The cost and intermediary cost-effectiveness of oral HIV self-test kit distribution across eleven distribution models in South Africa

BACKGROUND: South Africa has made progress in reaching the population aged 15-64 with HIV testing, but testing gaps remain among key populations and men. HIV self-testing (HIVST) can help fill these gaps by bringing testing closer. We conducted an economic evaluation of 11 innovative HIVST distribution approaches implemented across urban and rural settings in South Africa between 2018 and 2019 under the Self-Testing AfRica Initiative.
METHODS: We analysed the cost and outcomes along the care cascade from self-testing to initiation of antiretroviral treatment (ART) across the country (Table 1). We conducted an ingredients-based cost analysis from the provider's perspective, combining bottom-up and top-down approaches. Cost analysis was limited to a 12-months implementation period for all except two models with shorter implementation periods (transport hub and third-party workplace models). We categorised cost items as capital vs. recurrent. Capital costs were annualised over a 2 years lifespan to reflect the project duration and discounted using a 3% discount rate.

Distribution Setting	Model	Distribution Approach	Target Population
Facility	Horizontal primary healthcare (Antenatal care) / Horizontal primary healthcare (Index) / Vertical primary health care	Pregnant women received kits for their current sexual partner(s) / HIV positive clients attending PHC clinic received kits for their sexual partner(s) / On-site HIV screening for clients attending PHC clinic for a wide array of services	Men & partners of HIV positive people/ General population
Community distribution	Fixed point / Flexible community	Distribution at pre-selected locations within communities, especially where men tend to congregate / Door-to-door distribution of kits	Men/ Men and young people
	Mobile integration / Workplace	Integrating HIVST to community-based mobile HIV testing / Distributing kits at male-dominated sector workplaces
	Transport hub	Distributing kits in densely populated taxi ranks and train stations with high foot traffic	General population
	Key populations / Sex workers	Distributing kits to sex workers and truck drivers / Sex workers received kits for peers	Key populations / Sex workers

RESULTS: Slightly over a million kits were distributed; 49% through the flexible community model and the least kits (1%) through the mobile integration and PHC models. The self-test positivity rate varied between 4% in the workplace model and 23% in the horizontal PHC model, with most models reporting a 5% positivity rate. The average cost per kit distributed ranged from $4.87 in the sex worker model to $18.07 in the mobile integration models. Facility models exhibited higher unit costs than community models. The average cost per reactive HIVST ranged from $28 in the sex worker model to $414 in the mobile integration model. The cost per confirmed positive result was between $66 in the sex worker model and $1229 in vertical PHC. Finally, the cost per ART initiation was between $116 in the sex worker model and $1,278 in vertical PHC.
CONCLUSIONS: HIVST distribution cost varied widely across models, with the sex worker, transport hub, and workplace models being the most efficient and least costly distribution approaches.