Abstract

Although many African countries have achieved high levels of HIV diagnosis, funding constraints have necessitated greater focus on more efficient testing approaches. We compared the impact and cost-effectiveness of several potential new testing strategies in South Africa, and assessed the prospects of achieving the UNAIDS target of 95% of HIV-positive adults diagnosed by 2030. We developed a mathematical model to evaluate the potential impact of home-based testing, mobile testing, assisted partner notification, testing in schools and workplaces, and testing of female sex workers (FSWs), men who have sex with men (MSM), family planning clinic attenders and partners of pregnant women. In the absence of new testing strategies, the diagnosed fraction is expected to increase from 90.6% in 2020 to 93.8% by 2030. Home-based testing combined with self-testing would have the greatest impact, increasing the fraction diagnosed to 96.5% by 2030, and would be highly cost-effective compared to currently funded HIV interventions, with a cost per life year saved (LYS) of $394. Testing in FSWs and assisted partner notification would be cost-saving; the cost per LYS would also be low in the case of testing MSM ($20/LYS) and self-testing by partners of pregnant women ($130/LYS).

Highlights

  • HIV testing is a critical first step in ensuring that HIV-positive individuals are diagnosed and treated, which in turn is critical to reducing HIV incidence

  • By 2017, the model estimates that the fraction of HIV-positive adults who were diagnosed was 88.7%, though the proportion diagnosed was substantially lower among men (84.5%) than among women (91.2%), and substantially lower in the 15–24 age group (74.5%) than in the 25–49 and 50 + age groups (90.9% and 87.8% respectively) (Fig. 2)

  • The model estimates that over the 2010–2015 period, the HIV testing modalities that accounted for the greatest numbers of HIV tests were general HIV testing (63.0%), testing in sexually transmitted infection (STI) clinics (11.4%), testing of opportunistic infections (OIs) patients (9.8%) and antenatal testing (7.3%), while the testing modalities that accounted for the greatest numbers of new HIV diagnoses were general HIV testing (43.6%), testing of OI patients (32.5%), testing in STI clinics (8.1%), and testing partners of newly diagnosed individuals (7.4%) (Fig. S3.3)

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Summary

Introduction

HIV testing is a critical first step in ensuring that HIV-positive individuals are diagnosed and treated, which in turn is critical to reducing HIV incidence. Many other models have evaluated individual HIV testing strategies, few have compared a broad range of different HIV testing strategies[23,24,25,26,27,28], and most have assessed cost-effectiveness relative to internationally-accepted benchmarks (such as three times gross domestic product (GDP) per life year saved) rather than against locally-established ‘willingness to pay’ criteria. This study aims to evaluate the potential impact and cost-effectiveness of a number of potential new HIV testing strategies in South Africa, the country with the largest number of HIV infections globally In this setting, high levels of uptake and coverage have already been achieved for many HIV interventions, with the HIV-diagnosed fraction estimated at over 80% in recent years[29]. In this context of high baseline levels of intervention uptake, it is relatively difficult to identify new interventions that represent value for money, and the ‘willingness to pay’ threshold of the South African government (the main funder of the country’s HIV response) has been estimated at $547–842 per life year saved, substantially lower than the South African GDP per capita of around $6 00030

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