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


We found that the addition of HIVST increases the overall programme's affordability for HIV-positive case finding. The increase of HIV-positive case finding, and yield is driven by an increase in index testing activities, thanks to the efficient introduction of self-testing and booths in period 3, allowing more staff to conduct index testing instead of being mobilized at the mobile outreach. TMS data were also used to value potential impact on costs of efficiency gains in services provision, particularly regarding high personnel costs. As suggested by the scenario analysis, an increase of unsupervised on-site HIVST could have a significant impact on HIVST average costs, allowing more staff to focus on index testing or other activities.

Recent best practice guidelines on cost-effectiveness analysis recommend the use of quality-adjusted life years gained (QALYs) and disability-adjusted life year averted (DALYs) for valuing health outcomes.[27] Previous work suggests that cost-per-diagnosis is strongly correlated with cost per disability-adjusted life year averted when evaluating HTS and that it can be used as a metric to assess an intervention's cost-effectiveness.[28] Our micro-costing study, within its scope and timeframe, does not capture all individual and population-based costs and benefit of the intervention; therefore, these results should not be interpreted for cost-effectiveness analysis.

Our HIVST full economic average costs estimates are higher than recently published estimates by Mangenah et al..[23] The authors published a full economic average cost per HIVST kit distributed at US$8.15, US$16.42 and US$13.84 in Malawi, Zambia and Zimbabwe, respectively. The HIVST model was door-to-door only, where community-based agents were offering HIVST kits directly to households without immediate confirmatory testing and the costs reported per HIVST kit distributed. HIVST full costs are higher in Lesotho because HIVST volumes distributed were lower potentially leading to diseconomies of scale, and HIVST kits were distributed in the communities by either professional or lay counsellors resulting in higher field personnel costs. Because the test results were not reported, results from Mangenah et al.[23] are not comparable with average cost per positive case identified. In addition, our costs are higher than those reported in a recent studies on costs of HIV testing in sub-Saharan Africa including Lesotho (N. Ahmed, F. Terris-Prestholt, J.J. Ong, in preparation).[29–31] This difference may be explained by several factors. We included above service level costs, and our intervention is managed by an international NGO with high quality of services and M&E reporting relative to public sector. Furthermore, HIV-positive case finding in communities require additional staff time and equipment such as vehicles.[4] Finally, the number of positive cases identified was relatively low in a context where 81% of PLHIV already know their status with a yield of 3%.[1]

The differences in personnel cost allocation between full (personnel costs associated with travel and administrative activities is shared between HTS and HIVST based on the volume of activities[21]) and incremental (personnel costs of time spent on indirect client activities is allocated to the existing intervention HIVST is being added to) costing approaches have a significant impact on costs. This is particularly relevant for community-based interventions in remote areas where provider's indirect time is significant.[32,33] Budgeting of HIVST using incremental costs risks to underestimate needs if HTS is not running well. Incremental HIVST costing, only considering financial costs, assumes that the existing intervention has the capacity (particularly human resources) to absorb the new intervention. They may be applicable in a case of low HIVST distribution wherein the staff has the capacity to absorb the added testing modality and the effect on the services it is being added to is minor. This was not the case in Lesotho but is shown to highlight how incremental costs can potentially vary between interventions.

Programme costs and cost per HIV-positive identified tend to increase over time (N. Ahmed, F. Terris-Prestholt, J.J. Ong, in preparation). The increase in total costs over time is mainly explained by an increase of the team size in the field. Integration of HIVST improved the HTS efficiency as defined by increased rates of HIV-positive case finding, which is a great achievement in the current HIV testing landscape, where increasing HIV testing coverage makes it increasing harder to identify new HIV positive cases.

Cost and cost-effectiveness studies for HIVST need to account for capacity to improvement over time in order to avoid overestimating costs (period 2--3). New programmes should encourage implementation research and use early results to inform programme strategy. For instance, we applied this strategy with the ATLAS project on HIV self-testing in West Africa to identify opportunities for task shifting from medical doctors to less scarce healthcare workers.[34]

As well as guiding sustainable national scale-up for Lesotho, these data have relevance to other countries considering the addition of self-testing to community-based HTS.[35] First, HIVST can be added to improve community-based programme efficiency and allow a reallocation of scarce human resources to other key activities in the HIV response. Second, community-based interventions can incur important indirect personnel costs such as travel time to sites, other costing analyses should be transparent and report their inclusion/exclusion. Third, full and incremental costing approaches can provide a range to estimate health system needs for scale-up. The risks of using costs not fit for purpose or setting can lead to under-budgeting and depleting health system through cross-subsidization from core health services, or rejecting potentially cost-effective intervention seen as too expensive.

Our study has limitations. First, because HIVST was introduced in all sites of the intervention at the same time, there were no control sites against which to evaluate the effect of HIVST introduction. Second, only new positive cases detected are reported, the volume of known seropositive clients retesting was not reported and cannot be estimated. Third, stock-outs happened in period 3, limiting the number of kits distributed and potentially impacting on our costs, this might overestimate our average costs per HIVST kit distributed and per positive case identified.

To our knowledge, this is the first cost analysis using longitudinal data from a real-world intervention on HTS efficiency gains before and after introduction of HIVST. We showed that adding HIVST to community-based HTS can improve its overall affordability regarding HIV-positive case finding. We also highlighted the importance of transparency in reporting methods for priority setting, budgeting and financial planning.