the cost effectiveness and optimal configuration of hiv self test distribution in CORD-Papers-2022-06-02 (Version 1)

Title: The cost effectiveness and optimal configuration of HIV self-test distribution in South Africa: a model analysis
Abstract: BACKGROUND: HIV self-testing (HIVST) has been shown to be acceptable feasible and effective in increasing HIV testing uptake. Novel testing strategies are critical to achieving the UNAIDS target of 95% HIV-positive diagnosis by 2025 in South Africa and globally. METHODS: We modelled the impact of six HIVST kit distribution modalities (community fixed-point taxi ranks workplace partners of primary healthcare (PHC) antiretroviral therapy (ART) patients) partners of pregnant women primary PHC distribution) in South Africa over 20 years (20202039) using data collected alongside the Self-Testing AfRica Initiative. We modelled two annual distribution scenarios: (A) 1 million HIVST kits (current) or (B) up to 6.7 million kits. Incremental economic costs (2019 US$) were estimated from the provider perspective; assumptions on uptake and screening positivity were based on surveys of a subset of kit recipients and modelled using the Thembisa model. Cost-effectiveness of each distribution modality compared with the status-quo distribution configuration was estimated as cost per life year saved (estimated from life years lost due to AIDS) and optimised using a fractional factorial design. RESULTS: The largest impact resulted from secondary HIVST distribution to partners of ART patients at PHC (life years saved (LYS): 119 000 (scenario A); 393 000 (scenario B)). However it was one of the least cost-effective modalities (A: $1394/LYS; B: $4162/LYS). Workplace distribution was cost-saving ($52$76 million) and predicted to have a moderate epidemic impact (A: 40 000 LYS; B: 156 000 LYS). An optimised scale-up to 6.7 million tests would result in an almost threefold increase in LYS compared with a scale-up of status-quo distribution (216 000 vs 75 000 LYS). CONCLUSION: Optimisation-informed distribution has the potential to vastly improve the impact of HIVST. Using this approach HIVST can play a key role in improving the long-term health impact of investment in HIVST.
Published: 2021-07-18
Journal: BMJ Glob Health
DOI: 10.1136/bmjgh-2021-005598
DOI_URL: http://doi.org/10.1136/bmjgh-2021-005598
Author Name: Jamieson Lise
Author link: https://covid19-data.nist.gov/pid/rest/local/author/jamieson_lise
Author Name: Johnson Leigh F
Author link: https://covid19-data.nist.gov/pid/rest/local/author/johnson_leigh_f
Author Name: Matsimela Katleho
Author link: https://covid19-data.nist.gov/pid/rest/local/author/matsimela_katleho
Author Name: Sande Linda Alinafe
Author link: https://covid19-data.nist.gov/pid/rest/local/author/sande_linda_alinafe
Author Name: d aposElbe Marc
Author link: https://covid19-data.nist.gov/pid/rest/local/author/d_aposelbe_marc
Author Name: Majam Mohammed
Author link: https://covid19-data.nist.gov/pid/rest/local/author/majam_mohammed
Author Name: Johnson Cheryl
Author link: https://covid19-data.nist.gov/pid/rest/local/author/johnson_cheryl
Author Name: Chidarikire Thato
Author link: https://covid19-data.nist.gov/pid/rest/local/author/chidarikire_thato
Author Name: Hatzold Karin
Author link: https://covid19-data.nist.gov/pid/rest/local/author/hatzold_karin
Author Name: Terris Prestholt Fern
Author link: https://covid19-data.nist.gov/pid/rest/local/author/terris_prestholt_fern
Author Name: Nichols Brooke
Author link: https://covid19-data.nist.gov/pid/rest/local/author/nichols_brooke
Author Name: Meyer Rath Gesine
Author link: https://covid19-data.nist.gov/pid/rest/local/author/meyer_rath_gesine
sha: 1e15d4aa8a77f818cfc0aa5b2aa2facce6a68ccf
license: no-cc
license_url: [no creative commons license associated]
source_x: Medline; PMC; WHO
source_x_url: https://www.medline.com/https://www.ncbi.nlm.nih.gov/pubmed/https://www.who.int/
pubmed_id: 34275876
pubmed_id_url: https://www.ncbi.nlm.nih.gov/pubmed/34275876
pmcid: PMC8287627
pmcid_url: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8287627
url: https://www.ncbi.nlm.nih.gov/pubmed/34275876/ https://doi.org/10.1136/bmjgh-2021-005598
has_full_text: TRUE
Keywords Extracted from Text Content: 3200/life recipients US$ Facility-based 2000/life patients HIVST recipients 2030/life appendix figure S4 antiretroviral 55%-64 4162/life oral fluid ICER appendix figures S3 [7] [8] [9] men appendix figure S3 people Thembisa Unitaidfunded Self-Testing AfRica self-diagnose B. COVID-19 US President's Emergency Plan women B appendix figure S1 lockdowns facility-based briefly-fixed-point ICER/LYS appendix figure S2 Malawi, Zambia PHC 13%-50 Patients appendix table S1 PLHIV HIVST eSwatini appendix figures S1 Zambia patient approaches/ appendix individuals Patient Alinafe Sande http://
