The cost effectiveness and optimal configuration of HIV self-test distribution in South Africa: a model analysis

Tobacco smoking, smoking cessation and life expectancy among people with HIV on antiretroviral therapy in South Africa: a simulation modelling study

INTRODUCTION

As access to effective antiretroviral therapy (ART) has improved globally, tobacco-related illnesses, including cardiovascular disease, cancer and chronic respiratory conditions, account for a growing proportion of deaths among people with HIV (PWH). We estimated the impact of tobacco smoking and smoking cessation on life expectancy among PWH in South Africa.

METHODS

In a microsimulation model, we simulated 18 cohorts of PWH with virologic suppression, each homogenous by sex, initial age (35y/45y/55y) and smoking status (current/former/never). Input parameters were from data sources published between 2008 and 2022. We used South African data to estimate age-stratified mortality hazard ratios: 1.2-2.3 (females)/1.1-1.9 (males) for people with current versus never smoking status; and 1.0-1.3 (females)/1.0-1.5 (males) for people with former versus never smoking status, depending on age at cessation. We assumed smoking status remains unchanged during the simulation; people who formerly smoked quit at model start. Simulated PWH face a monthly probability of disengagement from care and virologic non-suppression. In sensitivity analysis, we varied smoking-associated and HIV-associated mortality risks. Additionally, we estimated the total life-years gained if a proportion of all virologically suppressed PWH stopped smoking.

RESULTS

Forty-five-year-old females/males with HIV with virologic suppression who smoke lose 5.3/3.7 life-years compared to PWH who never smoke. Smoking cessation at age 45y adds 3.4/2.4 life-years. Simulated PWH who continue smoking lose more life-years from smoking than from HIV (females, 5.3 vs. 3.0 life-years; males, 3.7 vs. 2.6 life-years). The impact of smoking and smoking cessation increase as smoking-associated mortality risks increase and HIV-associated mortality risks, including disengagement from care, decrease. Model results are most sensitive to the smoking-associated mortality hazard ratio; varying this parameter results in 1.0-5.1 life-years gained from cessation at age 45y. If 10-25% of virologically suppressed PWH aged 30-59y in South Africa stopped smoking now, 190,000-460,000 life-years would be gained.

CONCLUSIONS

Among virologically suppressed PWH in South Africa, tobacco smoking decreases life expectancy more than HIV. Integrating tobacco cessation interventions into HIV care, as endorsed by the World Health Organization, could substantially improve life expectancy.

Cost of SARS-CoV-2 self-test distribution programmes by different modalities: a micro-costing study in five countries (Brazil, Georgia, Malaysia, Ethiopia and the Philippines)

OBJECTIVE

Diagnostic testing is an important tool to combat the COVID-19 pandemic, yet access to and uptake of testing vary widely 3 years into the pandemic. The WHO recommends the use of COVID-19 self-testing as an option to help expand testing access. We aimed to calculate the cost of providing COVID-19 self-testing across countries and distribution modalities.

DESIGN

We estimated economic costs from the provider perspective to calculate the total cost and the cost per self-test kit distributed for three scenarios that differed by costing period (pilot, annual), the number of tests distributed (actual, planned, scaled assuming an epidemic peak) and self-test kit costs (pilot purchase price, 50% reduction).

SETTING

We used data collected between August and December 2022 in Brazil, Georgia, Malaysia, Ethiopia and the Philippines from pilot implementation studies designed to provide COVID-19 self-tests in a variety of settings-namely, workplace and healthcare facilities.

RESULTS

Across all five countries, 173 000 kits were distributed during pilot implementation with the cost/test distributed ranging from $2.44 to $12.78. The cost/self-test kit distributed was lowest in the scenario that assumed implementation over a longer period (year), with higher test demand (peak) and a test kit price reduction of 50% ($1.04-3.07). Across all countries and scenarios, test procurement occupied the greatest proportion of costs: 58-87% for countries with off-site self-testing (outside the workplace, for example, home) and 15-50% for countries with on-site self-testing (at the workplace). Staffing was the next key cost driver, particularly for distribution modalities that had on-site self-testing (29-35%) versus off-site self-testing (7-27%).

CONCLUSIONS

Our results indicate that it is likely to cost between $2.44 and $12.78 per test to distribute COVID-19 self-tests across common settings in five heterogeneous countries. Cost-effectiveness analyses using these results will allow policymakers to make informed decisions on optimally scaling up COVID-19 self-test distribution programmes across diverse settings and evolving needs.

Future HIV epidemic trajectories in South Africa and projected long-term consequences of reductions in general population HIV testing: a mathematical modelling study

BACKGROUND

After successful intensive interventions to rapidly increase HIV awareness, coverage of antiretroviral therapy (ART), and viral suppression, HIV programmes in eastern and southern Africa are considering scaling back of some interventions, such as widespread general population HIV testing. We aimed to model whether scaling back of general population HIV testing in South Africa could result in a resurgence of the HIV epidemic or substantial slowing of declines in HIV incidence, resulting in increased long-term ART.

METHODS

In this modelling study, we used the Thembisa 4.5 model (a deterministic compartmental model of HIV transmission in South Africa) to project the South African HIV epidemic to 2100 assuming the continuation of 2022 epidemiological conditions and HIV programme implementation. We assessed how implementing reductions in general population HIV testing services in 2025 (while maintaining antenatal, symptom-based, and risk-based testing modalities and other HIV prevention services at 2022 levels) would affect HIV incidence and prevalence among people aged 15-49 years, the year in which incidence would reach one per 1000 people aged 15-49 years (the threshold for virtual elimination of HIV), and associated costs, as well as numbers of additional new HIV infections and AIDS-related deaths. We also modelled the effects of delaying reductions in general population testing services by 5-year increments. Additionally, we modelled the potential effects of reductions in general population testing services in combination with increases or decreases in ART interruption rates (ie, the annual rate at which people who are on ART discontinue ART) and condom usage in 2025-35.

