The cost and intermediary cost-effectiveness of oral HIV self-test kit distribution across 11 distribution models in South Africa

Abstract

BackgroundCountries around the world seek innovative ways of closing their remaining gaps towards the target of 95% of people living with HIV (PLHIV) knowing their status by 2030. Offering kits allowing HIV self-testing (HIVST) in private might help close these gaps.MethodsWe analysed the cost, use and linkage to onward care of 11 HIVST kit distribution models alongside the Self-Testing AfRica Initiative’s distribution of 2.2 million HIVST kits in South Africa in 2018/2019. Outcomes were based on telephonic surveys of 4% of recipients; costs on a combination of micro-costing, time-and-motion and expenditure analysis. Costs were calculated from the provider perspective in 2019 US$, as incremental costs in integrated and full costs in standalone models.ResultsHIV positivity among kit recipients was 4%–23%, with most models achieving 5%–6%. Linkage to confirmatory testing and antiretroviral therapy (ART) initiation for those screening positive was 19%–78% and 2%–72% across models. Average costs per HIVST kit distributed varied between $4.87 (sex worker model) and $18.07 (mobile integration model), with differences largely driven by kit volumes. HIVST kit costs (at $2.88 per kit) and personnel costs were the largest cost items throughout. Average costs per outcome increased along the care cascade, with the sex worker network model being the most cost-effective model across metrics used (cost per kit distributed/recipient screening positive/confirmed positive/initiating ART). Cost per person confirmed positive for HIVST was higher than standard HIV testing.ConclusionHIV self-test distribution models in South Africa varied widely along four characteristics: distribution volume, HIV positivity, linkage to care and cost. Volume was highest in models that targeted public spaces with high footfall (flexible community, fixed point and transport hub distribution), followed by workplace models. Transport hub, workplace and sex worker models distributed kits in the least costly way. Distribution via index cases at facility as well as sex worker network distribution identified the highest number of PLHIV at lowest cost.

Effects of a multimedia campaign on HIV self-testing and PrEP outcomes among young people in South Africa: a mixed-methods impact evaluation of ‘MTV Shuga Down South’

“…Viewers were typically sceptical about the opportunity to access HIVST and PrEP in their area of Eastern Cape, despite recent investments in HIV self-test and PrEP distribution. 22 The survey showed that DS2 viewers were more likely than non-viewers to have paid a fee for their last HIV self-test kit, suggesting that the ability to pay or access a pharmacy may help to explain the observed differences in use of self-testing, even if MTV Shuga boosted motivation for HIV testing. To ensure equitable access to prevention tools and services, media campaigns that generate demand should be directly linked to distribution efforts that are available and acceptable to young people.…”

“…An important limitation to a multimedia campaign like MTV Shuga is its lack of influence on supply of services, either actual or perceived supply, including the HIV prevention technologies it promoted through DS2. Viewers were typically sceptical about the opportunity to access HIVST and PrEP in their area of Eastern Cape, despite recent investments in HIV self-test and PrEP distribution 22. The survey showed that DS2 viewers were more likely than non-viewers to have paid a fee for their last HIV self-test kit, suggesting that the ability to pay or access a pharmacy may help to explain the observed differences in use of self-testing, even if MTV Shuga boosted motivation for HIV testing.…”

“…The survey was open to 15–24 year old males and females and promoted through virtual marketing on Facebook, Instagram and social media platforms of schools, universities, community groups and clinics in Mthatha, Eastern Cape. This setting was targeted due to: recent distribution of HIV self-testing kits and availability of oral PrEP (ensuring a supply to meet any demand generated by the DS2 campaign) 22 ; availability of the offline components of the DS2 campaign, described above; less HIV prevention research and lower HIV testing levels in Eastern Cape relative to other provinces; and the recommendation of the South African Department of Health. We sought to enrol a minimum sample of 2250 young people (with equal numbers by sex and age-group), in order to identify a minimum 10% difference in the primary outcome between those exposed and not exposed to MTV Shuga DS2.…”

The Impact and Spillover Effects of HIV Self-Test Technology on HIV Outcomes of the South African Working Class

“…Two types of workplaces were included: (a) larger companies that did not have formalized HIV testing programs or had a significantly low HIV testing uptake. These companies were contacted before the distribution event for sensitization; (b) smaller workplaces, such as petrol stations or construction sites, without prior arrangement with management [14].…”

Cost of SARS-CoV-2 self-test distribution programmes by different modalities: a micro-costing study in five countries (Brazil, Georgia, Malaysia, Ethiopia and the Philippines)

“…Most of the empirical evidence on the cost of self-testing programmes originates from the human immunodeficiency virus (HIV) self-testing literature,6 9 10 and more recently from hepatitis C virus (HCV) self-testing 11. Studies have demonstrated the relative cost of different methods for rollout of HIV self-testing and found, broadly, that there are multiple ways of successfully distributing HIV self-testing, depending on the budget and desired outcome.…”