title: Reaching the First 90%: Cost-effectiveness of HIV self testing services in Zambia
Creators: name: Ahmed, N
Publisher: name: London School of Hygiene & Tropical Medicine
Year: 2021

description: Adult HIV prevalence in Zambia is approximately 12%, and an estimated 28% of people living with HIV remain undiagnosed. In 2016 Zambia adopted HIV self-testing (HIVST) as an additional approach to expand coverage and access to those in need of testing and who may not otherwise test. To inform HIV testing scale-up, this thesis aims to: 1. Assess state of the art in cost and cost-effectiveness analyses on HIV testing services in sub-Saharan Africa through a systematic review; 2. Estimate the costs of HIV self-testing in voluntary medical male circumcision (VMMC) and health facilities in Zambia; and 3. Evaluate the incremental cost-effectiveness ratio (ICER) of adding community-based (door-to-door) HIVST kit distribution to conventional facility-based HIV testing services (HTS) to reach people who otherwise will not access HTS while visiting health facilities in Zambia. A systematic literature review summarized the literature on costs and cost-effectiveness analyses of HTS in sub-Saharan Africa over the past decade. The costs to test individuals through health facility, home-based, and mobile services are comparable; however, the costs are higher for campaign-style and stand-alone HTS. Moreover, the review shows that few studies have undertaken cost-effectiveness analyses of HTS. Different HIV testing models are potentially cost-effective but will increase HIV testing budgets. Thus, it is essential to do more cost-effectiveness and budget analyses of different combinations of HIV testing modalities to inform HIV testing policy and budgets. A cost analysis of HIV testing (HTS and HIVST) across Malawi, Zambia, and Zimbabwe generated a detailed summary of observed resources used for HIV testing and how these vary across settings. The corresponding unit cost per community-based distribution by VMMC mobilizers are US$24.83 for Malawi and US$7.71 for Zimbabwe. The corresponding unit cost per HIVST kits distributed at the VMMC clinic are US$9.65, US$13.01, and US$7.71 for Malawi, Zambia, and Zimbabwe, respectively. For Zambia and Zimbabwe, the outpatient department (OPD) and integrated models distribution unit cost per kit distributed are US$15.81 and US$9.85. Lastly, the age- and sex-specific Markov microsimulation model evaluated the costs and impact of a one-year HIVST program in Zambia. The model simulated 100,000 individuals over a 20-year time horizon. Using HIV Self-Testing Africa (STAR) consortium’s endline who had not tested within the last 12 months were eligible for home-based HIVST; these people could then accept or reject HIVST with its associated costs and consequences. ICERs were calculated for the intervention relative to the HTS status quo. Effects were presented building on the HIV prevention and treatment cascade framework, ultimately estimating disability-adjusted life years (DALY) averted. The age and sex-stratified Markov microsimulation model predicted that the implementation of community-based (door-todoor) HIVST distribution would avert more DALYs relative to the standard facility-based HTS. The ICERs for adolescent men and women ages 15-24 were $101.81 and $154.73 per DALY averted. The ICERs for men and women were $35.26 and $25.18 for ages 25-34 and $32.10 and $23.03 for ages 35-49.