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

Disclosures

AIDS. 2020;34(14):2115-2123. 

In This Article

Results

Outcomes of the Community-based HIV Testing Services and HIV Self-testing Activities

In period 1, HTS activities are gradually increasing and reach a peak of 11 000 tests conducted monthly (Figure 2a). In period 2, mainly on-site HIVST is provided by HTS counsellors who, consequently, reduce their HTS activities both at the mobile outreach and index testing. In period 3, we observe an increase of the number of HIVST kits used on-site, and kits provided for off-site use, with the addition of individual booths. The number of HIV-positive case finding is increasing and is driven by index testing activities (Figure 2b). Yield is constant in periods 1 and 2 (at 3%), until the introduction of HIVST booth in period 3 where it gradually increases to an average of 5%.

Figure 2.

Outcomes of the community-based HIV testing services and HIV self-testing provision between May 2017 and April 2019: Volume of HTS and HIVST (a), number of new HIV-positive case identified and yield (b).

Results From the Time and Motion Study and Implication for the Estimation of Full Versus Incremental HIV Self-testing Costs

There are two central findings from using the TMS to allocate shared costs (Appendix Table S3, http://links.lww.com/QAD/B821). First, indirect time accounts for a significant proportion of the daily working hours of a provider. The way this time is allocated in the calculation of personnel costs has a significant impact on total costs in both the full and incremental costs analysis. Second, the difference between average observed time spent on-site by counsellors to provide unsupervised and supervised HIVST services is important [mean (standard deviation): 10.4 (3.2) versus 24.1 (5.2) minutes, respectively – t(53) = -8.6, P < 0.01].

Costs Analysis

For both HTS and HIVST, the main drivers of costs are personnel costs at headquarters and in the field, followed by testing supplies and vehicle operation and maintenance (Figure 3). The average HTS cost per test conducted is US$32.2 in period 1. In period 2 and 3, when an incremental costing method is applied to HIVST, HTS average costs are US$35.0 and US$34.3, and HIVST average costs are US$15.4 and US$14.0. In the case of a full costing approach, wherein joint costs are shared, HTS average costs are US$28.5 and US$23.5, and HIVST average costs are US$43.3 and US$37.7, in period 2 and 3, respectively. HIVST incremental financial costs, which includes only directly STAR project financial contributions for HIVST, were US$6.0 and US$5.6 in period 2 and 3, respectively. Total costs are increasing over time and are driven by increasing personnel costs (Figure 3). Cost per HIV-positive case identified increases between period 1 (US$956) and period 2 (US$1249), in the transition to distributing HIVST, but is the lowest in period 3 (US$813), when booths allowed onsite self-testing and immediate confirmatory testing (Table 1). Detailed total and average costs for all three periods for the full and incremental costs analysis are presented in Appendix Tables S4.a, S4.b and S4.c, http://links.lww.com/QAD/B821.

Figure 3.

HIV testing services and HIV self-testing costs drivers, average costs and volumes per analysis period (in 2019 US$).

Sensitivity and Scenario Analysis

Average costs per HIVST kit distributed and per HIV-positive case identified remained robust when key cost parameters were varied (Figure 4a,b). Start-up and capital costs account for a small proportion of the community-based HTS, therefore, our assumptions on the life years of start-up costs, vehicle life and discount rate applied have only a small impact on our results (ranges from US$14.0–US$14.1 and US$808.6–US$825.6 for cost per kit and cost per HIV-positive, respectively). The variation by 20% of the length of observed testing episodes used for personnel costs allocation has a slightly stronger effect on average cost per kit (range: US$12.3–US$15.7).

Figure 4.

Results from the sensitivity and scenario analysis on (a) the costs per HIVST kit distributed in period 3 and (b) on the costs per HIV-positive case identified in period 3 (in 2019 US$).

For both scenario analyses, we looked at factors potentially reducing average costs. The variation of headquarter-based personnel costs only has a minor effect (ranges from US$14.0 to US$14.1 and US$808.0–US$817.0) on cost per kit and cost per HIV-positive respectively. The reduction of the HIVST kit price and increase of distribution volumes reduced average cost per kit distributed (US$12.3 and US$12.8, respectively) but only had a minor effect on cost per HIV-positive (US$796.9 and US$810.0, respectively). As expected, a reduction of field-based personnel costs impacts on the average costs per HIV-positive (US$754.7), but the effect is less important on cost per kit (US$13.0). The yield strongly affects cost per positive (US$738.6). A 50% reduction of the level of supervision by PSI staff for on-site HIVST can also reduce costs per kit distributed (US$12.0) but is likely also to have effects on impact. Finally, the best-worst case scenarios show ranges of US$8.5–US$16.9 and US$668.6–US$969.3 for cost per kit and cost per HIV-positive, respectively.

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