Facility‐based HIV self‐testing strategies may substantially and cost‐effectively increase the number of men and youth tested for HIV in Malawi: results from an individual‐based mathematical model

Abstract

Introduction Malawi 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. The objective of this study is to model different combinations of facility‐based HIV testing modalities and determine the most cost‐effective strategy to increase the proportion of men and youth testing for HIV. Methods A data‐driven individual‐based model was parameterized with data from a community‐representative survey (socio‐demographic, health service utilization and HIV testing history) of men and youth in Malawi (data collected August 2019). In total, 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. The testing yield was assumed to be constant across the scenarios. Results Facility‐based HIVST offered year‐round resulted in the greatest increase in the 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. Conclusions Facility‐based HIVST is a cost‐effective strategy to increase the proportion of men/youth tested for HIV in Malawi and decreases the human resource requirements for HIV testing in the OPD—providing additional healthcare worker time for other priority healthcare activities.

Risk Screening Tools Could Potentially Miss HIV-Positive Individuals Who Seek Testing Services: A Secondary Program Data Analysis on the Performance Characteristics of an Adolescent and Adult HIV Risk Screening Tool in Uganda

“…Scaling up HIVST would require the formulation or adoption of HIVST policies and a considerable financial investment to roll out these policies, including commodity management. Recent research in Malawi has shown the potential of HIVST to expand testing coverage, while reducing human resource time and limiting the risk of screening PLHIV out, given the much higher sensitivity of antibody screening platforms compared to risk-based screening tools [ 17 ].…”

Risk screening tools could potentially miss out HIV positive individuals who seek testing services: A secondary program data analysis on the performance characteristics of an adolescent and adult HIV risk screening tool in Uganda

“…Scaling up HIVST would require formulation or adoption of HIVST policies and a considerable financial investment to roll out these policies, plus commodity management. Recent research in Malawi has shown the potential of HIVST to expand testing coverage, while reducing HR time and limiting the risk of screening PLHIV out, given the much higher sensitivity of antibody screening platforms compared to risk-based screening tools (12).…”

Risk Screening Tools Could Potentially Miss Out HIV Positive Individuals Who Seek Testing Services: A Secondary Program Data Analysis on the Performance Characteristics of an Adolescent and Adult HIV Risk Screening Tool in Uganda

“…Scaling up HIVST would require formulation or adoption of HIVST policies and a considerable financial investment to roll out these policies, plus commodity management. Recent research in Malawi has shown the potential of HIVST to expand testing coverage, while reducing human resource time and limiting the risk of screening PLHIV out, given the much higher sensitivity of antibody screening platforms compared to riskbased screening tools (17).…”