Reaching absent and refusing individuals during home-based HIV testing through self-testing: a costing perspective


BACKGROUND: In the HOSENG trial (NCT03598686) in 2018, secondary distribution of oral self-tests for persons absent or refusing to test during a home-based HIV testing campaign in rural Lesotho resulted in an increase in testing coverage of 21%. This study aims to determine the unit costs per person enumerated, eligible for testing, tested and confirmed new HIV+ during the home-based HIV testing with and without secondary distribution of self-tests.
METHODS: We conducted a micro-costing study to estimate the cost of home-based HIV testing with and without secondary self-test distribution from a provider's perspective. A mixture of top-down and bottom-up costing was used. We estimated both the financial and economic per patient costs of each possible testing cascade scenario.
RESULTS: The overall provider cost for delivering the home-based HIV testing with secondary distribution was US$36''481 among the 4174 persons enumerated and 3094 eligible for testing in the intervention villages, compared to US$28''620 for 3642 persons enumerated and 2727 eligible for testing in control. The cost per person eligible for testing was US$11.79 in intervention versus US$10.50 in control. This difference was mainly driven by the cost of distributed oral self-tests. The cost per person tested was, however, lower in intervention villages (US$15.70 vs US$22.15) due to the higher testing coverage achieved through self-test distribution. Cost per person confirmed new HIV+ was US$889.79 in intervention and US$753.17 in control.
CONCLUSIONS: A self-testing strategy yielding high coverage and the optimal integration of the self-test follow-up in the existing health system resulted in low cost of secondary self-test distribution during home-based HIV testing in Lesotho. These results may inform the current large-scale roll-out of HIV self-tests in Africa ' also driven by the COVID-19 pandemic ' and should be taken into account in home-based testing policies in similar settings.