distribution costs compared: (1) community-led HIVST, (2) PD HIVST and (3) PD costs when first implemented in 2016/2017. RESULTS From October 2018 to August 2019, 27 812 and 36 699 HIVST kits were distributed in community-led and PD communities, respectively. We surveyed 11 150 participants and 5683 were in community-led arm. New HIV diagnosis was reported by 211 (3.7%) community-led versus 197 (3.6%) PD arm participants, adjusted OR (aOR) 1.1 (95% CI 0.72 to 1.56); 318 (25.9%) community-led arm participants linked to post-test services versus 361 (23.9%) in PD arm, aOR 1.1 (95% CI 0.75 to 1.49.Cost per HIVST kit distributed was US$6.29 and US$10.25 for PD and community-led HIVST, both lower than 2016/2017 costs for newly implemented PD (US$14.52). No social harms were reported. CONCLUSIONS Community-led HIVST can perform as well as paid distribution, with lower costs in the first year. These costs may reduce with programme maturity/learning. TRIAL REGISTRATION NUMBER PACTR201811849455568.
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Affiliation(s)
- Euphemia Lindelwe Sibanda
- CeSHHAR Zimbabwe, Harare, Zimbabwe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Melissa Neuman
- Department of Infectious Disease Epidemiology and MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Miriam N Mutseta
- Department of Sexual Reproductive Health Rights and Innovations, Population Services International Zimbabwe, Harare, Zimbabwe
| | | | | | - Katherine L Fielding
- Department of Infectious Disease Epidemiology and MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Cheryl Johnson
- HIV, Hepatitis and STI Department, World Health Organisation, Geneva, Switzerland
| | - Getrude Ncube
- AIDS and TB Unit, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Karin Hatzold
- Population Services International, Washington, District of Columbia, USA
| | - Elizabeth Lucy Corbett
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
- TB-HIV Group, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Fern Terris-Prestholt
- Department of Global Health & Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
- Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland
| | - Frances M Cowan
- CeSHHAR Zimbabwe, Harare, Zimbabwe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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Amstutz A, Matsela L, Lejone TI, Kopo M, Glass TR, Labhardt ND. Reaching Absent and Refusing Individuals During Home-Based HIV Testing Through Self-Testing-at What Cost? Front Med (Lausanne) 2021; 8:653677. [PMID: 34268321 PMCID: PMC8276095 DOI: 10.3389/fmed.2021.653677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 05/18/2021] [Indexed: 11/21/2022] Open
Abstract
Introduction: In the HOSENG trial (NCT03598686), the secondary distribution of oral self-tests for persons absent or refusing to test during a home-based HIV testing campaign in rural Lesotho resulted in an increase in testing coverage of 21% compared to a testing campaign without secondary distribution. This study aims to determine the per patient costs of both HOSENG trial arms. Method: We conducted a micro-costing study to estimate the cost of home-based HIV testing with (HOSENG intervention arm) and without (HOSENG control arm) secondary self-test distribution from a provider's perspective. A mixture of top-down and bottom-up costing was used. We estimated both the financial and economic per patient costs of each possible testing cascade scenario. The costs were adjusted to 2018 US$. Results: The overall provider cost for delivering the home-based HIV testing with secondary distribution was US$36,481 among the 4,174 persons enumerated and 3,094 eligible for testing in the intervention villages compared to US$28,620 for 3,642 persons enumerated and 2,727 eligible for testing in the control. The cost per person eligible for testing was US$11.79 in the intervention vs. US$10.50 in the control. This difference was mainly driven by the cost of distributed oral self-tests. The cost per person tested was, however, lower in intervention villages (US$15.70 vs. US$22.15) due to the higher testing coverage achieved through self-test distribution. The cost per person confirmed new HIV+ was US$889.79 in the intervention and US$753.17 in the control. Conclusion: During home-based HIV testing in Lesotho, the secondary distribution of self-tests for persons absent or refusing to test during the visit reduced the costs per person tested and thus presents a promising add-on for such campaigns. Trial Registration:https://ClinicalTrials.gov/, identifier: NCT03598686
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Affiliation(s)
- Alain Amstutz
- Clinical Research Unit, Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland.,Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Lineo Matsela
- Health Economics Unit, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | | | - Mathebe Kopo
- SolidarMed, Partnerships for Health, Butha-Buthe, Lesotho
| | - Tracy Renée Glass
- Clinical Research Unit, Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Niklaus Daniel Labhardt
- Clinical Research Unit, Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland.,Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
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d'Elbée M, Traore MM, Badiane K, Vautier A, Simo Fotso A, Kabemba OK, Rouveau N, Godfrey-Faussett P, Maheu-Giroux M, Boily MC, Medley GF, Larmarange J, Terris-Prestholt F. Costs and Scale-Up Costs of Integrating HIV Self-Testing Into Civil Society Organisation-Led Programmes for Key Populations in Côte d'Ivoire, Senegal, and Mali. Front Public Health 2021; 9:653612. [PMID: 34109146 PMCID: PMC8182047 DOI: 10.3389/fpubh.2021.653612] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 04/26/2021] [Indexed: 11/13/2022] Open
Abstract
