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Vasantharoopan A, Simms V, Chan Y, Guinness L, Maheswaran H. Modelling Methods of Economic Evaluations of HIV Testing Strategies in Sub-Saharan Africa: A Systematic Review. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2023; 21:585-601. [PMID: 36853553 DOI: 10.1007/s40258-022-00782-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/04/2022] [Indexed: 06/01/2023]
Abstract
BACKGROUND AND OBJECTIVE Economic evaluations, a decision-support tool for policy makers, will be crucial in planning and tailoring HIV prevention and treatment strategies especially in the wake of stalled and decreasing funding for the global HIV response. As HIV testing and treatment coverage increase, case identification becomes increasingly difficult and costly. Determining which subset of the population these strategies should be targeted to becomes of vital importance as well. Generating quality economic evidence begins with the validity of the modelling approach and the model structure employed. This study synthesises and critiques the reporting around modelling methodology of economic models in the evaluation of HIV testing strategies in sub-Saharan Africa. METHODS The following databases were searched from January 2000 to September 2020: MEDLINE, Embase, Scopus, EconLit and Global Health. Any model-based economic evaluation of a unique HIV testing strategy conducted in sub-Saharan Africa presenting a cost-effectiveness measure published from 2013 onwards was eligible. Data were extracted around three components: general study characteristics; economic evaluation design; and quality of model reporting using a novel tool developed for the purposes of this study. RESULTS A total of 21 studies were included; 10 cost-effectiveness analyses, 11 cost-utility analyses. All but one study was conducted in Eastern and Southern Africa. Modelling approaches for HIV testing strategies can be broadly characterised as static aggregate models (3/21), static individual models (6/21), dynamic aggregate models (5/21) and dynamic individual models (7/21). Adequate reporting around data handling was the highest of the three categories assessed (74%), and model validation, the lowest (45%). Limitations to model structure, justification of chosen time horizon and cycle length, and description of external model validation process were all adequately reported in less than 40% of studies. The predominant limitation of this review relates to the potential implications of the narrow inclusion criteria. CONCLUSIONS This review is the first to synthesise economic evaluations of HIV testing strategies in sub-Saharan Africa. The majority of models exhibited dynamic, stochastic and individual properties. Model reporting against the 13 criteria in our novel tool was mixed. Future model-based economic evaluations of HIV testing strategies would benefit from transparency around the choice of modelling approach, model structure, data handling procedures and model validation techniques.
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Affiliation(s)
- Arthi Vasantharoopan
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Victoria Simms
- MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Yuyen Chan
- Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, UK
| | - Lorna Guinness
- London School of Hygiene and Tropical Medicine, London, UK
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Songane M, Magaia CC, Couto A, Dengo N, Cassamo AR, Nhantumbo R, Mahumane C, Mabote A, Mikusova S, Nhangave A, Bhatt N, Mukherjee SS. HIV community index testing reaches proportionally more males than facility-based testing and is cost-effective: A study from Gaza province, Mozambique. PLoS One 2023; 18:e0286458. [PMID: 37235565 DOI: 10.1371/journal.pone.0286458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 05/16/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND In Mozambique, 38.7% of women and 60.4% of men ages 15-59 years old living with HIV do not know their HIV status. A pilot home-based HIV counseling and testing program based on index cases in the community was implemented in eight districts in Gaza province (Mozambique). The pilot targeted the sexual partners, biological children under 14 years old living in the same household, and parents (for pediatric cases) of people living with HIV. The study aimed to estimate the cost-efficiency and effectiveness of community index testing and compare the HIV testing outputs with facility-based testing. METHODS Community index testing costs included the following categories: human resources, HIV rapid tests, travel and transportation for supervision and home visits, training, supplies and consumables, and review and coordination meetings. Costs were estimated from a health systems perspective using a micro-costing approach. All project costs were incurred between October 2017 and September 2018 and converted to U.S. dollars ($) using the prevailing exchange rate. We estimated the cost per individual tested, per new HIV diagnosis, and per infection averted. RESULTS A total of 91,411 individuals were tested for HIV through community index testing, of which 7,011 were newly diagnosed with HIV. Human resources (52%), purchase of HIV rapid tests (28%) and supplies (8%) were the major cost drivers. The cost per individual tested was $5.82, per new HIV diagnosis was $65.32, and per infection averted per year was $1,813. Furthermore, the community index testing approach proportionally tested more males (53%) than facility-based testing (27%). CONCLUSION These data suggest that expansion of the community index case approach may be an effective and efficient strategy to increase the identification of previously undiagnosed HIV-positive individuals, particularly males.
