HIV self-testing: A cost-saving approach?

Assessment of the potential impact and cost-effectiveness of self-testing for HIV in low-income countries.  

Cambiano V, Ford D, Mabugu T, Napierala Mavedzenge S, Miners A, Mugurungi O, Nakagawa F, Revill P, Phillips A. J Infect Dis. 2015 Aug 15;212(4):570-7. doi: 10.1093/infdis/jiv040. Epub 2015 Mar 12.

Background: Studies have demonstrated that self-testing for human immunodeficiency virus (HIV) is highly acceptable among individuals and could allow cost savings, compared with provider-delivered HIV testing and counseling (PHTC), although the longer-term population-level effects are uncertain. We evaluated the cost-effectiveness of introducing self-testing in 2015 over a 20-year time frame in a country such as Zimbabwe.

Methods: The HIV synthesis model was used. Two scenarios were considered. In the reference scenario, self-testing is not available, and the rate of first-time and repeat PHTC is assumed to increase from 2015 onward, in line with past trends. In the intervention scenario, self-testing is introduced at a unit cost of $3.

Results: We predict that the introduction of self-testing would lead to modest savings in healthcare costs of $75 million, while averting around 7000 disability-adjusted life-years over 20 years. Findings were robust to most variations in assumptions; however, higher cost of self-testing, lower linkage to care for people whose diagnosis is a consequence of a positive self-test result, and lower threshold for antiretroviral therapy eligibility criteria could lead to situations in which self-testing is not cost-effective.

Conclusions: This analysis suggests that introducing self-testing offers some health benefits and may well save costs.

Abstract  Full-text [free] access

Editor’s notes: In low-income countries 50% of people living with HIV are unaware of their HIV-status. Some barriers to diagnosis are associated with provider-based models and could potentially be overcome by introducing self-testing strategies. The cost of self-testing is expected to be lower than that of provider-based testing. However, self-testing may have a lower sensitivity, may necessitate provider-based diagnosis confirmation and may lead to lower linkages to care, among other potential disadvantages. This study assesses the cost-effectiveness of introducing self-testing in Zimbabwe over a 20-year time frame.

Two scenarios are modelled using an individual-based stochastic model of HIV transmission and infection progression and treatment: 1) a reference case where self-testing is not introduced, with continuous reliance on provider-based testing and 2) following self-testing introduction. Cost and health outcomes were compared.

The study suggests that introduction of self-testing would lead to a 7% higher proportion tested for HIV compared to the reference scenario. Also, it would lead to a cost reduction of 2.6% (USD 75 million) and to 7000 DALYs averted in a 20-year period. However, the costs and effects depend on a range of factors and in some scenarios (such as in situations of inadequate links to the care and treatment cascade) self-testing could result in worse outcomes than in the reference case. Sensitivity analyses illustrate that key determinants of the magnitude of health gains include the cost of self-testing, the initial level of HIV diagnosis and ART coverage, and self-testing availability.

This study contains some exciting findings that could lead to the use of resources more effectively. However, associated research needs to be carried out to ensure that the introduction of self-testing yields the greatest benefit. More work needs to be done in determining the cost of distribution and management of self-testing, as well as exploring the community acceptance. Further, given the importance of linkages to care, research on self-testing should be embedded into the larger literature around health system strengthening. 

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