Empringham Brianna, Karellis Angela, Fernandez-Suarez Marta, Carmona Sergio, Pai Nitika Pant, Zwerling Alice
School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.
Front Public Health. 2025 Jan 14;12:1440104. doi: 10.3389/fpubh.2024.1440104. eCollection 2024.
HIV self-testing (HIVST) is an innovative strategy that has been shown to increase uptake of HIV testing compared to conventional facility-based testing. HIVST implementation with digital-based supports may help facilitate testing accessibility and linkage to care after a reactive self-test. Economic evidence around community-based implementation of HIVST is growing; however, economic evidence around digital-based HIVST approaches remains limited.
We used previously published cost and efficacy data from HIVST interventions, with the specific intervention model differing between scenarios. Digital-based interventions included text messaging campaigns and online websites that promoted uptake and linkage to HIVST care. Community-based interventions included door-to-door distribution, peer-incentivized distribution, and mobile testing units. Using data obtained from the literature, we parameterized a combined Markov and decision analytic model to evaluate the cost-utility of digital-based HIVST implementation across Malawi, South Africa, and Brazil compared to both community-based HIVST and facility-based testing.
We found that HIVST was cost-effective compared to facility-based testing in all settings investigated. Our scenarios predicted that digital-based HIVST was associated with an incremental cost in the range of $769-$17,839/DALY (disability-adjusted life year) averted compared to facility-based testing across Malawi, South Africa, and Brazil. Digital-based HIVST cost savings had an incremental cost of $7,300/DALY averted compared to community-based HIVST. The main drivers of cost-utility included HIV test and treatment costs, HIV test-positivity, rates of linkage to care, and antiretroviral therapy (ART) initiation rates. Digital-based supports were associated with an increased cost compared to facility-based testing, but they also had increased utility, which led to favorable cost-utility estimates.
HIVST with digital supports has the potential to be a highly cost-effective approach, with the potential to make HIV testing more available and accessible, thereby increasing overall uptake and coverage of HIV testing. Digital supports can also support linkage to care, which we have identified as a major driver of cost-utility. Strategies to improve cost-utility include reducing testing costs, targeting key populations with increased rates of HIV test-positivity, and ensuring strong support for linkage to care.
与传统的基于机构的检测相比，HIV自我检测（HIVST）是一种创新策略，已被证明能提高HIV检测的接受度。采用数字化支持实施HIVST可能有助于促进检测的可及性，并在自我检测呈反应性后与护理建立联系。关于基于社区实施HIVST的经济证据正在增加；然而，关于基于数字化的HIVST方法的经济证据仍然有限。
我们使用了先前发表的HIVST干预措施的成本和效果数据，不同情景下的具体干预模型有所不同。基于数字化的干预措施包括短信宣传活动和推广HIVST检测接受度及与护理建立联系的在线网站。基于社区的干预措施包括挨家挨户分发、同伴激励分发和移动检测单位。利用从文献中获得的数据，我们构建了一个马尔可夫和决策分析相结合的模型，以评估在马拉维、南非和巴西实施基于数字化的HIVST与基于社区的HIVST及基于机构的检测相比的成本效益。
我们发现，在所有调查的环境中，与基于机构的检测相比，HIVST具有成本效益。我们的情景预测，与马拉维、南非和巴西基于机构的检测相比，基于数字化的HIVST每避免一个伤残调整生命年（DALY）的增量成本在769美元至17,839美元之间。与基于社区的HIVST相比，基于数字化的HIVST节省成本的增量成本为每避免一个DALY 7300美元。成本效益的主要驱动因素包括HIV检测和治疗成本、HIV检测阳性率、与护理建立联系的比例以及抗逆转录病毒疗法（ART）启动率。与基于机构的检测相比，数字化支持与成本增加相关，但也带来了效用增加，从而产生了有利的成本效益估计。
有数字化支持的HIVST有可能成为一种极具成本效益的方法，有可能使HIV检测更易于获得和使用，从而提高HIV检测的总体接受度和覆盖率。数字化支持还可以促进与护理建立联系，我们已将其确定为成本效益的主要驱动因素。提高成本效益的策略包括降低检测成本、针对HIV检测阳性率较高的关键人群，以及确保对与护理建立联系的有力支持。