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Affiliation(s)
- Mário Songane
- Elizabeth Glaser Pediatric AIDS Foundation, Maputo, Mozambique
| | - Célia C Magaia
- Elizabeth Glaser Pediatric AIDS Foundation, Maputo, Mozambique
| | - Aleny Couto
- Programa Nacional de Controle de HIV/SIDA, Maputo, Ministério da Saúde, Mozambique
| | - Nataniel Dengo
- Elizabeth Glaser Pediatric AIDS Foundation, Maputo, Mozambique
| | - Abdul R Cassamo
- Elizabeth Glaser Pediatric AIDS Foundation, Maputo, Mozambique
| | - Rene Nhantumbo
- Elizabeth Glaser Pediatric AIDS Foundation, Maputo, Mozambique
| | - Carlos Mahumane
- Elizabeth Glaser Pediatric AIDS Foundation, Maputo, Mozambique
| | - Atanásio Mabote
- Elizabeth Glaser Pediatric AIDS Foundation, Maputo, Mozambique
| | - Silvia Mikusova
- Elizabeth Glaser Pediatric AIDS Foundation, Maputo, Mozambique
| | - Amâncio Nhangave
- Direção Provincial de Saúde de Gaza, Xai-Xai, Ministério da Saúde, Mozambique
| | - Nilesh Bhatt
- Elizabeth Glaser Pediatric AIDS Foundation, Washington DC, United States of America
| | - Sushant S Mukherjee
- Elizabeth Glaser Pediatric AIDS Foundation, Washington DC, United States of America
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Ramponi F, Twea P, Chilima B, Nkhoma D, Kazanga Chiumia I, Manthalu G, Mfutso-Bengo J, Revill P, Drummond M, Sculpher M. Assessing the potential of HTA to inform resource allocation decisions in low-income settings: The case of Malawi. Front Public Health 2022; 10:1010702. [PMID: 36388387 PMCID: PMC9650047 DOI: 10.3389/fpubh.2022.1010702] [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: 08/03/2022] [Accepted: 10/03/2022] [Indexed: 01/27/2023] Open
Abstract
Health technology assessment (HTA) offers a set of analytical tools to support health systems' decisions about resource allocation. Although there is increasing interest in these tools across the world, including in some middle-income countries, they remain rarely used in low-income countries (LICs). In general, the focus of HTA is narrow, mostly limited to assessments of efficacy and cost-effectiveness. However, the principles of HTA can be used to support a broader series of decisions regarding new health technologies. We examine the potential for this broad use of HTA in LICs, with a focus on Malawi. We develop a framework to classify the main decisions on health technologies within health systems. The framework covers decisions on identifying and prioritizing technologies for detailed assessment, deciding whether to adopt an intervention, assessing alternative investments for implementation and scale-up, and undertaking further research activities. We consider the relevance of the framework to policymakers in Malawi and we use two health technologies as examples to investigate the main barriers and enablers to the use of HTA methods. Although the scarcity of local data, expertise, and other resources could risk limiting the operationalisation of HTA in LICs, we argue that even in highly resource constrained health systems, such as in Malawi, the use of HTA to support a broad range of decisions is feasible and desirable.