Despite significant progress on the proportion of individuals who know their HIV status in 2020, Côte d'Ivoire (76%), Senegal (78%), and Mali (48%) remain far below, and key populations (KP) including female sex workers (FSW), men who have sex with men (MSM), and people who use drugs (PWUD) are the most vulnerable groups with a HIV prevalence at 5-30%. HIV self-testing (HIVST), a process where a person collects his/her own specimen, performs a test, and interprets the result, was introduced in 2019 as a new testing modality through the ATLAS project coordinated by the international partner organisation Solthis (IPO). We estimate the costs of implementing HIVST through 23 civil society organisations (CSO)-led models for KP in Côte d'Ivoire (N = 7), Senegal (N = 11), and Mali (N = 5). We modelled costs for programme transition (2021) and early scale-up (2022-2023). Between July 2019 and September 2020, a total of 51,028, 14,472, and 34,353 HIVST kits were distributed in Côte d'Ivoire, Senegal, and Mali, respectively. Across countries, 64-80% of HIVST kits were distributed to FSW, 20-31% to MSM, and 5-8% to PWUD. Average costs per HIVST kit distributed were $15 for FSW (Côte d'Ivoire: $13, Senegal: $17, Mali: $16), $23 for MSM (Côte d'Ivoire: $15, Senegal: $27, Mali: $28), and $80 for PWUD (Côte d'Ivoire: $16, Senegal: $144), driven by personnel costs (47-78% of total costs), and HIVST kits costs (2-20%). Average costs at scale-up were $11 for FSW (Côte d'Ivoire: $9, Senegal: $13, Mali: $10), $16 for MSM (Côte d'Ivoire: $9, Senegal: $23, Mali: $17), and $32 for PWUD (Côte d'Ivoire: $14, Senegal: $50). Cost reductions were mainly explained by the spreading of IPO costs over higher HIVST distribution volumes and progressive IPO withdrawal at scale-up. In all countries, CSO-led HIVST kit provision to KP showed relatively high costs during the study period related to the progressive integration of the programme to CSO activities and contextual challenges (COVID-19 pandemic, country safety concerns). In transition to scale-up and integration of the HIVST programme into CSO activities, this model shows large potential for substantial economies of scale. Further research will assess the overall cost-effectiveness of this model.
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Affiliation(s)
- Marc d'Elbée
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | | | - Arlette Simo Fotso
- Centre Population et Développement (Ceped UMR 196), Institut de Recherche pour le Développement (IRD), Université de Paris, Inserm (ERL 1244), Paris, France
| | | | - Nicolas Rouveau
- Centre Population et Développement (Ceped UMR 196), Institut de Recherche pour le Développement (IRD), Université de Paris, Inserm (ERL 1244), Paris, France
| | - Peter Godfrey-Faussett
- Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Mathieu Maheu-Giroux
- Department of Epidemiology, Biostatistics, and Occupational Health, School of Population and Global Health, McGill University, Montréal, QC, Canada
| | - Marie-Claude Boily
- Department of Infectious Disease Epidemiology, Medical Research Council Centre for Global Infectious Disease Analysis, Imperial College London, London, United Kingdom
| | - Graham Francis Medley
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Joseph Larmarange
- Centre Population et Développement (Ceped UMR 196), Institut de Recherche pour le Développement (IRD), Université de Paris, Inserm (ERL 1244), Paris, France
| | - Fern Terris-Prestholt
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland
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30
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Rivera AS, Hernandez R, Mag-Usara R, Sy KN, Ulitin AR, O'Dwyer LC, McHugh MC, Jordan N, Hirschhorn LR. Implementation outcomes of HIV self-testing in low- and middle- income countries: A scoping review. PLoS One 2021; 16:e0250434. [PMID: 33939722 PMCID: PMC8092786 DOI: 10.1371/journal.pone.0250434] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/07/2021] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION HIV self-testing (HIV-ST) is an effective means of improving HIV testing rates. Low- and middle-income countries (LMIC) are taking steps to include HIV-ST into their national HIV/AIDS programs but very few reviews have focused on implementation in LMIC. We performed a scoping review to describe and synthesize existing literature on implementation outcomes of HIV-ST in LMIC. METHODS We conducted a systematic search of Medline, Embase, Global Health, Web of Science, and Scopus, supplemented by searches in HIVST.org and other grey literature databases (done 23 September 2020) and included articles if they reported at least one of the following eight implementation outcomes: acceptability, appropriateness, adoption, feasibility, fidelity, cost, penetration, or sustainability. Both quantitative and qualitative results were extracted and synthesized in a narrative manner. RESULTS AND DISCUSSION Most (75%) of the 206 included articles focused on implementation in Africa. HIV-ST was found to be acceptable and appropriate, perceived to be convenient and better at maintaining confidentiality than standard testing. The lack of counselling and linkage to care, however, was concerning to stakeholders. Peer and online distribution were found to be effective in improving adoption. The high occurrence of user errors was a common feasibility issue reported by studies, although, diagnostic accuracy remained high. HIV-ST was associated with higher program costs but can still be cost-effective if kit prices remain low and HIV detection improves. Implementation fidelity was not always reported and there were very few studies on, penetration, and sustainability. CONCLUSIONS Evidence supports the acceptability, appropriateness, and feasibility of HIV-ST in the LMIC context. Costs and user error rates are threats to successful implementation. Future research should address equity through measuring penetration and potential barriers to sustainability including distribution, cost, scale-up, and safety.
