Cost-Effectiveness of Community-based Human Immunodeficiency Virus Self-Testing in Blantyre, Malawi

HIV self-testing (HIVST) is effective, with scale-up underway in sub-Saharan Africa. We assessed cost-effectiveness of adding HIVST to existing facility-based HIV testing and counselling (HTC) services. Both 2010 (initiate at CD4<350 cells/μl) and 2015 (initiate all) WHO guidelines for antiretroviral treatment (ART) were considered. A microsimulation model was developed that evaluated cost-effectiveness, from both health provider and societal perspectives, of an HIVST service implemented in a cluster-randomised trial (CRT) (ISRCTN02004005) in Malawi. The economic model drew upon health outcomes data observed in the CRT, and primary health economic studies undertaken in the trial population. Costs and health outcomes were evaluated over a 20-year time horizon, using a discount rate of 3%. Probabilistic sensitivity analysis was conducted to account for parameter uncertainty. From the health provider perspective and 20-year time horizon, facility HTC using 2010 WHO ART guidelines was the least costly (US$294.71 per person, 95%CrI:270.79-318.45) and least effective (11.64 QALYs per person, 95%CrI:11.43-11.86) strategy. Compared to this strategy, the incremental cost-effectiveness ratio (ICER) for facility HTC using 2015 WHO ART guidelines was US$226.85 (95%CrI:198.79-284.35) per quality-adjusted life year (QALY) gained. The strategy of facility HTC plus HIVST, using 2010 WHO ART guidelines, was extendedly dominated. The ICER for facility HTC plus HIVST, using 2015 WHO ART guidelines, was US$253.90 (95%CrI:201.71-342.02) per QALY gained compared with facility HTC and using 2015 WHO ART guidelines. HIVST may be cost-effective in a Malawian population with high HIV prevalence. HIVST is suited to an early HIV diagnosis and treatment strategy.