Costs and scale-up costs of integrating HIV self-testing into civil society organisation-led programmes for key populations in Côte d'Ivoire, Senegal, and Mali

Despite significant progress on the proportion of individuals who know their HIV status in 2020, Côte d'Ivoire (76%), Senegal (78%), and Mali (48%) remain far below, and key populations (KP) including female sex workers (FSW), men who have sex with men (MSM), and people who use drugs (PWUD) are the most vulnerable groups with a HIV prevalence at 5-30%. HIV self-testing (HIVST), a process where a person collects his/her own specimen, performs a test, and interprets the result, was introduced in 2019 as a new testing modality through the ATLAS project coordinated by the international partner organisation Solthis (IPO). We estimate the costs of implementing HIVST through 23 civil society organisations (CSO)-led models for KP in Côte d'Ivoire (N = 7), Senegal (N = 11), and Mali (N = 5). We modelled costs for programme transition (2021) and early scale-up (2022-2023). Between July 2019 and September 2020, a total of 51,028, 14,472, and 34,353 HIVST kits were distributed in Côte d'Ivoire, Senegal, and Mali, respectively. Across countries, 64-80% of HIVST kits were distributed to FSW, 20-31% to MSM, and 5-8% to PWUD. Average costs per HIVST kit distributed were $15 for FSW (Côte d'Ivoire:$13, Senegal: $17, Mali:$16), $23 for MSM (Côte d'Ivoire:$15, Senegal: $27, Mali:$28), and $80 for PWUD (Côte d'Ivoire:$16, Senegal: $144), driven by personnel costs (47-78$11 for FSW (Côte d'Ivoire: $9, Senegal:$13, Mali: $10),$16 for MSM (Côte d'Ivoire: $9, Senegal:$23, Mali: $17), and$32 for PWUD (Côte d'Ivoire: $14, Senegal:$50). Cost reductions were mainly explained by the spreading of IPO costs over higher HIVST distribution volumes and progressive IPO withdrawal at scale-up. In all countries, CSO-led HIVST kit provision to KP showed relatively high costs during the study period related to the progressive integration of the programme to CSO activities and contextual challenges (COVID-19 pandemic, country safety concerns). In transition to scale-up and integration of the HIVST programme into CSO activities, this model shows large potential for substantial economies of scale. Further research will assess the overall cost-effectiveness of this model

Economic Analysis of Low Volume Interventions Using Real-World Data: Costs of HIV Self-Testing Distribution and HIV Testing Services in West Africa From the ATLAS Project

International audienceAchieving the first 95 of the UNAIDS targets requires the implementation of innovative approaches to knowing one's HIV status. Among these innovations is the provision of HIV self-testing (HIVST) kits in west Africa by the international partner organization Solthis (IPO). In order to provide guidance for the optimal use of financial resources, this study aims to estimate the program and site level costs of dispensing HIVST as well as HIV testing services (HTS)-excluding HIVST-in health facilities in Côte d'Ivoire, Mali and Senegal as part of the ATLAS project. We estimated from the provider's perspective, HIVST and HTS incremental costs using top-down and bottom-up costing approaches and conducted a time and motion study. We identified costs at the program level for HIVST (including IPO central costs) and at the site level for HIVST and HTS. The economic costs of distributing HIVST kits were assessed in 37 health facilities between July 2019 and March 2021 (21 months). Sensitivity analyses were also performed on unit costs to examine the robustness of our estimates related to key assumptions. In total, 16,001 HIVST kits were dispensed for 32,194 HTS sessions carried out. Program level HIVST average costs ranged $12–286, whereas site level costs ranged$4–26 across distribution channels and countries. Site level HTS costs ranged $7–8 per testing session, and ranged$72–705 per HIV diagnosis. Across countries and channels, HIVST costs were driven by personnel (27–68%) and HIVST kits (32–73%) costs. The drivers of HTS costs were personnel costs ranging between 65 and 71% of total costs across distribution channels and countries, followed by supplies costs between 21 and 30%. While program level HIVST average costs were high, site level HIVST average costs remained comparable to HTS costs in all countries. Health facility-based distribution channels operating at low volume exhibit high proportion of central costs which should be considered carefully for financial planning when run alongside high volumes mobile outreach distribution channels. HIVST can diversify the HIV testing offer at health facilities, thus improving access to screening for target populations not reached by HTS services

