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Original research
The cost effectiveness and optimal configuration of HIV self-test distribution in South Africa: a model analysis
  1. Lise Jamieson1,
  2. Leigh F Johnson2,
  3. Katleho Matsimela1,
  4. Linda Alinafe Sande3,
  5. Marc d'Elbée3,
  6. Mohammed Majam4,
  7. Cheryl Johnson5,
  8. Thato Chidarikire6,
  9. Karin Hatzold7,
  10. Fern Terris-Prestholt8,9,
  11. Brooke Nichols10,11,
  12. Gesine Meyer-Rath10,12
  1. 1Department of Internal Medicine, Health Economics and Epidemiology Research Office, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, Gauteng, South Africa
  2. 2Centre of Infectious Disease Epidemiology and Research (CIDER), University of Cape Town, Rondebosch, Western Cape, South Africa
  3. 3Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
  4. 4Ezintsha, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
  5. 5Global HIV, Hepatitis, STI programmes, World Health Organization, Geneve, Switzerland
  6. 6HIV Prevention Programmes, National Department of Health, Pretoria, South Africa, Pretoria, South Africa
  7. 7Population Services International, Johannesburg, South Africa
  8. 8Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
  9. 9Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneve, Switzerland
  10. 10Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts, USA
  11. 11Department of Medical Microbiology, Amsterdam University Medical Centres, Duivendrecht, Noord-Holland, The Netherlands
  12. 12Department of Internal Medicine, Health Economics and Epidemiology Research Office, University of the Witwatersrand School of Clinical Medicine, Johannesburg, Gauteng, South Africa
  1. Correspondence to Dr Lise Jamieson; ljamieson{at}heroza.org

Abstract

Background HIV self-testing (HIVST) has been shown to be acceptable, feasible and effective in increasing HIV testing uptake. Novel testing strategies are critical to achieving the UNAIDS target of 95% HIV-positive diagnosis by 2025 in South Africa and globally.

Methods We modelled the impact of six HIVST kit distribution modalities (community fixed-point, taxi ranks, workplace, partners of primary healthcare (PHC) antiretroviral therapy (ART) patients), partners of pregnant women, primary PHC distribution) in South Africa over 20 years (2020–2039), using data collected alongside the Self-Testing AfRica Initiative. We modelled two annual distribution scenarios: (A) 1 million HIVST kits (current) or (B) up to 6.7 million kits. Incremental economic costs (2019 US$) were estimated from the provider perspective; assumptions on uptake and screening positivity were based on surveys of a subset of kit recipients and modelled using the Thembisa model. Cost-effectiveness of each distribution modality compared with the status-quo distribution configuration was estimated as cost per life year saved (estimated from life years lost due to AIDS) and optimised using a fractional factorial design.

Results The largest impact resulted from secondary HIVST distribution to partners of ART patients at PHC (life years saved (LYS): 119 000 (scenario A); 393 000 (scenario B)). However, it was one of the least cost-effective modalities (A: $1394/LYS; B: $4162/LYS). Workplace distribution was cost-saving ($52–$76 million) and predicted to have a moderate epidemic impact (A: 40 000 LYS; B: 156 000 LYS). An optimised scale-up to 6.7 million tests would result in an almost threefold increase in LYS compared with a scale-up of status-quo distribution (216 000 vs 75 000 LYS).

Conclusion Optimisation-informed distribution has the potential to vastly improve the impact of HIVST. Using this approach, HIVST can play a key role in improving the long-term health impact of investment in HIVST.

  • health economics
  • HIV

Data availability statement

Data are available on request. Data will be made available on request.

https://creativecommons.org/licenses/by-nc/3.0/igo/

This is an open access article distributed under the terms of the Creative Commons Attribution IGO License (CC BY NC 3.0 IGO), which permits use, distribution,and reproduction in any medium, provided the original work is properly cited. In any reproduction of this article there should not be any suggestion that WHO or this article endorse any specific organization or products. The use of the WHO logo is not permitted. This notice should be preserved along with the article’s original URL.Disclaimer: The author is a staff member of the World Health Organization. The author alone is responsible for the views expressed in this publication and they do not necessarily represent the views, decisions or policies of the World Health Organization.

https://doi.org/10.1136/bmjgh-2021-005598

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    Data availability statement

    Data are available on request. Data will be made available on request.

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    Footnotes

    • Handling editor Edwine Barasa

    • Twitter @ccasejohn, @brookenichols

    • Contributors LJ and GM-R conceptualised the study. LFJ developed the epidemiological model. LJ did the analysis and drafted the manuscript. LJ, GM-R and LFJ contributed to the interpretation of the results. All authors contributed to the interpretation of the results, revision and approval of the manuscript.

    • Funding This analysis was funded through the grant “Enhancing the evidence-base of HIV self-testing for young men” (BMGF OPP1189095) to Ezintsha, a division of Wits RHI, and HE2RO.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.