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Affiliation(s)
- Francesco Ramponi
- Centre for Health Economics, University of York, Heslington, United Kingdom
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Pakwanja Twea
- Department of Planning and Policy Development, Ministry of Health Malawi, Lilongwe, Malawi
| | - Benson Chilima
- Public Health Institute, Ministry of Health Malawi, Lilongwe, Malawi
| | - Dominic Nkhoma
- Health Economics and Policy Unit (HEPU), College of Medicine, University of Malawi, Zomba, Malawi
| | - Isabel Kazanga Chiumia
- Health Economics and Policy Unit (HEPU), College of Medicine, University of Malawi, Zomba, Malawi
| | - Gerald Manthalu
- Department of Planning and Policy Development, Ministry of Health Malawi, Lilongwe, Malawi
| | - Joseph Mfutso-Bengo
- Health Economics and Policy Unit (HEPU), College of Medicine, University of Malawi, Zomba, Malawi
| | - Paul Revill
- Centre for Health Economics, University of York, Heslington, United Kingdom
| | - Michael Drummond
- Centre for Health Economics, University of York, Heslington, United Kingdom
| | - Mark Sculpher
- Centre for Health Economics, University of York, Heslington, United Kingdom
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Nichols BE, de Nooy A, Benade M, Balakasi K, Mphande M, Rao G, Claassen CW, Khan S, Stillson C, Russell CA, Doi N, Dovel K. Facility-based HIV self-testing strategies may substantially and cost-effectively increase the number of men and youth tested for HIV in Malawi: results from an individual-based mathematical model. J Int AIDS Soc 2022; 25:e26020. [PMID: 36251161 PMCID: PMC9575938 DOI: 10.1002/jia2.26020] [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: 03/09/2022] [Accepted: 09/15/2022] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Malawi is rapidly closing the gap in achieving the UNAIDS 95-95-95 targets, with 90% of people living with HIV in Malawi aware of their status. As we approach epidemic control, interventions to improve coverage will become more costly. There is, therefore, an urgent need to identify innovative and low-cost strategies to maintain and increase testing coverage without diverting resources from other HIV services. The objective of this study is to model different combinations of facility-based HIV testing modalities and determine the most cost-effective strategy to increase the proportion of men and youth testing for HIV. METHODS A data-driven individual-based model was parameterized with data from a community-representative survey (socio-demographic, health service utilization and HIV testing history) of men and youth in Malawi (data collected August 2019). In total, 79 different strategies for the implementation of HIV self-testing (HIVST) and provider-initiated-testing-and-counselling at the outpatient department (OPD) were evaluated. Outcomes included percent of men/youth tested for HIV in a 12-month period, cost-effectiveness and human resource requirements. The testing yield was assumed to be constant across the scenarios. RESULTS Facility-based HIVST offered year-round resulted in the greatest increase in the proportion of men and youth tested in the OPD (from 45% to 72%-83%), was considered cost-saving for HIVST kit priced at $1.00, and generally reduced required personnel as compared to the status quo. At higher HIVST kit prices, and more relaxed eligibility criteria, all scenarios that considered year-round HIVST in the OPD remained on the cost-effectiveness frontier. CONCLUSIONS Facility-based HIVST is a cost-effective strategy to increase the proportion of men/youth tested for HIV in Malawi and decreases the human resource requirements for HIV testing in the OPD-providing additional healthcare worker time for other priority healthcare activities.
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Affiliation(s)
- Brooke E. Nichols
- Department of Global Health, School of Public HealthBoston UniversityBostonMassachusettsUSA,Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, School of Clinical Medicine, University of the WitwatersrandJohannesburgSouth Africa,Department of Medical MicrobiologyAmsterdam University Medical CentreAmsterdamthe Netherlands,Foundation for Innovative New DiagnosticsGenevaSwitzerland
| | - Alexandra de Nooy