Décrire, analyser et comprendre les effets de l’introduction de l’autodépistage du VIH en Afrique de l’Ouest à travers l’exemple du programme ATLAS en Côte d’Ivoire, au Mali et au Sénégal: Protocole de Recherche · Version 3.0 du 8 octobre 2020

Research component of the ATLAS programmeThe ATLAS programme (2019-2021) aims to promote and deploy HIV self-testing (HIVST) in Côte d'Ivoire, Mali and Senegal and to distribute half a million HIVST through various delivery channels, targeting in particular key populations (sex workers, men who have sex with men, drug users), partners of people living with HIV (PLHIV) and patients with sexually transmitted infections. The dispensation of HIVST will be carried out in routine care, through the three countries' national AIDS strategies and in an integrated manner with existing screening policies, through eight delivery channels combining fixed and advanced strategies, primary distribution and secondary distribution. The research component presented here includes a set of observational surveys to describe, analyze and understand the social, health, epidemiological and economic effects of the introduction of HIVST in Côte d'Ivoire, Mali and Senegal to improve testing offer (accessibility, effectiveness and ethics). It is organized into 5 work packages: (i) a qualitative survey on HIVST targeted key populations, based on qualitative individual and group interviews with key implementers, members of key population communities and HIVST users; (ii) an ethnography on the integration of HIVST for screening of PLHIV’s partners in three HIV care clinics and an exploratory sub-survey on HIVST distribution in STI consultations; (iii) an anonymous telephone survey of HIVST users recruited through an invitation on HIVST kits to call a toll-free number; (iv) an economic survey of HIVST incremental costs with cost collections from a sample of HIVST dispensing sites and a time and motion study; (v) an epidemiological modelling (dynamic compartmental model) of the three countries and of the health and economic impacts of different scaling scenarios.Volet recherche du programme ATLASLe programme ATLAS (2019-2021) vise à promouvoir et à déployer l’autodépistage du VIH (ADVIH) en Côte d’Ivoire, au Mali et au Sénégal et prévoit la distribution d’un demi millions d’autotests à travers différents canaux de dispensation, visant en particulier les populations clés (travailleuses du sexe, hommes ayant des rapports sexuels avec des hommes, usager·e·s de drogues), les partenaires des personnes vivant avec le VIH (PvVIH) et les patient·e·s atteint·e·s d’une infection sexuellement transmissible. La dispensation des kits d’ADVIH sera réalisée en soins courants, dans le cadre des stratégies nationales de lutte contre le sida des trois pays et de manière intégrée aux politiques de dépistage déjà en place, à travers huit canaux de dispensation combinant des stratégies fixes et des stratégies avancées, une distribution primaire et une distribution secondaire. Le volet recherche présenté ici comporte un ensemble d’enquêtes observationnelles visant à décrire, analyser et comprendre les effets sociaux, sanitaires, épidémiologiques et économiques de l’introduction de l’autodépistage du VIH en Côte d’Ivoire, au Mali et au Sénégal pour améliorer l’offre de dépistage (accessibilité, efficacité et éthique). Il est organisé en 5 paquets d’activités : (i) une enquête qualitative sur l’ADVIH auprès des populations clés reposant sur des entretiens qualitatifs individuels et de groupes auprès d’acteurs clés de la mise en œuvre, de membres des communautés de populations clés et d’utilisatrices et utilisateurs de l’ADVIH ; (ii) une ethnographie portant sur l’intégration de l’ADVIH pour le dépistage des partenaires de PvVIH dans trois sites de prise en charge du VIH et une sous enquête exploratoire portant sur la diffusion de l’ADVIH à travers les consultations IST ; (iii) une enquête téléphonique anonyme auprès des utilisatrices et utilisateurs de l’ADVIH recruté·e·s via une invitation à appeler un numéro vert apposée sur les kits d’ADVIH distribués ; (iv) une enquête économique des coûts incrémentiels de l’ADVIH avec une collecte des coûts auprès d’un échantillon de sites de dispensation de l’ADVIH et une étude des temps et mouvements ; (v) une modélisation épidémiologique (modèle compartimental dynamique) des trois pays et des impacts sanitaires et économiques de différents scénarios de passage à l’échelle