Pragmatic economic evaluation of community-led delivery of HIV self-testing in Malawi

Abstract

Introduction: Community-based strategies can extend coverage of HIV testing and diagnose HIV at earlier stages of infection but can be costly to implement. We evaluated the costs and effects of community-led delivery of HIV self-testing (HIVST) in Mangochi District, Malawi.

Methods: This economic evaluation was based within a pragmatic cluster-randomised trial of 30 group village heads and their catchment areas comparing the community-led HIVST intervention in addition to the standard of care (SOC) versus the SOC alone. The intervention involved mobilising community health groups to lead 7-day HIVST campaigns including distribution of HIVST kits. The SOC included facility-based HIV testing services. Primary costings estimated economic costs of the intervention and SOC from the provider perspective, with costs annualised and measured in 2018 US$. A postintervention survey captured individual-level data on HIV testing events, which were combined with unit costs from primary costings, and outcomes. The incremental cost per person tested HIV-positive and associated uncertainty were estimated.

Results: Overall, the community-led HIVST intervention costed $138 624 or $5.70 per HIVST kit distributed, with test kits and personnel the main contributing costs. The SOC costed $263 400 or $4.57 per person tested. Individual-level provider costs were higher in the community-led HIVST arm than the SOC arm (adjusted mean difference $3.77, 95% CI $2.44 to $5.10; p<0.001), while the intervention effect on HIV positivity varied based on adjustment for previous diagnosis. The incremental cost per person tested HIV positive was $324 but increased to $1312 and $985 when adjusting for previously diagnosed self-testers or self-testers on treatment, respectively. Community-led HIVST demonstrated low probability of being cost-effective against plausible willingness-to-pay values, with HIV positivity a key determinant.

Conclusion: Community-led HIVST can provide HIV testing at a low additional unit cost. However, adding community-led HIVST to the SOC was not likely to be cost-effective, especially in contexts with low prevalence of undiagnosed HIV.

Trial registration number: NCT03541382.

Keywords: HIV; cluster randomized trial; health economics; other diagnostic or tool.

Figure 1

Cost-effectiveness plane for community-led HIV self-testing. Cost-effectiveness plane of adding community-led HIVST to the standard of care. The incremental cost per person tested HIV positive for alternative outcome definitions are illustrated. Each point represents the adjusted mean difference in cost (incremental cost) and adjusted risk difference in the proportion tested HIV positive (incremental effect) for one bootstrap replicate. The dark blue circle indicates the incremental cost per person tested positive and the dark blue line indicates the bootstrap confidence intervals using the bias-corrected percentile method. LL, lower limit; UL upper limit.

Figure 2

Cost-effectiveness acceptability curves for community-led HIVST by scenario. Cost-effectiveness acceptability curves of adding community-led HIVST to the standard of care. Cost-effectiveness probabilities for the incremental cost per person tested HIV positive are plotted for alternative outcome definitions across a range of willingness-to-pay values. HIVST, HIV self-testing.

Figure 3

Tornado diagram of one-way deterministic sensitivity and scenario analysis. Tornado diagram illustrating changes in the mean cost per HIVST kit distributed and incremental cost per person tested HIV positive based on variations to inputs. Light blue bars represent changes at minimum input values, while dark blue bars represent changes at maximum input values. LL, lower limit; UL upper limit.