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Affiliation(s)
- Adovich S Rivera
- Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
| | - Ralph Hernandez
- College of Medicine, University of the Philippines Manila, Manila, Philippines
| | - Regiel Mag-Usara
- College of Medicine, University of the Philippines Manila, Manila, Philippines
| | - Karen Nicole Sy
- College of Medicine, University of the Philippines Manila, Manila, Philippines
| | - Allan R Ulitin
- Institute of Health Policy and Development Studies, National Institutes for Health, Manila, Philippines
| | - Linda C O'Dwyer
- Galter Health Sciences Library & Learning Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
| | - Megan C McHugh
- Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
| | - Neil Jordan
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, Illinois, United States of America
| | - Lisa R Hirschhorn
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
- Institute of Global Health, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
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Indravudh PP, Fielding K, Kumwenda MK, Nzawa R, Chilongosi R, Desmond N, Nyirenda R, Neuman M, Johnson CC, Baggaley R, Hatzold K, Terris-Prestholt F, Corbett EL. Effect of community-led delivery of HIV self-testing on HIV testing and antiretroviral therapy initiation in Malawi: A cluster-randomised trial. PLoS Med 2021; 18:e1003608. [PMID: 33974621 PMCID: PMC8112698 DOI: 10.1371/journal.pmed.1003608] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 04/04/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Undiagnosed HIV infection remains substantial in key population subgroups including adolescents, older adults, and men, driving ongoing transmission in sub-Saharan Africa. We evaluated the impact, safety, and costs of community-led delivery of HIV self-testing (HIVST), aiming to increase HIV testing in underserved subgroups and stimulate demand for antiretroviral therapy (ART). METHODS AND FINDINGS This cluster-randomised trial, conducted between October 2018 and July 2019, used restricted randomisation (1:1) to allocate 30 group village head clusters in Mangochi district, Malawi to the community-led HIVST intervention in addition to the standard of care (SOC) or the SOC alone. The intervention involved mobilising community health groups to lead the design and implementation of 7-day HIVST campaigns, with cluster residents (≥15 years) eligible for HIVST. The primary outcome compared lifetime HIV testing among adolescents (15 to 19 years) between arms. Secondary outcomes compared: recent HIV testing (in the last 3 months) among older adults (≥40 years) and men; cumulative 6-month incidence of ART initiation per 100,000 population; knowledge of the preventive benefits of HIV treatment; and HIV testing stigma. Outcomes were measured through a post-intervention survey and at neighboring health facilities. Analysis used intention-to-treat for cluster-level outcomes. Community health groups delivered 24,316 oral fluid-based HIVST kits. The survey included 90.2% (3,960/4,388) of listed participants in the 15 community-led HIVST clusters and 89.2% (3,920/4,394) of listed participants in the 15 SOC clusters. Overall, the proportion of men was 39.0% (3,072/7,880). Most participants obtained primary-level education or below, were married, and reported a sexual partner. Lifetime HIV testing among adolescents was higher in the community-led HIVST arm (84.6%, 770/910) than the SOC arm (67.1%, 582/867; adjusted risk difference [RD] 15.2%, 95% CI 7.5% to 22.9%; p < 0.001), especially among 15 to 17 year olds and boys. Recent testing among older adults was also higher in the community-led HIVST arm (74.5%, 869/1,166) than the SOC arm (31.5%, 350/1,111; adjusted RD 42.1%, 95% CI 34.9% to 49.4%; p < 0.001). Similarly, the proportions of recently tested men were 74.6% (1,177/1,577) and 33.9% (507/1,495) in the community-led HIVST and SOC arms, respectively (adjusted RD 40.2%, 95% CI 32.9% to 47.4%; p < 0.001). Knowledge of HIV treatment benefits and HIV testing stigma showed no differences between arms. Cumulative incidence of ART initiation was respectively 305.3 and 226.1 per 100,000 population in the community-led HIVST and SOC arms (RD 72.3, 95% CI -36.2 to 180.8; p = 0.18). In post hoc analysis, ART initiations in the 3-month post-intervention period were higher in the community-led HIVST arm than the SOC arm (RD 97.7, 95% CI 33.4 to 162.1; p = 0.004). HIVST uptake was 74.7% (2,956/3,960), with few adverse events (0.6%, 18/2,955) and at US$5.70 per HIVST kit distributed. The main limitations include the use of self-reported HIV testing outcomes and lack of baseline measurement for the primary outcome. CONCLUSIONS In this study, we found that community-led HIVST was effective, safe, and affordable, with population impact and coverage rapidly realised at low cost. This approach could enable community HIV testing in high HIV prevalence settings and demonstrates potential for economies of scale and scope. TRIAL REGISTRATION Clinicaltrials.gov NCT03541382.