- Department of Medical MicrobiologyAmsterdam University Medical CentreAmsterdamthe Netherlands,Right to CareJohannesburgSouth Africa
| | - Mariet Benade
- Department of Global Health, School of Public HealthBoston UniversityBostonMassachusettsUSA
| | | | | | | | - Cassidy W. Claassen
- Center for International Health, Education, and BiosecurityUniversity of Maryland School of MedicineBaltimoreMarylandUSA,Division of Infectious Diseases, Department of MedicineUniversity of Zambia School of MedicineLusakaZambia
| | - Shaukat Khan
- Clinton Health Access InitiativeBostonMarylandUSA
| | | | - Colin A. Russell
- Department of Global Health, School of Public HealthBoston UniversityBostonMassachusettsUSA,Department of Medical MicrobiologyAmsterdam University Medical CentreAmsterdamthe Netherlands
| | - Naoko Doi
- Clinton Health Access InitiativeBostonMarylandUSA
| | - Kathryn Dovel
- Right to CareJohannesburgSouth Africa,Division of Infectious Diseases, Department of MedicineUniversity of California Los Angeles David Geffen School of MedicineLos AngelesCaliforniaUSA
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Mugwanya KK, Matemo D, Scoville CW, Beima-Sofie KM, Meisner A, Onyango D, Mugambi M, Feutz E, Grabow C, Barnabas R, Weiner B, Baeten JM, Kinuthia J. Integrating PrEP delivery in public health family planning clinics: a protocol for a pragmatic stepped wedge cluster randomized trial in Kenya. Implement Sci Commun 2021; 2:135. [PMID: 34895357 PMCID: PMC8665600 DOI: 10.1186/s43058-021-00228-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 10/15/2021] [Indexed: 12/14/2022] Open
Abstract
Background Adolescent girls and young women account for a disproportionate fraction of new HIV infections in Africa and are a priority population for HIV prevention, including provision of pre-exposure prophylaxis (PrEP). Anchoring PrEP delivery to care settings like family planning (FP) services that women already access routinely may offer an efficient platform to reach HIV at-risk women. However, context-specific implementation science evaluation is needed. Methods The Family Planning Plus Project is a prospective, pragmatic implementation evaluation, designed as a stepped wedge, cluster randomized trial, at 12 clinics in Kenya. In collaboration with the Kenya Ministry of Health and Kisumu County Department of Health, we will introduce integration of HIV risk screening and PrEP delivery in public health FP clinics. The core multifaceted implementation strategies to integrate PrEP in FP clinics will include: (1) PrEP delivery by existing FP clinic staff, (2) health provider training, (3) PrEP technical assistance to coach and mentor providers, (4) joint supervision with Kisumu County health officials, and (5) stakeholder engagement. All core components of PrEP delivery—including screening for HIV risk, HIV testing, dispensing, adherence and risk reduction counseling, assessment of side effects, and provision of refills, or safety assessment—will be conducted by existing FP clinic staff as part of a standard care service package. The goal is to catalyze sustainable scale-up within existing infrastructures beyond the project. We will rigorously evaluate implementation outcomes and impact, using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework, and we will use Organizational Readiness for Implementing Change (ORIC) and the Consolidated Framework for Implementation Science Research (CFIR) to assess readiness to implement and contextual enablers and barriers of implementation, including how clinics innovate efficient delivery systems. Discussion Anchoring PrEP delivery to existing FP systems and staffing has tremendous potential to address barriers that women face in accessing HIV prevention and PrEP care, including lack of time, cost, and stigma of visiting a facility solely for HIV prevention. The FP Plus Project will initiate preparation for full-scale and sustainable model of integration of comprehensive HIV prevention services, including PrEP implementation, in public health FP clinics in low-income settings. Trial registration Registered with ClinicalTrials.gov on December 14, 2020: NCT04666792
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Affiliation(s)
- Kenneth K Mugwanya
- Departments of Global Health and Epidemiology, University of Washington, 325 Ninth Avenue, #HMC 359927, Seattle, WA, 98104, USA.