Extracted Text Content in Record: First 5000 Characters:South Africa has the highest number of HIV infections worldwide, with an estimated 7.8 million people living with HIV (PLHIV) and 5.0 million on antiretroviral therapy (ART) in 2019. 1 Despite having the largest ART programme in the world, over 23% of all deaths in South Africa in 2019 were AIDSrelated. 2 HIV transmission and AIDS-related deaths can be greatly reduced by identifying PLHIV who are unaware of their HIV status early, linking all PLHIV to ART and retaining them in care. 3 The South African government is dedicated to meeting the UNAIDS 95-95-95 fast-track targets by 2025, 4 What is already known? ► HIV self-testing (HIVST) is an acceptable and feasible testing strategy that is also effective in increasing HIV testing uptake. ► Testing strategies which focus on high yield populations (eg, female sex workers) and high-volume distribution modalities (eg, taxi ranks and workplaces) have been found to be more cost-effective than some community-based or any facility-based testing strategies. What are the new findings? ► Secondary distribution to partners of antiretroviral therapy patients has the largest impact in terms of saving life years lost due to AIDS; however, it is one of the least cost-effective strategies. ► Taxi rank and workplace distribution is the most cost-effective, even cost-saving of strategies. ► An optimisation-informed distribution of scaling up HIVST can greatly improve the impact of HIVST and result in a more cost-effective strategy compared with a status quo distribution of scaling up HIVST. What do the new findings imply? ► Determining the optimal mix of HIVST kit distribution is crucial in ensuring the most effective and costeffective strategy for national roll-out of HIVST. 95% of PLHIV diagnosed, 95% of those diagnosed on ART and 95% of those on ART virally suppressed by 2025. In 2017, a HIV household survey showed that 85% of South African PLHIV aged 15-64 years had been diagnosed, although men had a lower rate of diagnosis compared with women (80% vs 89%, respectively). 5 Increasing the uptake of HIV testing services (HTS) by introducing novel testing strategies is critical to achieving the UNAIDS target to diagnose 95% of PLHIV in the coming years. In order to expand HIV testing coverage, the South African National Department of Health (NDoH) has implemented community-based testing to accompany existing conventional HTS, which is most frequently conducted at primary healthcare (PHC) clinics. Recently, HIV self-testing (HIVST) technology has been introduced to give people the opportunity to self-diagnose their HIV status. HIVST involves a person being able to privately collect their own specimen (most often oral fluid), performing the rapid diagnostic test and interpreting the result themselves, either assisted by HIVST distribution staff or unassisted. 6 Recent studies in sub-Saharan Africa, including South Africa, have shown that HIVST is acceptable, feasible and effective in increasing HIV testing uptake, [7] [8] [9] providing an alternative testing strategy that can overcome sociostructural barriers associated with conventional HTS in a clinic setting, including the stigma associated with accessing testing and limited hours of clinic availability. 10 Furthermore, many health services have been disrupted due to COVID-19 as governments across high HIV prevalence countries instituted lockdowns and other forms of restrictions to curb the spread of COVID-19. 11 Though many of the restrictions have since been lifted, there remains a concern that with the pandemic still ongoing, people might be reluctant to attend PHC clinics for HIV testing. For this reason, US President's Emergency Plan for AIDS Relief (PEPFAR) and PEPFAR-supported partners have recently recommended scaling up decentralised access to HIVST. 12 Since 2016, the Unitaidfunded Self-Testing AfRica (STAR) Initiative started distributing HIVST kits through a variety of approaches/ modalities in Malawi, Zambia and Zimbabwe, and later expanded to eSwatini, Lesotho and South Africa. Coordinated economic analyses alongside this roll-out found that the cost per kit distributed (in 2019 US$) was $8.91 in Malawi, $14.70 in Lesotho, $14.90 in Zimbabwe and $17.70 in Zambia using community-based distribution strategies, 13 14 $12.82 in circumcision clinics in Zambia 14 and $8.66 in Malawi, $9.15 in Zimbabwe, $5.37 in Zambia and $13.40 in South Africa when kit distribution was integrated into public primary care facilities. 15 A costeffectiveness analysis of an array of community-based distribution approaches and settings in Sub-Saharan Africa showed these can be cost-effective if implementation is targeted based on HIV prevalence and health benefits, and if costs are considered over a relatively long time horizon. 16 In our analysis of South Africa's distribution programme, we found that facility-based distribution modalities had on average higher cost per kit distributed than community-based distribution approaches, whic
Keywords Extracted from PMC Text: AIDS-related.2 elsewhere.1 appendix figures S1 B Self-Testing AfRica 4162/life appendix figure S4 Zimbabwe.17 18 people men HIVST work.19 unassisted.6 2000/life patient 's appendix table S1 oral fluid individuals Facility-based PLHIV HIVST.12 Zambia14 ICER Thembisa patients antiretroviral availability.10 Patients ICER/LYS 2030/life appendix figures S3 PHC level.19 HIVST recipients appendix figure S2 facility-based 3200/life Zambia Africa.20 appendix table S2 approaches/modalities PHC women appendix figure S1 HIV.20 21 appendix figure S3 2899/life recipients 2018–201922 diagnosis.1 briefly-fixed-point US$ COVID-19.11 9000–28 COVID-19 lockdowns self-diagnose appendix modalities.24
