Institute for Global Health, University College London, London, United Kingdom.
World Health Organization, Geneva, Switzerland.
J Int AIDS Soc. 2019 Mar;22 Suppl 1(Suppl Suppl 1):e25243. doi: 10.1002/jia2.25243.
The prevalence of undiagnosed HIV is declining in Africa, and various HIV testing approaches are finding lower positivity rates. In this context, the epidemiological impact and cost-effectiveness of community-based HIV self-testing (CB-HIVST) is unclear. We aimed to assess this in different sub-populations and across scenarios characterized by different adult HIV prevalence and antiretroviral treatment programmes in sub-Saharan Africa.
The synthesis model was used to address this aim. Three sub-populations were considered for CB-HIVST: (i) women having transactional sex (WTS); (ii) young people (15 to 24 years); and (iii) adult men (25 to 49 years). We assumed uptake of CB-HIVST similar to that reported in epidemiological studies (base case), or assumed people use CB-HIVST only if exposed to risk (condomless sex) since last HIV test. We also considered a five-year time-limited CB-HIVST programme. Cost-effectiveness was defined by an incremental cost-effectiveness ratio (ICER; cost-per-disability-adjusted life-year (DALY) averted) below US$500 over a time horizon of 50 years. The efficiency of targeted CB-HIVST was evaluated using the number of additional tests per infection or death averted.
In the base case, targeting adult men with CB-HIVST offered the greatest impact, averting 1500 HIV infections and 520 deaths per year in the context of a simulated country with nine million adults, and impact could be enhanced by linkage to voluntary medical male circumcision (VMMC). However, the approach was only cost-effective if the programme was limited to five years or the undiagnosed prevalence was above 3%. CB-HIVST to WTS was the most cost-effective. The main drivers of cost-effectiveness were the cost of CB-HIVST and the prevalence of undiagnosed HIV. All other CB-HIVST scenarios had an ICER above US$500 per DALY averted.
CB-HIVST showed an important epidemiological impact. To maximize population health within a fixed budget, CB-HIVST needs to be targeted on the basis of the prevalence of undiagnosed HIV, sub-population and the overall costs of delivering this testing modality. Linkage to VMMC enhances its cost-effectiveness.
非洲的未确诊 HIV 感染率正在下降，各种 HIV 检测方法的阳性率也有所降低。在这种情况下，社区为基础的 HIV 自我检测（CB-HIVST）的流行病学影响和成本效益尚不清楚。我们旨在评估撒哈拉以南非洲不同亚人群和不同成人 HIV 流行率和抗逆转录病毒治疗方案特征下的这种情况。
采用综合模型来实现这一目标。考虑了 CB-HIVST 的三种亚人群：（i）有商业性性行为的妇女（WTS）；（ii）年轻人（15 至 24 岁）；以及（iii）成年男性（25 至 49 岁）。我们假设 CB-HIVST 的使用率与流行病学研究报告的使用率相似（基础情况），或者假设人们仅在最近一次 HIV 检测后发生无保护性行为（ condomless sex ）时才使用 CB-HIVST。我们还考虑了一个为期五年的有限 CB-HIVST 方案。成本效益通过增量成本效益比（ICER；每避免一个残疾调整生命年（DALY）的成本）来定义，其时间范围为 50 年。通过避免每例感染或死亡所需的额外检测次数来评估针对 CB-HIVST 的效率。
在基础情况下，针对成年男性进行 CB-HIVST 具有最大的影响，在一个模拟的有 900 万成年人的国家中，每年可避免 1500 例 HIV 感染和 520 例死亡，通过与自愿男性包皮环切术（VMMC）相结合，可以提高效果。但是，只有在方案限制为五年或未确诊的流行率高于 3%的情况下，该方法才具有成本效益。针对 WTS 的 CB-HIVST 最具成本效益。成本效益的主要驱动因素是 CB-HIVST 的成本和未确诊 HIV 的流行率。所有其他 CB-HIVST 方案的增量成本效益比都超过了每 DALY 避免 500 美元。
CB-HIVST 显示出重要的流行病学影响。为了在固定预算内最大限度地提高人群健康水平，需要根据未确诊 HIV 的流行率、亚人群和提供这种检测方式的总体成本来确定 CB-HIVST 的目标人群。与 VMMC 相结合可以提高其成本效益。