| | - Daniel Matemo
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | | | | | - Allison Meisner
- Department of Global Health, University of Washington, Seattle, USA.,Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, USA
| | | | - Mary Mugambi
- National AIDS and STI Control Program Ministry of Health, Nairobi, Kenya
| | - Erika Feutz
- Department of Global Health, University of Washington, Seattle, USA
| | - Cole Grabow
- Department of Global Health, University of Washington, Seattle, USA
| | - Ruanne Barnabas
- Departments of Global Health and Medicine, University of Washington, Seattle, USA
| | - Bryan Weiner
- Department of Global Health, University of Washington, Seattle, USA
| | - Jared M Baeten
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, USA.,Present affiliation: Gilead Sciences, Foster City, USA
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Vasantharoopan A, Maheswaran H, Simms V, Dziva Chikwari C, Chigwenah T, Chikodzore R, Nyathi K, Ncube G, Ferrand RA, Guinness L. A costing analysis of B-GAP: index-linked HIV testing for children and adolescents in Zimbabwe. BMC Health Serv Res 2021; 21:1082. [PMID: 34641871 PMCID: PMC8507161 DOI: 10.1186/s12913-021-07070-3] [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: 01/24/2021] [Accepted: 09/22/2021] [Indexed: 11/23/2022] Open
Abstract
Background By testing children and adolescents of HIV positive caretakers, index-linked HIV testing, a targeted HIV testing strategy, has the ability to identify high risk children and adolescents earlier and more efficiently, compared to blanket testing. We evaluated the incremental cost of integrating index-linked HIV testing via three modalities into HIV services in Zimbabwe. Methods A mixture of bottom-up and top-down costing was employed to estimate the provider cost per test and per HIV diagnosis for 2–18 year olds, through standard of care testing, and the incremental cost of index-linked HIV testing via three modalities: facility-based testing, home-based testing by a healthcare worker, and testing at home by the caregiver using an oral mucosal transudate test. In addition to interviews, direct observation and study process data, facility registries were abstracted to extract outcome data and resource use. Costs were converted to 2019 constant US$. Results The average cost per standard of care test in urban facilities was US$5.91 and US$7.15 at the rural facility. Incremental cost of an index-linked HIV test was driven by the uptake and number of participants tested. The lowest cost approach in the urban setting was home-based testing (US$6.69) and facility-based testing at the rural clinic (US$5.36). Testing by caregivers was almost always the most expensive option (rural US$62.49, urban US$17.49). Conclusions This is the first costing analysis of index-linked HIV testing strategies. Unit costs varied across sites and with uptake. When scaling up, alternative testing solutions that increase efficiency such as index-linked HIV testing of the entire household, as opposed to solely targeting children/adolescents, need to be explored. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07070-3.
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Affiliation(s)
- Arthi Vasantharoopan
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.
| | | | - Victoria Simms
- MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK.,Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Chido Dziva Chikwari
- Biomedical Research and Training Institute, Harare, Zimbabwe.,Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Tariro Chigwenah
- Health Economics Unit, University of Cape Town, Cape Town, South Africa
| | - Rudo Chikodzore
- Matebeleland South, Ministry of Health and Child Care, Bulawayo, Zimbabwe
| | - Khulamuzi Nyathi
- City Health Department, Bulawayo City Council, Bulawayo, Zimbabwe
| | | | - Rashida A Ferrand
- Biomedical Research and Training Institute, Harare, Zimbabwe.,Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Lorna Guinness
- London School of Hygiene and Tropical Medicine, London, UK
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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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Long LC, Rosen S, Nichols B, Larson BA, Ndlovu N, Meyer‐Rath G. Getting resources to those who need them: the evidence we need to budget for underserved populations in sub-Saharan Africa. J Int AIDS Soc 2021; 24 Suppl 3:e25707. [PMID: 34189873 PMCID: PMC8242975 DOI: 10.1002/jia2.25707] [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: 10/14/2020] [Revised: 03/17/2021] [Accepted: 03/23/2021] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION In recent years, many countries have adopted evidence-based budgeting (EBB) to encourage the best use of limited and decreasing HIV resources. The lack of data and evidence for hard to reach, marginalized and vulnerable populations could cause EBB to further disadvantage those who are already underserved and who carry a disproportionate HIV burden (USDB). We outline the critical data required to use EBB to support USDB people in the context of the generalized epidemics of sub-Saharan Africa (SSA). DISCUSSION To be considered in an EBB cycle, an intervention needs at a minimum to have an estimate of a) the average cost, typically per recipient of the intervention; b) the effectiveness of the intervention and c) the size of the intervention target population. The methods commonly used for general populations are not sufficient for generating valid estimates for USDB populations. USDB populations may require additional resources to learn about, access, and/or successfully participate in an intervention, increasing the cost per recipient. USDB populations may experience different health outcomes and/or other benefits than in general populations, influencing the effectiveness of the interventions. Finally, USDB population size estimation is critical for accurate programming but is difficult to obtain with almost no national estimates for countries in SSA. We explain these limitations and make recommendations for addressing them. CONCLUSIONS EBB is a strong tool to achieve efficient allocation of resources, but in SSA the evidence necessary for USDB populations may be lacking. Rather than excluding USDB populations from the budgeting process, more should be invested in understanding the needs of these populations.
