Facility-based HIV self-testing strategies may substantially increase number of men and youth tested for HIV in Malawi: results from a data-driven individual-based model

Abstract

BackgroundMalawi is rapidly closing the gap in achieving the UNAIDS 95-95-95 targets, with 90% of people living with HIV in Malawi aware of their status. As we approach epidemic control, interventions to improve coverage will become more costly. There is therefore an urgent need to identify innovative and low-cost strategies to maintain and increase testing coverage without diverting resources from other HIV services.MethodsA data-driven individual-based model was parameterized with data from a community-representative survey (sociodemographic, health service utilization, HIV testing history) of men and youth in Malawi (data collected 08/2019). 79 different strategies for the implementation of HIV self-testing (HIVST) and provider-initiated-testing-and-counselling at the outpatient department (OPD) were evaluated. Outcomes included percent of men/youth tested for HIV in a 12-month period, cost-effectiveness, and human resource requirements. Testing yield was assumed to be constant across the scenarios.FindingsFacility-based HIVST offered year-round resulted in the greatest increase in proportion of men and youth tested in the OPD (from 45% to 72%-83%), was considered cost-saving for HIVST kit priced at $1.00, and generally reduced required personnel as compared to the status quo. At higher HIVST kit prices, and more relaxed eligibility criteria, all scenarios that considered year-round HIVST in the OPD remained on the cost-effectiveness frontier.InterpretationFacility-based HIVST is a cost-effective strategy to increase the proportion of men/youth tested for HIV and decreases the human resource requirements for HIV testing in the OPD-providing additional health care worker time for other priority health care activities.FundingFCDO; USAID

Manuscript Title: Facility-based HIV self-testing as an additional testing option in health facilities: A systematic review and meta-analysis

“…The searches yielded 2,203 citations, of which, 11 studies were deemed eligible, including 4 randomized controlled trials [4,[13][14][15], 2 prospective single-arm cohort studies [16,17], 2 qualitative studies employing individually-based in-depth interviews (IDI) [18,19], 2 costing studies [20,21] and 1 costeffective analysis [22] (Figure 1). Malawi, including a costing study [20], a modelled cost-effectiveness study [22], and a qualitative study [18], targeting adolescent & adult outpatients in high burden health facilities. The remaining RCTs [13][14][15] were individual RCTs, targeting truck drivers and female sex workers at roadside wellness clinics in Kenya.…”

“…The searches yielded 2,203 citations, of which, 11 studies were deemed eligible, including 4 randomized controlled trials [4,13–15], 2 prospective single-arm cohort studies [16,17], 2 qualitative studies employing individually-based in-depth interviews (IDI) [18,19], 2 costing studies [20,21] and 1 cost-effective analysis [22] (Figure 1).…”

“…Among the 4 RCTs, Dovel 2020 [4], a cluster RCT, served as a parent trial for subsequent studies in Malawi, including a costing study [20], a modelled cost-effectiveness study [22], and a qualitative study [18], targeting adolescent & adult outpatients in high burden health facilities. The remaining RCTs [13– 15] were individual RCTs, targeting truck drivers and female sex workers at roadside wellness clinics in Kenya.…”

“…Three studies reported on resource use [20][21][22] and were all in sub-Saharan Africa (see summary in Appendix 3, Supplementary materials). In one multi-country study [21], the average cost per HIVST kit distributed in facilities was less than or equal to home-based HIVST.…”

“…However, when results were adapted and modelled to public health clinics, the average unit costs for FB-HIVST was more comparable to standard testing. Despite somewhat higher costs than standard facility-based HTS, when using this same data a modelling study found that when assuming a threshold analysis of $200 USD (2017) per new diagnosis, FB-HIVST would be cost-effective and potentially cost-saving if lower cost HIVST kits ($1.80-1.00) were used or if FB-HIVST was limited to individuals who had not tested in the past year [22].…”