Extracted PMC Text Content in Record: First 5000 Characters:South Africa has the highest number of HIV infections worldwide, with an estimated 7.8 million people living with HIV (PLHIV) and 5.0 million on antiretroviral therapy (ART) in 2019.1 Despite having the largest ART programme in the world, over 23% of all deaths in South Africa in 2019 were AIDS-related.2 HIV transmission and AIDS-related deaths can be greatly reduced by identifying PLHIV who are unaware of their HIV status early, linking all PLHIV to ART and retaining them in care.3 The South African government is dedicated to meeting the UNAIDS 95-95-95 fast-track targets by 2025,4 which aim to have 95% of PLHIV diagnosed, 95% of those diagnosed on ART and 95% of those on ART virally suppressed by 2025. In 2017, a HIV household survey showed that 85% of South African PLHIV aged 15–64 years had been diagnosed, although men had a lower rate of diagnosis compared with women (80% vs 89%, respectively).5 Increasing the uptake of HIV testing services (HTS) by introducing novel testing strategies is critical to achieving the UNAIDS target to diagnose 95% of PLHIV in the coming years. In order to expand HIV testing coverage, the South African National Department of Health (NDoH) has implemented community-based testing to accompany existing conventional HTS, which is most frequently conducted at primary healthcare (PHC) clinics. Recently, HIV self-testing (HIVST) technology has been introduced to give people the opportunity to self-diagnose their HIV status. HIVST involves a person being able to privately collect their own specimen (most often oral fluid), performing the rapid diagnostic test and interpreting the result themselves, either assisted by HIVST distribution staff or unassisted.6 Recent studies in sub-Saharan Africa, including South Africa, have shown that HIVST is acceptable, feasible and effective in increasing HIV testing uptake,7–9 providing an alternative testing strategy that can overcome sociostructural barriers associated with conventional HTS in a clinic setting, including the stigma associated with accessing testing and limited hours of clinic availability.10 Furthermore, many health services have been disrupted due to COVID-19 as governments across high HIV prevalence countries instituted lockdowns and other forms of restrictions to curb the spread of COVID-19.11 Though many of the restrictions have since been lifted, there remains a concern that with the pandemic still ongoing, people might be reluctant to attend PHC clinics for HIV testing. For this reason, US President's Emergency Plan for AIDS Relief (PEPFAR) and PEPFAR-supported partners have recently recommended scaling up decentralised access to HIVST.12 Since 2016, the Unitaid-funded Self-Testing AfRica (STAR) Initiative started distributing HIVST kits through a variety of approaches/modalities in Malawi, Zambia and Zimbabwe, and later expanded to eSwatini, Lesotho and South Africa. Coordinated economic analyses alongside this roll-out found that the cost per kit distributed (in 2019 US$) was $8.91 in Malawi, $14.70 in Lesotho, $14.90 in Zimbabwe and $17.70 in Zambia using community-based distribution strategies,13 14 $12.82 in circumcision clinics in Zambia14 and $8.66 in Malawi, $9.15 in Zimbabwe, $5.37 in Zambia and $13.40 in South Africa when kit distribution was integrated into public primary care facilities.15 A cost-effectiveness analysis of an array of community-based distribution approaches and settings in Sub-Saharan Africa showed these can be cost-effective if implementation is targeted based on HIV prevalence and health benefits, and if costs are considered over a relatively long time horizon.16 In our analysis of South Africa's distribution programme, we found that facility-based distribution modalities had on average higher cost per kit distributed than community-based distribution approaches, which was unlike observations in Zambia and Zimbabwe.17 18 Previous modelling work by our team in 2019 using preliminary cost and effectiveness data on HIVST from other settings, showed that out of ten testing modalities analysed, HIVST combined with home-based testing would have the greatest impact on the proportion of PLHIV who are diagnosed, increasing the fraction of diagnosed PLHIV to 96.5% by 2030 and would be highly cost-effective compared with currently funded HIV interventions.19 More recently, using data on intermediate outcomes such as person screened positive, tested positive in confirmatory testing and initiated on ART from the STAR-supported HIVST roll-out in South Africa, we established that testing strategies which focus on high yield populations such as female sex workers and high-volume distribution modalities such as taxi rank and workplace distribution were more cost-effective than other community-based or any of the facility-based testing strategies.18 This work is an update to our previous work, using data collected under the STAR Initiative to inform both effectiveness and cost parameters in the Thembisa model
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