The cost effectiveness and optimal configuration of oral HIV self-test kit distribution in South Africa: a model analysis


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 and maintaining the UNAIDS target of 95% HIV-positive diagnosis by 2030 in South Africa and globally.
METHODS: We modelled the impact of six HIVST distribution models (fixed-point, taxi ranks, workplace, partners of primary healthcare (PHC) index cases, partners of pregnant women, primary PHC distribution) in South Africa over 20years (2020-39), using data collected alongside the Self-Testing AfRica (STAR) Initiative. We modelled two coverage scenarios: A) 1 million HIVST kits (current) or B) up to 6.3 million kits (target) distributed annually. Incremental economic costs (2019USD) were estimated from the provider perspective; outcomes were based on surveys of a subset of kit recipients and modelled using the Thembisa model. We calculated the cost-effectiveness of each distribution model compared to the status-quo distribution configuration favouring primary PHC distribution, and optimised using a fractional factorial design.
RESULTS: The largest impact resulted from secondary distribution to partners of PHC index cases; however, it was one of the least cost-effective models (Figure 1). Workplace distribution was cost-saving ($52-$76 million), but had moderate epidemiological impact (Figure 1). Optimisation produced the largest epidemiological impact for the following distribution configurations: 50-70% through PHC index cases; 0-18% each through fixed point, taxi ranks, workplaces; 0-9% each through partners of pregnant women and primary distribution to PHC clients. An optimised scale-up of distribution to 6.3 million tests would result in a ~3-fold increase in life years saved (LYS) compared to a scale-up of current distribution patterns (216,000 vs 75,000 LYS).

CONCLUSIONS: Optimisation-informed distributions have 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, and assist in catching up testing targets post-COVID-19.