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Affiliation(s)
- Pitchaya P. Indravudh
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Katherine Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Moses K. Kumwenda
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Rebecca Nzawa
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - Nicola Desmond
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Rose Nyirenda
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - Melissa Neuman
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Cheryl C. Johnson
- Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organisation, Geneva, Switzerland
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Rachel Baggaley
- Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organisation, Geneva, Switzerland
| | - Karin Hatzold
- Population Services International, Washington, District of Columbia, United States of America
| | - Fern Terris-Prestholt
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Elizabeth L. Corbett
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Thomas R, Probert WJM, Sauter R, Mwenge L, Singh S, Kanema S, Vanqa N, Harper A, Burger R, Cori A, Pickles M, Bell-Mandla N, Yang B, Bwalya J, Phiri M, Shanaube K, Floyd S, Donnell D, Bock P, Ayles H, Fidler S, Hayes RJ, Fraser C, Hauck K. Cost and cost-effectiveness of a universal HIV testing and treatment intervention in Zambia and South Africa: evidence and projections from the HPTN 071 (PopART) trial. Lancet Glob Health 2021; 9:e668-e680. [PMID: 33721566 PMCID: PMC8050197 DOI: 10.1016/s2214-109x(21)00034-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 12/15/2020] [Accepted: 01/21/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND The HPTN 071 (PopART) trial showed that a combination HIV prevention package including universal HIV testing and treatment (UTT) reduced population-level incidence of HIV compared with standard care. However, evidence is scarce on the costs and cost-effectiveness of such an intervention. METHODS Using an individual-based model, we simulated the PopART intervention and standard care with antiretroviral therapy (ART) provided according to national guidelines for the 21 trial communities in Zambia and South Africa (for all individuals aged >14 years), with model parameters and primary cost data collected during the PopART trial and from published sources. Two intervention scenarios were modelled: annual rounds of PopART from 2014 to 2030 (PopART 2014-30; as the UNAIDS Fast-Track target year) and three rounds of PopART throughout the trial intervention period (PopART 2014-17). For each country, we calculated incremental cost-effectiveness ratios (ICERs) as the cost per disability-adjusted life-year (DALY) and cost per HIV infection averted. Cost-effectiveness acceptability curves were used to indicate the probability of PopART being cost-effective compared with standard care at different thresholds of cost per DALY averted. We also assessed budget impact by projecting undiscounted costs of the intervention compared with standard care up to 2030. FINDINGS During 2014-17, the mean cost per person per year of delivering home-based HIV counselling and testing, linkage to care, promotion of ART adherence, and voluntary medical male circumcision via community HIV care providers for the simulated population was US$6·53 (SD 0·29) in Zambia and US$7·93 (0·16) in South Africa. In the PopART 2014-30 scenario, median ICERs for PopART delivered annually until 2030 were $2111 (95% credible interval [CrI] 1827-2462) per HIV infection averted in Zambia and $3248 (2472-3963) per HIV infection averted in South Africa; and $593 (95% CrI 526-674) per DALY averted in Zambia and $645 (538-757) per DALY averted in South Africa. In the PopART 2014-17 scenario, PopART averted one infection at a cost of $1318 (1098-1591) in Zambia and $2236 (1601-2916) in South Africa, and averted one DALY at $258 (225-298) in Zambia and $326 (266-391) in South Africa, when outcomes were projected until 2030. The intervention had almost 100% probability of being cost-effective at thresholds greater than $700 per DALY averted in Zambia, and greater than $800 per DALY averted in South Africa, in the PopART 2014-30 scenario. Incremental programme costs for annual rounds until 2030 were $46·12 million (for a mean of 341 323 people) in Zambia and $30·24 million (for a mean of 165 852 people) in South Africa. INTERPRETATION Combination prevention with universal home-based testing can be delivered at low annual cost per person but accumulates to a considerable amount when scaled for a growing population. Combination prevention including UTT is cost-effective at thresholds greater than $800 per DALY averted and can be an efficient strategy to reduce HIV incidence in high-prevalence settings. FUNDING US National Institutes of Health, President's Emergency Plan for AIDS Relief, International Initiative for Impact Evaluation, Bill & Melinda Gates Foundation.
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Affiliation(s)
- Ranjeeta Thomas
- Department of Health Policy, London School of Economics and Political Science, London, UK.
| | - William J M Probert
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Rafael Sauter
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Surya Singh
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Nosivuyile Vanqa
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Abigail Harper
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Ronelle Burger
- Department of Economics, Stellenbosch University, Cape Town, South Africa
| | - Anne Cori
- Medical Research Council Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Michael Pickles
- Medical Research Council Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Nomtha Bell-Mandla
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Blia Yang
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | | | | | | | - Sian Floyd
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Peter Bock
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Helen Ayles
- Zambart, University of Zambia, Lusaka, Zambia; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Sarah Fidler
- Department of Infectious Disease, Imperial College London, London, UK
| | - Richard J Hayes
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Christophe Fraser
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Katharina Hauck
- Medical Research Council Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK; Abdul Latif Jameel Institute for Disease and Emergency Analytics, School of Public Health, Imperial College London, London, UK
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Okoboi S, Castelnuovo B, Van Geertruyden JP, Lazarus O, Vu L, Kalibala S, Kamara Y, Ochanda PN, King R, Mujugira A. Cost-Effectiveness of Peer-Delivered HIV Self-Tests for MSM in Uganda. Front Public Health 2021; 9:651325. [PMID: 33816426 PMCID: PMC8010300 DOI: 10.3389/fpubh.2021.651325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 02/23/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Distribution of HIV self-testing (HIVST) kits through MSM peer networks is a novel and effective strategy to increase HIV testing coverage in this high-risk population. No study has evaluated the cost or cost effectiveness of peer distribution of HIVST strategies among MSM in sub-Saharan Africa. Methods: From June to August 2018, we conducted a pilot study of secondary MSM peer HIVST kit distribution at The AIDS Support Organization at Entebbe and Masaka. We used an ingredients approach to estimate the cost of MSM peer HIVST kit distribution relative to standard-of-care (SOC) hotspot testing using programme expenditure data reported in US dollars. The provider perspective was used to estimate incremental cost-effective ratios per HIV infection averted using the difference in HIV annual transmission rates between MSM with HIV who knew their status and were not virologically suppressed and MSM with HIV who did not know their status. Results: We enrolled 297 participants of whom 150 received MSM peer HIVST kit distribution (intervention group) and 147 received TASO standard of care HIV testing (control group). Provider cost for the intervention was $2,276 compared with $1,827 for SOC during the 3-month study period. Overall, the intervention resulted in higher HIV positivity yield (4.9 vs. 1.4%) and averted more HIV infections per quarter (0.364 vs. 0.104) compared with SOC. The cost per person tested was higher for the intervention compared to SOC ($15.90 vs. $12.40). Importantly, the cost per new HIV diagnosis ($325 vs. $914) and cost per transmission averted ($6,253 vs. $ 17,567) were lower for the intervention approach relative to SOC. The incremental cost per HIV transmission averted by the self-testing program was $1,727. The incremental cost to providers per additional HIV-positive person identified by the intervention was $147.30. Conclusion: The intervention strategy was cost-effective, and identified more undiagnosed HIV infections than SOC hotspot testing at a cost-effectiveness threshold of US $2,129. Secondary distribution of HIVST kits through peers should further be evaluated with longer duration aimed at diagnosing 95% of all persons with HIV by 2030; the first UNAIDS 95-95-95 target.
