Cost-effectiveness analysis of community-led HIV self-testing among key populations in Côte d'Ivoire, Mali, and Senegal - Lu, Ingrid Jiayin; Silhol, Romain; d'Elbée, Marc; Boily, Marie-Claude; Soni, Nirali; Ky-Zerbo, Odette; Vautier, Anthony; Simo Fotso, Arlette; Badiane, Kéba; Traoré, Metogara; Terris-Prestholt, Fern; Larmarange, Joseph; et al. (Journal of the International AIDS Society, 2024)
Introduction 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. Methods 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 𝑈𝑆𝐷2022𝑎𝑛𝑑𝑒𝑠𝑡𝑖𝑚𝑎𝑡𝑒𝑑𝑢𝑠𝑖𝑛𝑔𝑎𝑐𝑜𝑠𝑡‐𝑓𝑢𝑛𝑐𝑡𝑖𝑜𝑛𝑡𝑜𝑎𝑐𝑐𝑜𝑚𝑚𝑜𝑑𝑎𝑡𝑒𝑒𝑐𝑜𝑛𝑜𝑚𝑖𝑒𝑠𝑜𝑓𝑠𝑐𝑎𝑙𝑒.𝑅𝑒𝑠𝑢𝑙𝑡𝑠𝑇ℎ𝑒𝐴𝑇𝐿𝐴𝑆‐𝑜𝑛𝑙𝑦𝑠𝑐𝑒𝑛𝑎𝑟𝑖𝑜𝑤𝑎𝑠ℎ𝑖𝑔ℎ𝑙𝑦𝑐𝑜𝑠𝑡‐𝑒𝑓𝑓𝑒𝑐𝑡𝑖𝑣𝑒𝑜𝑣𝑒𝑟20𝑦𝑒𝑎𝑟𝑠,𝑒𝑣𝑒𝑛𝑎𝑡𝑙𝑜𝑤𝑤𝑖𝑙𝑙𝑖𝑛𝑔𝑛𝑒𝑠𝑠‐𝑡𝑜‐𝑝𝑎𝑦𝑡ℎ𝑟𝑒𝑠ℎ𝑜𝑙𝑑𝑠.𝑇ℎ𝑒𝑚𝑒𝑑𝑖𝑎𝑛𝐼𝐶𝐸𝑅𝑠𝑤𝑒𝑟𝑒USD2022andestimatedusingacost‐functiontoaccommodateeconomiesofscale.ResultsTheATLAS‐onlyscenariowashighlycost‐effectiveover20years,evenatlowwillingness‐to‐paythresholds.ThemedianICERswereUSD 2022 and estimated using a cost‐function to accommodate economies of scale. Results The ATLAS‐only scenario was highly cost‐effective over 20 years, even at low willingness‐to‐pay thresholds. The median ICERs were 126 (88–88–88–210) per DALY averted in Côte d'Ivoire, 92(92(92 (88–210)𝑖𝑛𝑀𝑎𝑙𝑖𝑎𝑛𝑑27210)inMaliand27210) in Mali and 27 (88–88–88–210) 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(199(199 (122–338)𝑝𝑒𝑟𝐷𝐴𝐿𝑌𝑎𝑣𝑒𝑟𝑡𝑒𝑑𝑖𝑛𝐶ô𝑡𝑒𝑑′𝐼𝑣𝑜𝑖𝑟𝑒,338)perDALYavertedinCôted′Ivoire,338) per DALY averted in Côte d'Ivoire, 224 (118–118–118–415) in Mali and 61(61(61 (18–$128) in Senegal. Conclusions 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.
Keywords: journalArticle; Côte d'Ivoire; HIV testing services; HIV-self testing; Mali; Senegal; community-led delivery; cost function; cost-effectiveness; key population