The impact and cost-effectiveness of community-based HIV self-testing in sub-Saharan Africa: a health economic and modelling analysis

Abstract

Introduction: The prevalence of undiagnosed HIV is declining in Africa, and various HIV testing approaches are finding lower positivity rates. In this context, the epidemiological impact and cost-effectiveness of community-based HIV self-testing (CB-HIVST) is unclear. We aimed to assess this in different sub-populations and across scenarios characterized by different adult HIV prevalence and antiretroviral treatment programmes in sub-Saharan Africa.

Methods: The synthesis model was used to address this aim. Three sub-populations were considered for CB-HIVST: (i) women having transactional sex (WTS); (ii) young people (15 to 24 years); and (iii) adult men (25 to 49 years). We assumed uptake of CB-HIVST similar to that reported in epidemiological studies (base case), or assumed people use CB-HIVST only if exposed to risk (condomless sex) since last HIV test. We also considered a five-year time-limited CB-HIVST programme. Cost-effectiveness was defined by an incremental cost-effectiveness ratio (ICER; cost-per-disability-adjusted life-year (DALY) averted) below US$500 over a time horizon of 50 years. The efficiency of targeted CB-HIVST was evaluated using the number of additional tests per infection or death averted.

Results: In the base case, targeting adult men with CB-HIVST offered the greatest impact, averting 1500 HIV infections and 520 deaths per year in the context of a simulated country with nine million adults, and impact could be enhanced by linkage to voluntary medical male circumcision (VMMC). However, the approach was only cost-effective if the programme was limited to five years or the undiagnosed prevalence was above 3%. CB-HIVST to WTS was the most cost-effective. The main drivers of cost-effectiveness were the cost of CB-HIVST and the prevalence of undiagnosed HIV. All other CB-HIVST scenarios had an ICER above US$500 per DALY averted.

Conclusions: CB-HIVST showed an important epidemiological impact. To maximize population health within a fixed budget, CB-HIVST needs to be targeted on the basis of the prevalence of undiagnosed HIV, sub-population and the overall costs of delivering this testing modality. Linkage to VMMC enhances its cost-effectiveness.

Keywords: HIV; HIV testing, community-based HIV self-testing; benefits and cost; cost-effectiveness; mathematical modelling.

Figure 1

Cost per DALY averted of community‐based HIVST by implementation option, prevalence of undiagnosed HIV (quartile) and cost of testing in the sub‐population indicated – 2018 to 2068. Cost‐saving; ICER $0‐$249 per DALY; ICER $250‐$499 per DALY; ICER $500‐$999 per DALY; ICER $1,000‐$2,499 per DALY; ICER ≥$2,500 per DALY; ^†DALYs averted not reported when showing the ICERs using the cost of CB‐HIVST of $5.61 and HTS of $4.82, as the same regardless of the costs assumed; ^‡10% of men with negative HIVST and aged 25‐50 link to circumcision; CB‐HIVST: community‐based HIVST; DALY: disability‐adjusted life years; HIVST: HIV self‐test; HTS: HIV testing services; ICER: incremental cost‐effectiveness ratio; VMMC: voluntary medical male circumcision; WTS: women having transactional sex;