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Affiliation(s)
- Stephen Okoboi
- College of Health Sciences, Infectious Diseases Institute, Makerere University, Kampala, Uganda.,Faculty of Medicine and Health Sciences and Global Health Institute, University of Antwerp, Antwerp, Belgium.,Global Health Institute, Clarke International University, Kampala, Uganda
| | - Barbara Castelnuovo
- College of Health Sciences, Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jean-Pierre Van Geertruyden
- Faculty of Medicine and Health Sciences and Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Oucul Lazarus
- The AIDS Support Organization (TASO), Kampala, Uganda
| | - Lung Vu
- Population Council, Washington, DC, United States
| | - Sam Kalibala
- Population Council, Washington, DC, United States
| | - Yvonne Kamara
- College of Health Sciences, Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Perez N Ochanda
- College of Health Sciences, Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Rachel King
- Department of Global Health, University of California, San Francisco, San Francisco, CA, United States.,School of Public Health, Makerere University, Kampala, Uganda
| | - Andrew Mujugira
- College of Health Sciences, Infectious Diseases Institute, Makerere University, Kampala, Uganda.,School of Public Health, Makerere University, Kampala, Uganda
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Abstract
OBJECTIVES This study estimates the costs of community-based HIV testing services (HTS) in Lesotho and assesses the potential efficiency gains achieved by adding HIV self-testing (HIVST) and then self-testing booths. DESIGN Micro-costing analysis using longitudinal data from a real-world intervention. METHODS We collected data prospectively on provider's costs and programmatic outcomes over three time periods of approximately 8 months each, between May 2017 and April 2019. The scope of services was extended during each period as follows: HTS only, HTS and HIVST, HTS and HIVST with individual HIVST booths wherein clients were encouraged to self-test on-site followed by on-site confirmative testing for those with reactive self-test. For each implementation period, we estimated the full financial and economic implementation costs, the incremental costs of adding HIVST onto conventional HTS and the cost per HIV positive case identified. RESULTS Costs per HIV-positive case identified increased between period 1 (US$956) and period 2 (US$1249) then dropped in period 3 (US$813). Full versus incremental cost analyses resulted in large differences in the magnitude of costs, attributable to methods rather than resource use: for example, in period 3, the average full and incremental cost estimates for HTS were US$34.3 and US$23.5 per person tested, and for HIVST were US$37.7 and US$14.0 per kit provided, respectively. CONCLUSION In Lesotho, adding HIVST to community-based HTS improves its overall affordability for HIV-positive case finding. The reporting of both full and incremental cost estimates increase transparency for use in priority setting, budgeting and financial planning for scale-up.
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Indravudh PP, Hensen B, Nzawa R, Chilongosi R, Nyirenda R, Johnson CC, Hatzold K, Fielding K, Corbett EL, Neuman M. Who is Reached by HIV Self-Testing? Individual Factors Associated With Self-Testing Within a Community-Based Program in Rural Malawi. J Acquir Immune Defic Syndr 2020; 85:165-173. [PMID: 32501815 PMCID: PMC7611247 DOI: 10.1097/qai.0000000000002412] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION HIV self-testing (HIVST) is an alternative strategy for reaching population subgroups underserved by available HIV testing services. We assessed individual factors associated with ever HIVST within a community-based program. SETTING Malawi. METHODS We conducted secondary analysis of an end line survey administered under a cluster-randomized trial of community-based distribution of HIVST kits. We estimated prevalence differences and prevalence ratios (PRs) stratified by sex for the outcome: self-reported ever HIVST. RESULTS Prevalence of ever HIVST was 45.0% (475/1055) among men and 40.1% (584/1456) among women. Age was associated with ever HIVST in both men and women, with evidence of a strong declining trend across categories of age. Compared with adults aged 25-39 years, HIVST was lowest among adults aged 40 years and older for both men [34.4%, 121/352; PR 0.74, 95% confidence interval (CI): 0.62 to 0.88] and women (30.0%, 136/454; PR 0.71, 95% CI: 0.6 to 0.84). Women who were married, had children, had higher levels of education, or were wealthier were more likely to self-test. Men who had condomless sex in the past 3 months (47.9%, 279/582) reported a higher HIVST prevalence compared with men who did not have recent condomless sex (43.1%, 94/218; adjusted PR 1.37, 95% CI: 1.06 to 1.76). Among men and women, the level of previous exposure to HIV testing and household HIVST uptake was associated with HIVST. CONCLUSIONS Community-based HIVST reached men, younger age groups, and some at-risk individuals. HIVST was lowest among older adults and individuals with less previous exposure to HIV testing, suggesting the presence of ongoing barriers to HIV testing.