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Affiliation(s)
- Lawrence C Long
- Department of Global HealthSchool of Public HealthBoston UniversityBostonMAUSA
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of WitwatersrandJohannesburgSouth Africa
- Health Economics and Epidemiology Research OfficeWits Health ConsortiumJohannesburgSouth Africa
| | - Sydney Rosen
- Department of Global HealthSchool of Public HealthBoston UniversityBostonMAUSA
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of WitwatersrandJohannesburgSouth Africa
- Health Economics and Epidemiology Research OfficeWits Health ConsortiumJohannesburgSouth Africa
| | - Brooke Nichols
- Department of Global HealthSchool of Public HealthBoston UniversityBostonMAUSA
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of WitwatersrandJohannesburgSouth Africa
- Health Economics and Epidemiology Research OfficeWits Health ConsortiumJohannesburgSouth Africa
| | - Bruce A Larson
- Department of Global HealthSchool of Public HealthBoston UniversityBostonMAUSA
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of WitwatersrandJohannesburgSouth Africa
- Health Economics and Epidemiology Research OfficeWits Health ConsortiumJohannesburgSouth Africa
| | - Nhlanhla Ndlovu
- Centre for Economic Governance and Accountability in Africa (CEGAA)PietermaritzburgSouth Africa
| | - Gesine Meyer‐Rath
- Department of Global HealthSchool of Public HealthBoston UniversityBostonMAUSA
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of WitwatersrandJohannesburgSouth Africa
- Health Economics and Epidemiology Research OfficeWits Health ConsortiumJohannesburgSouth Africa
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9
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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, 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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Pines HA, Semple SJ, Magis‐Rodríguez C, Harvey‐Vera A, Strathdee SA, Patrick R, Rangel G, Patterson TL. A comparison of the effectiveness of respondent-driven and venue-based sampling for identifying undiagnosed HIV infection among cisgender men who have sex with men and transgender women in Tijuana, Mexico. J Int AIDS Soc 2021; 24:e25688. [PMID: 33759361 PMCID: PMC7987819 DOI: 10.1002/jia2.25688] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 01/21/2021] [Accepted: 02/17/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Efforts to increase HIV testing, diagnosis and care are critical to curbing HIV epidemics among cisgender men who have sex with men (MSM) and transgender women (TW) in low- and middle-income countries (LMIC). We compared the effectiveness of respondent-driven sampling (RDS) and venue-based sampling (VBS) for identifying previously undiagnosed HIV infection among MSM and TW in Tijuana, Mexico. METHODS Between March 2015 and December 2018, we conducted RDS within the social networks of MSM and TW and VBS at venues frequented by MSM and TW to socialize and meet sexual partners. Those reached by RDS/VBS who reported at least 18 years of age, anal sex with MSM or TW, and no previous HIV diagnosis were eligible for HIV testing. RESULTS Of those screened following recruitment via RDS (N = 1232; 98.6% MSM; 1.3% TW), 60.8% (749/1232) were eligible for HIV testing and 97.5% (730/749) were tested for HIV infection, which led to the identification of 36 newly diagnosed HIV infections (4.9%). Of those screened following recruitment via VBS (N = 2560; 95.2% MSM; 4.6% TW), 56.5% (1446/2560) were eligible for HIV testing and 92.8% (1342/1446) were tested for HIV infection, which led to the identification of 82 newly diagnosed HIV infections (6.1%). The proportion of new HIV diagnoses did not differ by recruitment method (ratio = 0.81, 95% confidence interval: 0.55 to 1.18). Compared to those recruited via RDS, those tested following recruitment via VBS were younger, more likely to identify as gay, and more likely to identify as TW. Compared to those recruited via VBS, those newly diagnosed with HIV infection following recruitment via RDS reported higher levels of internalized stigma and were more likely to report injection drug use and a history of deportation from the United States. CONCLUSIONS Despite RDS and VBS being equally effective for identifying undiagnosed HIV infection, each recruitment method reached different subgroups of MSM and TW in Tijuana. Our findings suggest that there may be benefits to using both RDS and VBS to increase the identification of previously undiagnosed HIV infection and ultimately support HIV care engagement among MSM and TW in Mexico and other similar LMIC.
