Centre for Sexual Health, HIV and AIDS Research, Harare, Zimbabwe.
Zambart, Lusaka, Zambia.
J Int AIDS Soc. 2019 Mar;22 Suppl 1(Suppl Suppl 1):e25255. doi: 10.1002/jia2.25255.
HIV self-testing (HIVST) is recommended by the World Health Organization in addition to other testing modalities to increase uptake of HIV testing, particularly among harder-to-reach populations. This study provides the first empirical evidence of the costs of door-to-door community-based HIVST distribution in Malawi, Zambia and Zimbabwe.
HIVST kits were distributed door-to-door in 71 sites across Malawi, Zambia and Zimbabwe from June 2016 to May 2017. Programme expenditures, supplemented by on-site observation and monitoring and evaluation data were used to estimate total economic and unit costs of HIVST distribution, by input and site. Inputs were categorized into start-up, capital and recurrent costs. Sensitivity and scenario analyses were performed to assess the impact of key parameters on unit costs.
In total, 152,671, 103,589 and 93,459 HIVST kits were distributed in Malawi, Zambia and Zimbabwe over 12, 11 and 10 months respectively. Across these countries, 43% to 51% of HIVST kits were distributed to men. The average cost per HIVST kit distributed was US$8.15, US$16.42 and US$13.84 in Malawi, Zambia and Zimbabwe, respectively, with pronounced intersite variation within countries driven largely by site-level fixed costs. Site-level recurrent costs were 70% to 92% of full costs and 20% to 62% higher than routine HIV testing services (HTS) costs. Personnel costs contributed from 26% to 52% of total costs across countries reflecting differences in remuneration approaches and country GDP.
These early door-to-door community HIVST distribution programmes show large potential, both for reaching untested populations and for substantial economies of scale as HIVST programmes scale-up and mature. From a societal perspective, the costs of HIVST appear similar to conventional HTS, with the higher providers' costs substantially offsetting user costs. Future approaches to minimizing cost and/or maximize testing coverage could include unpaid door-to-door community-led distribution to reach end-users and integrating HIVST into routine clinical services via direct or secondary distribution strategies with lower fixed costs.
世界卫生组织建议将 HIV 自我检测（HIVST）与其他检测方式相结合，以增加 HIV 检测的普及率，尤其是在更难接触到的人群中。本研究提供了在马拉维、赞比亚和津巴布韦首次进行基于社区的上门 HIVST 分发成本的实证证据。
2016 年 6 月至 2017 年 5 月，HIVST 试剂盒在马拉维、赞比亚和津巴布韦的 71 个地点进行了上门分发。根据投入和地点，利用方案支出以及现场观察、监测和评估数据，估算了 HIVST 分发的总经济成本和单位成本。投入分为启动、资本和经常性成本。进行了敏感性和情景分析，以评估关键参数对单位成本的影响。
在马拉维、赞比亚和津巴布韦，12、11 和 10 个月分别分发了 152671、103589 和 93459 份 HIVST 试剂盒。在这些国家中，43%至 51%的 HIVST 试剂盒分发给了男性。每份 HIVST 试剂盒的平均分发成本分别为 8.15 美元、16.42 美元和 13.84 美元，各国之间的站点间差异很大，主要原因是站点级别的固定成本。站点级别的经常性成本占总成本的 70%至 92%，比常规 HIV 检测服务（HTS）成本高 20%至 62%。人员成本占各国总成本的 26%至 52%，反映了薪酬方法和国家 GDP 的差异。
这些早期的上门社区 HIVST 分发方案显示出巨大的潜力，既能接触到未接受检测的人群，又能在 HIVST 项目扩大规模和成熟时实现大规模经济。从社会角度来看，HIVST 的成本似乎与传统 HTS 相似，较高的提供者成本大大抵消了用户成本。未来可以通过非付费上门社区主导的分发方式来接触最终用户，以及通过固定成本较低的直接或二级分发策略将 HIVST 整合到常规临床服务中，以降低成本和/或最大限度地提高检测覆盖率。