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Affiliation(s)
- Pitchaya P. Indravudh
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Malawi-Liverpool-Wellcome Trust Clinical Research Program, Blantyre, Malawi
| | - Bernadette Hensen
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Rebecca Nzawa
- Malawi-Liverpool-Wellcome Trust Clinical Research Program, Blantyre, Malawi
| | | | - Rose Nyirenda
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - Cheryl C. Johnson
- Global HIV, hepatitis and sexually transmitted infections programs, World Health Organization, Geneva, Switzerland
| | | | - Katherine Fielding
- Department of Infectious Disease Epidemiology and MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Elizabeth L. Corbett
- Malawi-Liverpool-Wellcome Trust Clinical Research Program, Blantyre, Malawi
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Melissa Neuman
- Department of Infectious Disease Epidemiology and MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Woods B, Schmitt L, Rothery C, Phillips A, Hallett TB, Revill P, Claxton K. Practical metrics for establishing the health benefits of research to support research prioritisation. BMJ Glob Health 2020; 5:e002152. [PMID: 32868268 PMCID: PMC7462234 DOI: 10.1136/bmjgh-2019-002152] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 05/28/2020] [Accepted: 05/31/2020] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION We present practical metrics for estimating the expected health benefits of specific research proposals. These can be used by research funders, researchers and healthcare decision-makers within low-income and middle-income countries to support evidence-based research prioritisation. METHODS The methods require three key assessments: (1) the current level of uncertainty around the endpoints the proposed study will measure; (2) how uncertainty impacts on the health benefits and costs of healthcare programmes and (3) the health opportunity costs imposed by programme costs. Research is valuable because it can improve health by informing the choice of which programmes should be implemented. We provide a Microsoft Excel tool to allow readers to generate estimates of the health benefits of research studies based on these three assessments. The tool can be populated using existing studies, existing cost-effectiveness models and expert opinion. Where such evidence is not available, the tool can quantify the value of research under different assumptions. Estimates of the health benefits of research can be considered alongside research costs, and the consequences of delaying implementation until research reports, to determine whether research is worthwhile. We illustrate the method using a case study of research on HIV self-testing programmes in Malawi. This analysis combines data from the literature with outputs from the HIV synthesis model. RESULTS For this case study, we found a costing study that could be completed and inform decision making within 1 year offered the highest health benefits (67 000 disability-adjusted life years (DALYs) averted). Research on outcomes improved population health to a lesser extent (12 000 DALYs averted) and only if carried out alongside programme implementation. CONCLUSION Our work provides a method for estimating the health benefits of research in a practical and timely fashion. This can be used to support accountable use of research funds.
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Affiliation(s)
- Beth Woods
- Centre for Health Economics, University of York, York, Yorkshire, UK
| | - Laetitia Schmitt
- Centre for Health Economics, University of York, York, Yorkshire, UK
| | - Claire Rothery
- Centre for Health Economics, University of York, York, Yorkshire, UK
| | - Andrew Phillips
- Institute for Global Health, University College London, London, UK
| | - Timothy B Hallett
- Department of Infectious Disease Epidemiology, Imperial College London, London, London, UK
| | - Paul Revill
- Centre for Health Economics, University of York, York, Yorkshire, UK
| | - Karl Claxton
- Centre for Health Economics, University of York, York, Yorkshire, UK
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Bulterys MA, Mujugira A, Nakyanzi A, Nampala M, Taasi G, Celum C, Sharma M. Costs of Providing HIV Self-Test Kits to Pregnant Women Living with HIV for Secondary Distribution to Male Partners in Uganda. Diagnostics (Basel) 2020; 10:E318. [PMID: 32438594 PMCID: PMC7277977 DOI: 10.3390/diagnostics10050318] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/14/2020] [Accepted: 05/16/2020] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Secondary distribution of HIV self-testing kits (HIVST) to pregnant women attending antenatal care (ANC) clinics to give to their male partners is a promising strategy to increase testing coverage among men, but its costs are unknown. METHODS We conducted micro-costing of a trial evaluating secondary distribution of HIVST on pregnant women living with HIV (PWLHIV) in an ANC in Kampala, Uganda. Costs (2019 USD) were collected from program budgets, expenditure records, time and motion observations, and staff interviews and estimated for three scenarios: as-studied, reflecting full costs of the research intervention, Ministry of Health (MOH) implementation, reflecting the research intervention if implemented by the MOH, and MOH roll-out, the current strategy being used to roll out HIVST distribution. RESULTS In the as-studied scenario, cost of HIVST provision was $13.96/PWLHIV reached, and $11.89 and $10.55 per HIV-positive and HIV-negative male partner, respectively, who linked to a clinic for facility-based testing. In the MOH implementation scenario, costs were $9.45/PWLHIV, and $7.87 and $6.99, respectively, per HIV-positive and HIV-negative male partner linking to the clinic. In the MOH roll-out scenario, the cost of HIVST provision to pregnant women regardless of HIV status was $3.70/woman, and $6.65/HIV-positive male partner. CONCLUSION Secondary distribution of HIVST from pregnant women can be implemented at reasonable cost to increase testing among men in Uganda and similar settings in Africa.
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Affiliation(s)
- Michelle A. Bulterys
- International Clinical Research Center, Department of Global Health, University of Washington, Seattle, WA 98104, USA; (M.A.B.); (A.M.); (C.C.)
| | - Andrew Mujugira
- International Clinical Research Center, Department of Global Health, University of Washington, Seattle, WA 98104, USA; (M.A.B.); (A.M.); (C.C.)
- Infectious Diseases Institute, Makerere University, Kampala P.O. Box 22418, Uganda; (A.N.); (M.N.)
| | - Agnes Nakyanzi
- Infectious Diseases Institute, Makerere University, Kampala P.O. Box 22418, Uganda; (A.N.); (M.N.)
| | - Miriam Nampala
- Infectious Diseases Institute, Makerere University, Kampala P.O. Box 22418, Uganda; (A.N.); (M.N.)
| | - Geoffrey Taasi
- Division of HIV Testing, Uganda Ministry of Health, Kampala P.O. Box 7272, Uganda;
| | - Connie Celum
- International Clinical Research Center, Department of Global Health, University of Washington, Seattle, WA 98104, USA; (M.A.B.); (A.M.); (C.C.)
| | - Monisha Sharma
- International Clinical Research Center, Department of Global Health, University of Washington, Seattle, WA 98104, USA; (M.A.B.); (A.M.); (C.C.)
