Department of Epidemiology and Biostatistics, School of Population and Global Health, Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada.
Medical Research Council Centre for Global Infectious Disease Analysis, Imperial College London, London, UK.
J Int AIDS Soc. 2024 Jul;27(7):e26334. doi: 10.1002/jia2.26334.
HIV self-testing (HIVST) is a promising strategy to improve diagnosis coverage among key populations (KP). The ATLAS (Auto Test VIH, Libre d'Accéder à la connaissance de son Statut) programme implemented HIVST in three West African countries, distributing over 380,000 kits up between 2019 and 2021, focussing on community-led distribution by KP to their peers and subsequent secondary distribution to their partners and clients. We aim to evaluate the cost-effectiveness of community-led HIVST in Côte d'Ivoire, Mali and Senegal.
An HIV transmission dynamics model was adapted and calibrated to country-specific epidemiological data and used to predict the impact of HIVST. We considered the distribution of HIVST among two KP-female sex workers (FSW), and men who have sex with men (MSM)-and their sexual partners and clients. We compared the cost-effectiveness of two scenarios against a counterfactual without HIVST over a 20-year horizon (2019-2039). The ATLAS-only scenario mimicked the 2-year implemented ATLAS programme, whereas the ATLAS-scale-up scenario achieved 95% coverage of HIVST distribution among FSW and MSM by 2025 onwards. The primary outcome is the number of disability-adjusted life-years (DALY) averted. Scenarios were compared using incremental cost-effectiveness ratios (ICERs). Costing was performed using a healthcare provider's perspective. Costs were discounted at 4%, converted to $USD 2022 and estimated using a cost-function to accommodate economies of scale.
The ATLAS-only scenario was highly cost-effective over 20 years, even at low willingness-to-pay thresholds. The median ICERs were $126 ($88-$210) per DALY averted in Côte d'Ivoire, $92 ($88-$210) in Mali and 27$ ($88-$210) in Senegal. Scaling-up the ATLAS programme would also be cost-effective, and substantial epidemiological impacts would be achieved. The ICERs for the scale-up scenario were $199 ($122-$338) per DALY averted in Côte d'Ivoire, $224 ($118-$415) in Mali and $61 ($18-$128) in Senegal.
Both the implemented and the potential scale-up of community-led HIVST programmes in West Africa, where KP are important to overall transmission dynamics, have the potential to be highly cost-effective, as compared to a scenario without HIVST. These findings support the scale-up of community-led HIVST to reach populations that otherwise may not access conventional testing services.
艾滋病病毒自我检测（HIVST）是提高重点人群（KP）诊断覆盖率的一项很有前途的策略。ATLAS（Auto Test VIH， Libre d'Accéder à la connaissance de son Statut）计划在三个西非国家实施 HIVST，在 2019 年至 2021 年间分发了超过 38 万套检测包，重点是由 KP 主导向其同行分发，并随后向其伴侣和客户进行二次分发。我们旨在评估社区主导的 HIVST 在科特迪瓦、马里和塞内加尔的成本效益。
我们对 HIV 传播动力学模型进行了调整和校准，以适应国家特定的流行病学数据，并用于预测 HIVST 的影响。我们考虑了两种 KP-女性性工作者（FSW）和男男性行为者（MSM）及其性伴侣和客户之间的 HIVST 分布情况。我们比较了在没有 HIVST 的情况下，20 年（2019-2039 年）内两种情景的成本效益。ATLAS 情景模拟了实施的 2 年 ATLAS 计划，而 ATLAS 扩大规模情景则在 2025 年及以后实现了 FSW 和 MSM 中 HIVST 分布的 95%覆盖率。主要结果是避免的残疾调整生命年（DALY）数。使用增量成本效益比（ICER）比较情景。成本分析采用医疗保健提供者的视角。成本以 4%的贴现率计算，转换为 2022 年美元，并使用成本函数进行估计，以适应规模经济。
ATLAS 情景在 20 年内非常具有成本效益，即使在低支付意愿阈值下也是如此。科特迪瓦的中位 ICER 为每避免 1 个 DALY 花费 126 美元（88-210 美元），马里为 92 美元（88-210 美元），塞内加尔为 27 美元（88-210 美元）。扩大 ATLAS 计划也将具有成本效益，并将实现重大的流行病学影响。扩大规模情景的 ICER 分别为科特迪瓦每避免 1 个 DALY 花费 199 美元（122-338 美元），马里为 224 美元（118-415 美元），塞内加尔为 61 美元（18-128 美元）。
在科特迪瓦、马里和塞内加尔，KP 对整体传播动态很重要，无论是已实施的还是潜在的社区主导的 HIVST 计划都有可能具有成本效益，与没有 HIVST 的情况相比。这些发现支持扩大社区主导的 HIVST，以覆盖那些可能无法获得常规检测服务的人群。
