Costs and Scale-Up Costs of Integrating HIV Self-Testing Into Civil Society Organisation-Led Programmes for Key Populations in Côte d'Ivoire, Senegal, and Mali

Abstract

Despite significant progress on the proportion of individuals who know their HIV status in 2020, Côte d'Ivoire (76%), Senegal (78%), and Mali (48%) remain far below, and key populations (KP) including female sex workers (FSW), men who have sex with men (MSM), and people who use drugs (PWUD) are the most vulnerable groups with a HIV prevalence at 5–30%. HIV self-testing (HIVST), a process where a person collects his/her own specimen, performs a test, and interprets the result, was introduced in 2019 as a new testing modality through the ATLAS project coordinated by the international partner organisation Solthis (IPO). We estimate the costs of implementing HIVST through 23 civil society organisations (CSO)-led models for KP in Côte d'Ivoire (N = 7), Senegal (N = 11), and Mali (N = 5). We modelled costs for programme transition (2021) and early scale-up (2022–2023). Between July 2019 and September 2020, a total of 51,028, 14,472, and 34,353 HIVST kits were distributed in Côte d'Ivoire, Senegal, and Mali, respectively. Across countries, 64–80% of HIVST kits were distributed to FSW, 20–31% to MSM, and 5–8% to PWUD. Average costs per HIVST kit distributed were $15 for FSW (Côte d'Ivoire: $13, Senegal: $17, Mali: $16), $23 for MSM (Côte d'Ivoire: $15, Senegal: $27, Mali: $28), and $80 for PWUD (Côte d'Ivoire: $16, Senegal: $144), driven by personnel costs (47–78% of total costs), and HIVST kits costs (2–20%). Average costs at scale-up were $11 for FSW (Côte d'Ivoire: $9, Senegal: $13, Mali: $10), $16 for MSM (Côte d'Ivoire: $9, Senegal: $23, Mali: $17), and $32 for PWUD (Côte d'Ivoire: $14, Senegal: $50). Cost reductions were mainly explained by the spreading of IPO costs over higher HIVST distribution volumes and progressive IPO withdrawal at scale-up. In all countries, CSO-led HIVST kit provision to KP showed relatively high costs during the study period related to the progressive integration of the programme to CSO activities and contextual challenges (COVID-19 pandemic, country safety concerns). In transition to scale-up and integration of the HIVST programme into CSO activities, this model shows large potential for substantial economies of scale. Further research will assess the overall cost-effectiveness of this model.

Costs and Scale-Up Costs of Community-Based HIV Self-Testing for Female Sex Workers and Men Who have Sex with Men in Jakarta and Bali, Indonesia

“…To our knowledge, this is the rst published study estimating cost of HIV self-testing in Indonesia or others similar settings in South East Asia, thus we cannot make study comparation to other location in Indonesia or South East Asia. The costs per HIVST kits distributed to client for screening in our study across all area and KPs are higher compare to other similar studies in African countries [15][16][17][18][19] . This nding may due to several factors.…”

Economic Analysis of Low Volume Interventions Using Real-World Data: Costs of HIV Self-Testing Distribution and HIV Testing Services in West Africa From the ATLAS Project

“…HIVST small-scale health facility distribution channels are part of a national HIVST implementation program with large scale distribution channels for outreach HIVST generating high central costs (16,26), so central costs are likely negligible for these low-scale distribution channels, when run alongside largerscale models. In addition, central costs are also particularly high with the ATLAS integrated approach that entailed a lengthy implementation process with partners (16,17), so even if our cost allocation method of central costs was based on volumes, these central costs would still remain high-as shown by our sensitivity analysis.…”

“…A site is defined either as a primary health care facility for general population and/or key populations, a sexual health clinic, or a community health centre recognized by government authorities. Overall, HIVST kits were distributed by 208 agents (Côte d'Ivoire (16,21). We conducted two economic cost analyses from the provider's perspective: HIVST and HTS.…”

“…Secondary distribution strategies is preferred with the ATLAS project, allowing to reach hidden key populations, such as clients of FSW, partners of MSM, or index partners of pregnant women who are not routinely tested (12)(13)(14)(15). Large scale programs being expanded nationally often benefit from economy of scale, even when incurring high initial fixed costs during the pilot phases as observed with ATLAS mobile strategies presented elsewhere (16,17). On the other hand, low-volume interventions such as ATLAS health facilities strategies often pose challenges to estimating average costs (=total program costs/number of HIVST kits distributed) for informing analyses of cost-effectiveness and national program budgets.…”

Routine programmatic data show a positive population-level impact of HIV self-testing: the case of Côte d’Ivoire and implications for implementation

“…This specificity of HIVST kit distribution implies that HIVST beneficiaries (end-users) are not limited to primary contacts. ATLAS's program results have shown that HIVST can reduce stigma; preserve anonymity and confidentiality; reach KPs that do not access testing via other testing approaches; save opportunity costs for users and providers; empower users with autonomy and responsibility; and is noninvasive and easy to use [19][20][21][22].…”