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Indravudh PP, Fielding K, Kumwenda MK, Nzawa R, Chilongosi R, Desmond N, Nyirenda R, Johnson CC, Baggaley RC, Hatzold K, Terris-Prestholt F, Corbett EL. Community-led delivery of HIV self-testing to improve HIV testing, ART initiation and broader social outcomes in rural Malawi: study protocol for a cluster-randomised trial. BMC Infect Dis 2019; 19:814. [PMID: 31533646 PMCID: PMC6751650 DOI: 10.1186/s12879-019-4430-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 08/30/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Prevention of new HIV infections is a critical public health issue. The highest HIV testing gaps are in men, adolescents 15-19 years old, and adults 40 years and older. Community-based HIV testing services (HTS) can contribute to increased testing coverage and early HIV diagnosis, with HIV self-testing (HIVST) strategies showing promise. Community-based strategies, however, are resource intensive, costly and not widely implemented. A community-led approach to health interventions involves supporting communities to plan and implement solutions to improve their health. This trial aims to determine if community-led delivery of HIVST can improve HIV testing uptake, ART initiation, and broader social outcomes in rural Malawi. METHODS The trial uses a parallel arm, cluster-randomised design with group village heads (GVH) and their defined catchment areas randomised (1:1) to community-led HIVST or continue with the standard of the care (SOC). As part of the intervention, informal community health cadres are supported to plan and implement a seven-day HIVST campaign linked to HIV treatment and prevention. Approximately 12 months after the initial campaign, intervention GVHs are randomised to lead a repeat HIVST campaign. The primary outcome includes the proportion of adolescents 15-19 years old who have tested for HIV in their lifetime. Secondary outcomes include recent testing in adults 40 years and older and men; ART initiation; knowledge of HIV prevention; and HIV testing stigma. Outcomes will be measured through cross-sectional surveys and clinic registers. Economic evaluation will determine the cost per person tested, cost per person diagnosed, and incremental cost effectiveness ratio. DISCUSSION To the best of our knowledge, this is the first trial to assess the effectiveness of community-led HTS, which has only recently been enabled by the introduction of HIVST. Community-led delivery of HIVST is a promising new strategy for providing periodic HIV testing to support HIV prevention in rural communities. Further, introduction of HIVST through a community-led framework seems particularly apt, with control over healthcare concurrently devolved to individuals and communities. TRIAL REGISTRATION Clinicaltrials.gov registry ( NCT03541382 ) registered 30 May 2018.
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Affiliation(s)
- Pitchaya P. Indravudh
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Katherine Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Moses K. Kumwenda
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Rebecca Nzawa
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - Nicola Desmond
- Clinical Sciences Department, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Rose Nyirenda
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - Cheryl C. Johnson
- Department of HIV/AIDS, World Health Organisation, Geneva, Switzerland
| | | | - Karin Hatzold
- Population Services International, Johannesburg, South Africa
| | - Fern Terris-Prestholt
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Elizabeth L. Corbett
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
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Hatzold K, Gudukeya S, Mutseta MN, Chilongosi R, Nalubamba M, Nkhoma C, Munkombwe H, Munjoma M, Mkandawire P, Mabhunu V, Smith G, Madidi N, Ahmed H, Kambeu T, Stankard P, Johnson CC, Corbett EL. HIV self-testing: breaking the barriers to uptake of testing among men and adolescents in sub-Saharan Africa, experiences from STAR demonstration projects in Malawi, Zambia and Zimbabwe. J Int AIDS Soc 2019; 22 Suppl 1:e25244. [PMID: 30907505 PMCID: PMC6432104 DOI: 10.1002/jia2.25244] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 01/18/2019] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Social, structural and systems barriers inhibit uptake of HIV testing. HIV self-testing (HIVST) has shown promising uptake by otherwise underserved priority groups including men, young people and first-time testers. Here, we use characteristics of HIVST kit recipients to investigate delivery to these priority groups during HIVST scale-up in three African countries. METHODS Kit distributors collected individual-level age, sex and testing history from all clients. These data were aggregated and analysed by country (Malawi, Zambia and Zimbabwe) for five distribution models: local community-based distributor (CBD: door-to-door, street and local venues), workplace distribution (WD), integration into HIV testing services (IHTS), or public health facilities (IPHF) and during demand creation for voluntary male medical circumcision (VMMC). Used kits were collected and re-read from CBD and IHTS recipients. RESULTS Between May 2015 and July 2017, 628,705 HIVST kits were distributed in Malawi (172,830), Zambia (190,787) and Zimbabwe (265,091). Community-based models, the first to be established, accounted for 519,658 (82.7%) of kits distributed, with 275,419 (53.0%) used kits returned. Subsequent model diversification delivered 54,453 (8.7%) test-kits through IHTS, 23,561 (3.7%) through VMMC, 21,183 (3.4%) through IPHF and 9850 (1.7%) through WD. Men took 294,508 (48.2%) kits, and 263,073 (43.1%) went to young people (16 to 24 years). A higher proportion of male self-testers (65,577; 22.3%) were first-time testers than women (54,096; 17.1%) with this apparent in Zimbabwe (16.2% vs. 11.4%), Zambia (25.4% vs. 17.7%) and Malawi (27.9% vs. 25.9%). The highest proportions of first-time testers were in young (16 to 24 years) and older (>50 years) men (country-ranges: 18.7% to 35.9% and 13.8% to 26.8% respectively). Most IHTS clients opted for HIVST in preference to standard HTS in each of 12 delivery sites, with those selecting HIVST having lower HIV prevalence, potentially due to self-selection. CONCLUSIONS HIVST delivered at scale using several different models reached a high proportion of men, young people and first-time testers in Malawi, Zambia and Zimbabwe, some of whom may not have tested otherwise. As men and young people have limited uptake under standard facility-and community-based HIV testing, innovative male- and youth-sensitive approaches like HIVST may be essential to reaching UNAIDS fast-track targets for 2020.
