Department of Global Health, School of Public Health, Boston University, Boston, MA, USA.
Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
J Int AIDS Soc. 2020 Sep;23(9):e25612. doi: 10.1002/jia2.25612.
HIV self-testing (HIVST) in outpatient departments (OPD) is a promising strategy for HIV testing in Malawi, given high OPD patient volumes and substantial wait times. To evaluate the relative cost and expected impact of facility-based HIVST (FB-HIVST) at OPDs in Malawi for increasing HIV status awareness, we conducted an economic evaluation of an HIVST cluster-randomized controlled trial.
A cluster-randomized trial was conducted at 15 sites in Malawi from September 2017 to February 2018 with three arms: 1) Standard provider-initiated-testing-and-counselling (PITC); 2) Optimized PITC (additional provider training and job-aids) and 3) FB-HIVST (HIVST demonstration, distribution and kit use in OPD, private kit interpretation and optional HIV counselling). The total production cost per newly identified positive and per person newly initiated on ART were calculated by study arm. These were calculated as the total cost of testing everyone divided by the number of newly identified positives; and the total cost of testing everyone divided by the number of those initiated on ART. Cost-outcomes were calculated under three cost scenarios: (1) full study costs, (2) routine implementation costs and (3) routine implementation + reduced cost for HIVST kits.
The average cost per person newly diagnosed in the full study cost scenario was $101, $156 and $189, and cost per person initiated on ART was $121, $156 and $279 for Standard PITC, Optimized PITC and FB-HIVST respectively. In the routine implementation cost scenario, the average cost per person newly diagnosed was reduced to $83, and $93, and cost per person initiated on ART to $83, and $137 for Optimized PITC and FB-HIVST respectively. In the negotiated HIVST cost scenario, the average cost per person newly diagnosed was reduced to $55 and cost per person newly initiated on ART reduced to $81 in the FB-HIVST arm.
While the cost per new ART initiation through FB-HIVST was higher than Standard PITC, FB-HIVST could become cost-saving compared to PITC if the cost of kits is reduced or if treatment linkage rate were increased in the FB-HIVST arm. For high volume OPDs, HIVST may increase facility capacity and increase the number of newly diagnosed positives.
鉴于门诊部门（OPD）的大量患者量和大量等待时间，HIV 自我检测（HIVST）是马拉维 HIV 检测的一项很有前景的策略。为了评估基于设施的 HIVST（FB-HIVST）在马拉维 OPD 中提高 HIV 状况知晓率的相对成本和预期影响，我们对一项 HIVST 整群随机对照试验进行了经济评估。
2017 年 9 月至 2018 年 2 月，在马拉维的 15 个地点进行了一项整群随机试验，共分为三个组：1）标准提供者启动的检测和咨询（PITC）；2）优化的 PITC（额外的提供者培训和工作辅助）和 3）FB-HIVST（在 OPD 中进行 HIVST 示范、分发和试剂盒使用、私人试剂盒解释和可选的 HIV 咨询）。按研究组计算了每个新发现的阳性和每个新开始接受抗逆转录病毒治疗（ART）的人的总生产成本。这些是通过将检测每个人的总成本除以新发现的阳性人数来计算的；以及通过将检测每个人的总成本除以开始接受 ART 的人数来计算的。根据三种成本情况计算了成本结果：（1）完整的研究成本，（2）常规实施成本，（3）常规实施+HIVST 试剂盒成本降低。
在完整的研究成本情况下，标准 PITC、优化的 PITC 和 FB-HIVST 组中，每人新诊断的平均成本分别为 101 美元、156 美元和 189 美元，每人开始接受 ART 的平均成本分别为 121 美元、156 美元和 279 美元。在常规实施成本情况下，每人新诊断的平均成本分别降低到 83 美元和 93 美元，每人开始接受 ART 的平均成本分别降低到 83 美元和 137 美元，在优化的 PITC 和 FB-HIVST 组中。在协商的 HIVST 成本情况下，在 FB-HIVST 组中，每人新诊断的平均成本降低到 55 美元，每人新开始接受 ART 的成本降低到 81 美元。
虽然通过 FB-HIVST 进行新的 ART 启动的成本高于标准 PITC，但如果试剂盒的成本降低或 FB-HIVST 组的治疗联系率提高，FB-HIVST 可能比 PITC 更具成本效益。对于高容量的 OPD，HIVST 可以增加设施能力，并增加新诊断的阳性人数。