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Affiliation(s)
- Heather A Pines
- Department of MedicineUniversity of CaliforniaSan DiegoCAUSA
- Department of Family Medicine and Public HealthUniversity of CaliforniaSan DiegoCAUSA
| | | | | | - Alicia Harvey‐Vera
- Department of MedicineUniversity of CaliforniaSan DiegoCAUSA
- Universidad XochicalcoTijuanaMexico
| | | | - Rudy Patrick
- Department of MedicineUniversity of CaliforniaSan DiegoCAUSA
| | - Gudelia Rangel
- United States‐Mexico Border Health CommissionTijuanaMexico
- El Colegio de la Frontera NorteTijuanaMexico
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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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Nichols BE, Offorjebe OA, Cele R, Shaba F, Balakasi K, Chivwara M, Hoffman RM, Long LC, Rosen S, Dovel K. Economic evaluation of facility-based HIV self-testing among adult outpatients in Malawi. J Int AIDS Soc 2020; 23:e25612. [PMID: 32909387 PMCID: PMC7507468 DOI: 10.1002/jia2.25612] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 07/24/2020] [Accepted: 08/02/2020] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION HIV self-testing (HIVST) in outpatient departments (OPD) is a promising strategy for HIV testing in Malawi, given high OPD patient volumes and substantial wait times. To evaluate the relative cost and expected impact of facility-based HIVST (FB-HIVST) at OPDs in Malawi for increasing HIV status awareness, we conducted an economic evaluation of an HIVST cluster-randomized controlled trial. METHODS A cluster-randomized trial was conducted at 15 sites in Malawi from September 2017 to February 2018 with three arms: 1) Standard provider-initiated-testing-and-counselling (PITC); 2) Optimized PITC (additional provider training and job-aids) and 3) FB-HIVST (HIVST demonstration, distribution and kit use in OPD, private kit interpretation and optional HIV counselling). The total production cost per newly identified positive and per person newly initiated on ART were calculated by study arm. These were calculated as the total cost of testing everyone divided by the number of newly identified positives; and the total cost of testing everyone divided by the number of those initiated on ART. Cost-outcomes were calculated under three cost scenarios: (1) full study costs, (2) routine implementation costs and (3) routine implementation + reduced cost for HIVST kits. RESULTS The average cost per person newly diagnosed in the full study cost scenario was $101, $156 and $189, and cost per person initiated on ART was $121, $156 and $279 for Standard PITC, Optimized PITC and FB-HIVST respectively. In the routine implementation cost scenario, the average cost per person newly diagnosed was reduced to $83, and $93, and cost per person initiated on ART to $83, and $137 for Optimized PITC and FB-HIVST respectively. In the negotiated HIVST cost scenario, the average cost per person newly diagnosed was reduced to $55 and cost per person newly initiated on ART reduced to $81 in the FB-HIVST arm. CONCLUSIONS While the cost per new ART initiation through FB-HIVST was higher than Standard PITC, FB-HIVST could become cost-saving compared to PITC if the cost of kits is reduced or if treatment linkage rate were increased in the FB-HIVST arm. For high volume OPDs, HIVST may increase facility capacity and increase the number of newly diagnosed positives.