FINDINGS

If general population HIV testing services and the HIV risk environment of 2022 were maintained, we projected that HIV incidence would steadily decline from 4·95 (95% CI 4·40-5·34) per 1000 population in 2025 to 0·14 (0·05-0·31) per 1000 in 2100, and that the so-called virtual elimination threshold of less than one new infection per 1000 population per year would be reached in 2055 (95% CI 2051-2060). Scaling back of general population HIV testing services by 25%, 50%, or 75% in 2025 delayed time to reaching the virtual elimination threshold by 5, 13, or 35 years, respectively, whereas complete cessation of general population testing would result in the threshold not being attained by 2100. Although the incidence of HIV continued to fall when general HIV testing services were reduced, our modelling suggested that, with reductions of between 25% and 100%, between 396 000 (95% CI 299 000-474 000) and 2·50 million (1·97 million-2·98 million) additional HIV infections and between 115 000 (94 000-135 000) and 795 000 (670 000-926 000) additional AIDS-related deaths would occur between 2025 and 2075, depending on the extent of reduction in testing. Delaying reductions in general population HIV testing services for 5-25 years mitigated some of these effects. HIV testing accounted for only 5% of total programmatic costs at baseline; reducing testing moderately reduced short-term total annual costs, but increased annual costs after 25 years. Increases in ART interruption and reductions in condom usage were projected to slow the decline in incidence and increase the coverage of general HIV testing services required to control transmission but did not cause rapid resurgence in HIV infections.

INTERPRETATION

Our modelling suggests that scaling back of general population HIV testing would not result in a resurgence of HIV infections, but would delay attainment of incidence-reduction targets and result in long-term increases in HIV infections, AIDS-related deaths, and costs (via increased need for ART provision). HIV programmes need to balance short-term potential resource savings with long-term epidemic control objectives.

FUNDING

Bill & Melinda Gates Foundation.

Determinants and acceptability of HIV self-testing among vulnerable groups in sub-Saharan Africa: A scoping review protocol

INTRODUCTION

HIV self-testing (HIVST) is where individuals collect their specimens and perform the HIV test privately. HIVST has improved testing uptake and coverage, especially among vulnerable groups of sub-Saharan Africa (SSA). Vulnerable groups include key populations such as men who have sex with men, sex workers, people who inject drugs, lesbian, gay, bisexual and transgender persons and young women. However, little is known about the determinants and acceptability of HIVST among these groups in SSA. Therefore, this scoping review aims to explore the determinants and acceptability of HIVST among vulnerable groups in SSA.

METHODS

A scoping review will be conducted using the Arksey and O'Malley framework and further refined by Levac framework. The review will follow a six-step approach: (1) identifying the research question, (2) identifying relevant studies, (3) study selection eligibility, (4) charting the data, (5) collating, summarising and reporting the results and (6) consultation. A comprehensive search strategy will be developed, and the following electronic databases will be searched: MEDLINE, Embase, Global Health and the Cochrane Library. Grey literature will also be searched, including conference abstracts and reports. Eligibility criteria will include studies conducted in SSA, published between 2010 and 2023, focusing on vulnerable groups and exploring the determinants and acceptability of HIVST. Two independent reviewers will screen identified studies' titles, abstracts and full texts. Any disagreements will be resolved through discussion or consultation with a third reviewer. Data extraction will be conducted using a standardised form.

ETHICS AND DISSEMINATION

This review, not requiring ethical approval, aims to inform policy and intervention design to boost HIV testing adoption within vulnerable communities. We plan to disseminate our findings via a peer-reviewed journal, policy briefs, conference presentations and stakeholder engagement.

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

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.

How much does HIV self-testing cost in low and middle income countries? A systematic review of evidence from economic studies

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.

Perceptions of and Preparedness for the Application of Pharmacoeconomics in Practice, among Final Year Bachelor of Pharmacy Students in South Africa: A National Cross-Sectional Study

For the improvement of access to health, many countries including South Africa, have adopted universal healthcare. However, this requires skills to apply health technology assessments for the facilitation of investment decisions. This study aimed to ascertain final year Bachelor of Pharmacy (BPharm) students' perceptions of the relevance of pharmacoeconomics in pharmacy practice, and their level of preparedness to apply pharmacoeconomic principles, using a quantitative, cross-sectional, and descriptive design. Data were collected using a self-administered questionnaire over 12 months, and included student demographics, knowledge about pharmacoeconomics and its applicability in practice, as well as students' satisfaction with the appropriateness of the curriculum content. Five of nine universities offering pharmacy education took part. The overallstudent response rate was 38.1% (189/496), with 26.2% (45/172) of students signifying a good understanding of basic pharmacoeconomic concepts. Pharmacoeconomics application in South Africa was perceived to be relevant by 87.5% (140/160); however, 47.0% (79/168) felt they were not prepared to apply pharmacoeconomic principles in medicine management, and 86.7% (137/158) wanted to acquire additional pharmacoeconomic knowledge. Whilst students' perceptions of the relevance of pharmacoeconomics were positive, results indicated a gap in knowledge, understanding, and application. Addressing this gap may increase students' preparedness to apply pharmacoeconomic principles and better equip them for the practical application of pharmacoeconomics post qualification. Consequently, we have started this process.