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Affiliation(s)
- Karin Hatzold
- Population Services International (PSI)WashingtonDCUSA
| | | | | | | | | | | | | | | | | | | | | | | | - Hussein Ahmed
- Population Services International (PSI)WashingtonDCUSA
| | - Taurai Kambeu
- Population Services International (PSI)WashingtonDCUSA
| | | | - Cheryl C Johnson
- Department of HIVWorld Health OrganizationGenevaSwitzerland
- Faculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Elizabeth L Corbett
- Faculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
- Malawi‐Liverpool Wellcome TrustBlantyreMalawi
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Wong V, Jenkins E, Ford N, Ingold H. To thine own test be true: HIV self-testing and the global reach for the undiagnosed. J Int AIDS Soc 2019; 22 Suppl 1:e25256. [PMID: 30912306 PMCID: PMC6433601 DOI: 10.1002/jia2.25256] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 01/24/2019] [Indexed: 11/08/2022] Open
Affiliation(s)
- Vincent Wong
- United States Agency for International Development (USAID)Global Health BureauOffice of HIV/AIDSPrevention Care and Treatment Division
| | - Erin Jenkins
- United States Agency for International Development (USAID)Global Health BureauOffice of HIV/AIDSPrevention Care and Treatment Division
| | - Nathan Ford
- HIV/AIDS DepartmentOrganisation mondiale de la SanteGenevaSwitzerland
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Cambiano V, Johnson CC, Hatzold K, Terris‐Prestholt F, Maheswaran H, Thirumurthy H, Figueroa C, Cowan FM, Sibanda EL, Ncube G, Revill P, Baggaley RC, Corbett EL, Phillips A. The impact and cost-effectiveness of community-based HIV self-testing in sub-Saharan Africa: a health economic and modelling analysis. J Int AIDS Soc 2019; 22 Suppl 1:e25243. [PMID: 30907498 PMCID: PMC6432108 DOI: 10.1002/jia2.25243] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 01/18/2019] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION The prevalence of undiagnosed HIV is declining in Africa, and various HIV testing approaches are finding lower positivity rates. In this context, the epidemiological impact and cost-effectiveness of community-based HIV self-testing (CB-HIVST) is unclear. We aimed to assess this in different sub-populations and across scenarios characterized by different adult HIV prevalence and antiretroviral treatment programmes in sub-Saharan Africa. METHODS The synthesis model was used to address this aim. Three sub-populations were considered for CB-HIVST: (i) women having transactional sex (WTS); (ii) young people (15 to 24 years); and (iii) adult men (25 to 49 years). We assumed uptake of CB-HIVST similar to that reported in epidemiological studies (base case), or assumed people use CB-HIVST only if exposed to risk (condomless sex) since last HIV test. We also considered a five-year time-limited CB-HIVST programme. Cost-effectiveness was defined by an incremental cost-effectiveness ratio (ICER; cost-per-disability-adjusted life-year (DALY) averted) below US$500 over a time horizon of 50 years. The efficiency of targeted CB-HIVST was evaluated using the number of additional tests per infection or death averted. RESULTS In the base case, targeting adult men with CB-HIVST offered the greatest impact, averting 1500 HIV infections and 520 deaths per year in the context of a simulated country with nine million adults, and impact could be enhanced by linkage to voluntary medical male circumcision (VMMC). However, the approach was only cost-effective if the programme was limited to five years or the undiagnosed prevalence was above 3%. CB-HIVST to WTS was the most cost-effective. The main drivers of cost-effectiveness were the cost of CB-HIVST and the prevalence of undiagnosed HIV. All other CB-HIVST scenarios had an ICER above US$500 per DALY averted. CONCLUSIONS CB-HIVST showed an important epidemiological impact. To maximize population health within a fixed budget, CB-HIVST needs to be targeted on the basis of the prevalence of undiagnosed HIV, sub-population and the overall costs of delivering this testing modality. Linkage to VMMC enhances its cost-effectiveness.
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Affiliation(s)
- Valentina Cambiano
- Institute for Global HealthUniversity College LondonLondonUnited Kingdom
| | | | | | - Fern Terris‐Prestholt
- Department of Global Health and DevelopmentLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Hendy Maheswaran
- Institute of Psychology, Health and SocietyUniversity of LiverpoolLiverpoolUnited Kingdom
| | - Harsha Thirumurthy
- Department of Medical Ethics and Health PolicyPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | | | - Frances M Cowan
- Centre for Sexual Health and HIV AIDS Research (CeSHHAR)HarareZimbabwe
- Liverpool School of Tropical MedicineLiverpoolUnited Kingdom
| | - Euphemia L Sibanda
- Centre for Sexual Health and HIV AIDS Research (CeSHHAR)HarareZimbabwe
- Liverpool School of Tropical MedicineLiverpoolUnited Kingdom
| | - Getrude Ncube
- Zimbabwe Ministry of Health and Child CareHarareZimbabwe
| | - Paul Revill
- Centre for Health EconomicsUniversity of YorkYorkUnited Kingdom
| | | | - Elizabeth L Corbett
- Malawi–Liverpool–Wellcome Trust Clinical Research ProgrammeBlantyreMalawi
- Department of Clinical ResearchLondon School of Hygiene& Tropical MedicineLondonUnited Kingdom
| | - Andrew Phillips
- Institute for Global HealthUniversity College LondonLondonUnited Kingdom
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