Economic cost analysis of door‐to‐door community‐based distribution of HIV self‐test kits in Malawi, Zambia and Zimbabwe

Abstract

Introduction HIV self‐testing (HIVST) is recommended by the World Health Organization in addition to other testing modalities to increase uptake of HIV testing, particularly among harder‐to‐reach populations. This study provides the first empirical evidence of the costs of door‐to‐door community‐based HIVST distribution in Malawi, Zambia and Zimbabwe. Methods HIVST kits were distributed door‐to‐door in 71 sites across Malawi, Zambia and Zimbabwe from June 2016 to May 2017. Programme expenditures, supplemented by on‐site observation and monitoring and evaluation data were used to estimate total economic and unit costs of HIVST distribution, by input and site. Inputs were categorized into start‐up, capital and recurrent costs. Sensitivity and scenario analyses were performed to assess the impact of key parameters on unit costs. Results In total, 152,671, 103,589 and 93,459 HIVST kits were distributed in Malawi, Zambia and Zimbabwe over 12, 11 and 10 months respectively. Across these countries, 43% to 51% of HIVST kits were distributed to men. The average cost per HIVST kit distributed was US$8.15, US$16.42 and US$13.84 in Malawi, Zambia and Zimbabwe, respectively, with pronounced intersite variation within countries driven largely by site‐level fixed costs. Site‐level recurrent costs were 70% to 92% of full costs and 20% to 62% higher than routine HIV testing services (HTS) costs. Personnel costs contributed from 26% to 52% of total costs across countries reflecting differences in remuneration approaches and country GDP. Conclusions These early door‐to‐door community HIVST distribution programmes show large potential, both for reaching untested populations and for substantial economies of scale as HIVST programmes scale‐up and mature. From a societal perspective, the costs of HIVST appear similar to conventional HTS, with the higher providers’ costs substantially offsetting user costs. Future approaches to minimizing cost and/or maximize testing coverage could include unpaid door‐to‐door community‐led distribution to reach end‐users and integrating HIVST into routine clinical services via direct or secondary distribution strategies with lower fixed costs.

HIV self‐testing: breaking the barriers to uptake of testing among men and adolescents in sub‐Saharan Africa, experiences from STAR demonstration projects in Malawi, Zambia and Zimbabwe

“…Costs (range US$7.23 per kit distributed in Malawi, to US$14.58 in Zambia) and affordability of the CBD model are discussed in the accompanying manuscript by Mangenah et al . , and the potential to devolve HIVST further through community‐led approaches is currently under investigation within STAR. Community‐led models can deliver better outcomes at or below the cost of less integrated approaches and are widely used in Africa for mass drug administration and distribution of insecticide‐treated bed nets .…”

“…This type of community-based HIVST distribution could then contribute to activities such as national HIV testing campaigns, targeted "catch-up" campaigns in districts with low testing coverage, and as a way of providing ongoing or periodical HIV testing access in remote communities. Costs (range US$7.23 per kit distributed in Malawi, to US$14.58 in Zambia) and affordability of the CBD model are discussed in the accompanying manuscript by Mangenah et al [24], and the potential to devolve HIVST further through communityled approaches is currently under investigation within STAR. Community-led models can deliver better outcomes at or below the cost of less integrated approaches and are widely used in Africa for mass drug administration and distribution of insecticide-treated bed nets [30].…”

“…46.1% of CBDAs were men, with most (55.5%) being in the 30 to 49-year-old age-group. Costs per test distributed (US$7.23, US$14.58 and US$13.79 in Malawi, Zambia and Zimbabwe respectively) and evidence for likely economies of scale are detailed in an accompanying manuscript by Mangenah et al in this issue[24].…”

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

“…Community‐based distribution of HIVST kits can take place in different ways and this partly drives the differences in costs seen in Zimbabwe compared to Malawi. The costs of government implementation CB‐HIVST may be lower than estimated in the STAR project and we anticipate that delivery costs will continue to fall due to economies of scale and efficiencies from increasing familiarity with this concept. This would increase the likelihood of HIVST programmes being cost‐effective.…”

To thine own test be true: HIV self‐testing and the global reach for the undiagnosed

“…In this Supplement , Mangenah et al . performed a cost analysis of community HIVST kit distribution in Malawi, Zambia and Zimbabwe as well as a sensitivity and scenario analysis to project future costs . The average cost per kit distributed (i.e.…”