Using HIV Self-testing to Increase the Affordability of Community-based HIV Testing Services

Marc d'Elbée; Molemo Charles Makhetha; Makhahliso Jubilee; Matee Taole; Cyril Nkomo; Albert Machinda; Mphotleng Tlhomola; Linda A. Sande; Gabriela B. Gomez Guillen; Elizabeth L. Corbett; Cheryl C. Johnson; Karin Hatzold; Gesine Meyer-Rath; Fern Terris-Prestholt


AIDS. 2020;34(14):2115-2123. 

In This Article

Materials and Methods

Setting and Intervention

In Lesotho, the community-based HTS programme was expanded in five districts over 2 years starting in May 2017.[4] The programme was offering community-based HTS. HIVST was added as an alternative option to conventional HTS in December 2017. Finally, from September 2018, individual HIVST booths were introduced at mobile outreach sites and clients were encouraged to self-test on-site (Figure 1). These are defined as period 1, 2 and 3, respectively.

Figure 1.

Timelines of the community-based HIV testing services, major changes in strategy and analysis periods.

Two community-based HTS interventions were assessed: mobile outreach with tents providing HTS, and index testing where counsellors travel to the index case household and offer testing door-to-door to all those in the area, so avoiding stigmatisation. At the mobile outreach site, the client was offered the option to receive HTS or to self-test on-site at the HTS tent (with or without the HTS provider supervision) with immediate confirmatory testing available, or to take the kit away for use off-site. All HIV-positive clients were offered a home visit by a counsellor for index testing. If the client refused a home visit, HIVST kits were offered to their sexual partner(s). If the client accepted a home visit, the contact details of the sexual partners (index cases) were recorded. The index cases were contacted by the provider by telephone and offered HIV testing either at the nearby health facility, or during a home visit by the providers. During home visits, index cases who refused conventional testing by the providers could opt for HIVST. A more detailed presentation of the community-based HTS is published elsewhere.[4] Client flows for the mobile outreach and index testing models are presented in Appendix Figures S1 & S2, When individual HIVST booths were introduced, the revised strategy allowed multiple clients to self-test at the same time and encouraged clients with a reactive self-test to get immediate confirmatory testing and referral for linkage to care.

Because the same team and resources are used to provide these two HTS interventions (single provider potentially conducting these two activities in the same day), we analyse costs of this intervention as one and use the term 'community-based HTS' to cover the two testing approaches.

The analysis is divided in three time periods corresponding to major changes in the HTS strategy presented in Figure 1.

Study Design and Data Collection

We conducted a micro-costing study alongside programme implementation over 2 years (May 2017–April 2019) from a provider's perspective (PSI). We collected data on costs and programmatic outcomes prospectively following guidelines.[14,20,21]

We conducted two types of cost analysis for HTS and HIVST. A full cost analysis wherein we estimated the financial and economic (e.g. donated goods and services) costs of all resources used in running the HTS and HIVST programmes independently from each other, including PSI Lesotho headquarter costs.[14] Because HIVST is added onto the existing HTS as an alternative option within community-based HTS, we also estimated incremental costs where shared costs (such as operational costs) are fully allocated to the full package of community-based HTS, thus accounting only for the new inputs that were required by the new intervention.[21] The composition of cost categories in the full versus incremental cost analysis for each activity is presented in Appendix Table S1,

Firstly, we analysed PSI financial reports, referred as top-down costing, collating all financial expenditures from financial reports and categorizing each line item by cost category allocating them to distribution model.[22] On the basis of these reports, the average purchasing cost per HIVST kit, including freight costs, was US$2.71. Costs were allocated to community-based activities following predefined allocation factors. A more detailed description of this costing method is described elsewhere.[23] We estimated quarterly cost averages to allow for comparison between periods. Secondly, a time and motion study (TMS) was conducted to observe staff providing both HTS/index testing and HIVST services and allocate personnel costs based on the time spent on each activity.[24,25] The TMS differentiates between supervised and unsupervised (provider is absent at least while the client waits for the self-test results) HIVST episodes on-site. This study also estimates provider's indirect time, which corresponds to the personnel time spent not seeing any clients, travel time and administrative work. In the case of the incremental HIVST costing analysis, providers' indirect time is allocated fully to conventional HTS, while in the full HIVST cost analysis, indirect time is shared between HTS and HIVST, following time allocations from the TMS. Methods and results for the TMS are presented in Appendix text document S1 and Table S3, Thirdly, we used a bottom-up costing approach through site observations and interviews with senior staff to include the economic costs not captured in financial reports. All local goods costs were adjusted for inflation over time using the gross domestic product deflators in the local currency, then all costs were converted to 2019 United States dollars (US$) using the Central Bank of Lesotho exchange rate for each year.[14] Start-up, training and other capital costs were annualized over the assumed years of useful life of each item using a 3% discount rate, which was varied in sensitivity analysis.[14] Research costs were excluded. We calculated the average costs per person tested with HTS, per HIVST kit distributed and per HIV-positive identified as the conventional HTS and HIVST costs, respectively, by dividing the relevant total costs by the relevant outcomes for each period.

Output data were collected from paper-based monitoring and evaluation (M&E) forms filled by HTS providers, compiled in an excel database, cleaned using consistency checks and analysed by PSI M&E officers. Confirmed yield rate was defined as the proportion of new HIV-positive cases out of all clients tested with HTS, including confirmatory testing following a reactive self-test.

Sensitivity and Scenario Analysis

We conducted a series of univariate sensitivity analyses to assess the impact of key cost assumptions on the average incremental costs per HIVST kit distributed and costs per HIV-positive case identified for the latest costs data (period 3). For the costs per HIVST kit distributed and per HIV-positive case identified, the sensitivity analysis assessed the impact of the discount rate used to annualize capital costs to capture the influence of not discounting or using a higher local central bank discount rate (base: 3%; 0%; 15%), the years of useful life of start-up costs (base: 2 years; 1 year; 3 years). For the costs per HIVST kit distributed only, the durations of sessions for providing HTS and HIVST services estimated from the TMS (±20%); TMS results were not affecting costs per HIV-positive case identified because all personnel members were involved in HIV testing only and the TMS only affects the allocation between the types of testing. For the costs per HIV-positive case only, we also assessed the years of useful life of vehicles (base: 15 years; 10; 20), absent for the incremental cost per HIVST kit distributed.

We also added a scenario analysis to inform the scale-up of the programme to the other districts. In the scenario analysis, we assessed headquarter and field-based personnel costs (±10%) reflecting variation of headquarter costs and the shift of HIVST distribution by lay providers rather than professional counsellors; the volume of HIVST kits distributed (±10%), which could vary according to the personnel capacity to provide unsupervised on-site HIVST or to the effect of HIVST stock-outs; the market price of HIVST kits to reflect a hypothetical price approximately equal to the current cost of a rapid kit (US$1).[26] For HIVST costs only, we also varied the proportion of unsupervised HIVST session on-site, allowing for more clients to self-test with the same number of staff available. For costs per HIV-positive case detected only, we varied the number of HIV-positive test to reflect the variation of yield (±10%). Variations in individual parameter values informed our best/worst case scenario in which all the parameters were combined to yield the lowest/highest average costs.

Ethical approval was obtained from the National Health Research Ethics Committee of Lesotho and the London School of Hygiene and Tropical Medicine Ethics Committee (protocol numbers: ID64-2018 and 14887, respectively).