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Affiliation(s)
- Brooke E Nichols
- Department of Global HealthSchool of Public HealthBoston UniversityBostonMAUSA
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - O Agatha Offorjebe
- David Geffen School of MedicineUniversity of California Los AngelesLos AngelesCAUSA
- Charles R. Drew University of Medicine and ScienceLos AngelesCAUSA
| | - Refiloe Cele
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | | | | | | | - Risa M Hoffman
- Partners in HopeLilongweMalawi
- Division of Infectious DiseasesDepartment of MedicineUniversity of California Los AngelesLos AngelesCAUSA
| | - Lawrence C Long
- Department of Global HealthSchool of Public HealthBoston UniversityBostonMAUSA
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Sydney Rosen
- Department of Global HealthSchool of Public HealthBoston UniversityBostonMAUSA
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Kathryn Dovel
- Partners in HopeLilongweMalawi
- Division of Infectious DiseasesDepartment of MedicineUniversity of California Los AngelesLos AngelesCAUSA
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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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Johnson C, Neuman M, MacPherson P, Choko A, Quinn C, Wong VJ, Hatzold K, Nyrienda R, Ncube G, Baggaley R, Terris-Prestholt F, Corbett EL. Use and awareness of and willingness to self-test for HIV: an analysis of cross-sectional population-based surveys in Malawi and Zimbabwe. BMC Public Health 2020; 20:779. [PMID: 32450840 PMCID: PMC7249304 DOI: 10.1186/s12889-020-08855-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 05/05/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Many southern African countries are nearing the global goal of diagnosing 90% of people with HIV by 2020. In 2016, 84 and 86% of people with HIV knew their status in Malawi and Zimbabwe, respectively. However, gaps remain, particularly among men. We investigated awareness and use of, and willingness to self-test for HIV and explored sociodemographic associations before large-scale implementation. METHODS We pooled responses from two of the first cross-sectional Demographic and Health Surveys to include HIV self-testing (HIVST) questions in Malawi and Zimbabwe in 2015-16. We investigated sociodemographic factors and sexual risk behaviours associated with previously testing for HIV, and past use, awareness of, and future willingness to self-test using univariable and multivariable logistic regression, adjusting for the sample design and limiting analysis to participants with a completed questionnaire and valid HIV test result. We restricted analysis of willingness to self-test to Zimbabwean men, as women and Malawians were not systematically asked this question. RESULTS Of 31,385 individuals, 31.2% of men had never tested compared with 16.5% of women (p < 0.001). For men, the likelihood of having ever tested increased with age. Past use and awareness of HIVST was very low, 1.2 and 12.6%, respectively. Awareness was lower among women than men (9.1% vs 15.3%, adjusted odds ratio [aOR] = 1.55; 95% confidence interval [CI]: 1.37-1.75), and at younger ages, and lower education and literacy levels. Willingness to self-test among Zimbabwean men was high (84.5%), with greater willingness associated with having previously tested for HIV, being at high sexual risk (highest willingness [aOR = 3.74; 95%CI: 1.39-10.03, p < 0.009]), and being ≥25 years old. Wealthier men had greater awareness of HIVST than poorer men (p < 0.001). The highest willingness to self-test (aOR = 3.74; 95%CI: 1.39-10.03, p < 0.009) was among men at high HIV-related sexual risk. CONCLUSIONS In 2015-16, many Malawian and Zimbabwean men had never tested for HIV. Despite low awareness and minimal HIVST experience, willingness to self-test was high among Zimbabwean men, especially older men with moderate-to-high HIV-related sexual risk. These data provide a valuable baseline against which to investigate population-level uptake of HIVST as programmes scale up. Programmes introducing, or planning to introduce, HIVST should consider including relevant questions in population-based surveys.
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Affiliation(s)
- Cheryl Johnson
- Global HIV, Hepatitis and STI programme, World Health Organization, Geneva, Switzerland
- Department of Clinical Research and Infection Disease, London School of Hygiene and Tropical Medicine, London, UK
| | - Melissa Neuman
- Department of Infectious Disease Epidemiology and MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Peter MacPherson
- Malawi-Liverpool Wellcome Trust, HIV/TB Group, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Augustine Choko
- Department of Clinical Research and Infection Disease, London School of Hygiene and Tropical Medicine, London, UK
- Malawi-Liverpool Wellcome Trust, HIV/TB Group, Blantyre, Malawi
| | - Caitlin Quinn
- Global HIV, Hepatitis and STI programme, World Health Organization, Geneva, Switzerland
| | - Vincent J. Wong
- U.S. Agency for International Development, Washington, DC USA
| | - Karin Hatzold
- Population Services International, Johannesburg, South Africa
| | | | | | - Rachel Baggaley
- Global HIV, Hepatitis and STI programme, World Health Organization, Geneva, Switzerland
| | - Fern Terris-Prestholt
- Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Elizabeth L. Corbett
- Department of Clinical Research and Infection Disease, London School of Hygiene and Tropical Medicine, London, UK
- Malawi-Liverpool Wellcome Trust, HIV/TB Group, Blantyre, Malawi
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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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