title: Cost and quality of life analysis of HIV self-testing and facility-based HIV testing and counselling in Blantyre, Malawi.
abstract: BACKGROUND
  HIV self-testing (HIVST) has been found to be highly effective, but no cost analysis has been undertaken to guide the design of affordable and scalable implementation strategies.
  
  
  METHODS
  Consecutive HIV self-testers and facility-based testers were recruited from participants in a community cluster-randomised trial ( ISRCTN02004005 ) investigating the impact of offering HIVST in addition to facility-based HIV testing and counselling (HTC). Primary costing studies were undertaken of the HIVST service and of health facilities providing HTC to the trial population. Costs were adjusted to 2014 US$ and INT$. Recruited participants were asked about direct non-medical and indirect costs associated with accessing either modality of HIV testing, and additionally their health-related quality of life was measured using the EuroQol EQ-5D.
  
  
  RESULTS
  A total of 1,241 participants underwent either HIVST (n = 775) or facility-based HTC (n = 446). The mean societal cost per participant tested through HIVST (US$9.23; 95 % CI: US$9.14-US$9.32) was lower than through facility-based HTC (US$11.84; 95 % CI: US$10.81-12.86). Although the mean health provider cost per participant tested through HIVST (US$8.78) was comparable to facility-based HTC (range: US$7.53-US$10.57), the associated mean direct non-medical and indirect cost was lower (US$2.93; 95 % CI: US$1.90-US$3.96). The mean health provider cost per HIV positive participant identified through HIVST was higher (US$97.50) than for health facilities (range: US$25.18-US$76.14), as was the mean cost per HIV positive individual assessed for anti-retroviral treatment (ART) eligibility and the mean cost per HIV positive individual initiated onto ART. In comparison to the facility-testing group, the adjusted mean EQ-5D utility score was 0.046 (95 % CI: 0.022-0.070) higher in the HIVST group.
  
  
  CONCLUSIONS
  HIVST reduces the economic burden on clients, but is a costlier strategy for the health provider aiming to identify HIV positive individuals for treatment. The provider cost of HIVST could be substantially lower under less restrictive distribution models, or if costs of oral fluid HIV test kits become comparable to finger-prick kits used in health facilities.
authors.affiliation: Division of Health Sciences, University of Warwick Medical School, Gibbet Hill Campus, Coventry, CV4 7AL, UK. H.Maheswaran@warwick.ac.uk.|Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi. H.Maheswaran@warwick.ac.uk.
authors.forename: Hendramoorthy
authors.initials: H
authors.lastname: Maheswaran
authors.affiliation: Division of Health Sciences, University of Warwick Medical School, Gibbet Hill Campus, Coventry, CV4 7AL, UK.
authors.forename: Stavros
authors.initials: S
authors.lastname: Petrou
authors.affiliation: Department of Public Health and Policy, University of Liverpool, Liverpool, Merseyside, L69 3BX, UK.|Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Pl, Liverpool, L3 5QA, UK.
authors.forename: Peter
authors.initials: P
authors.lastname: MacPherson
authors.affiliation: Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.
authors.forename: Augustine T
authors.initials: AT
authors.lastname: Choko
authors.affiliation: Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.
authors.forename: Felistas
authors.initials: F
authors.lastname: Kumwenda
authors.affiliation: Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.|Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Pl, Liverpool, L3 5QA, UK.
authors.forename: David G
authors.initials: DG
authors.lastname: Lalloo
authors.affiliation: Division of Health Sciences, University of Warwick Medical School, Gibbet Hill Campus, Coventry, CV4 7AL, UK.
authors.forename: Aileen
authors.initials: A
authors.lastname: Clarke
authors.affiliation: Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.|London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Elizabeth L
authors.initials: EL
authors.lastname: Corbett
mesh_terms: D000293:Adolescent; D000328:Adult; D003376:Counseling / Q000191:economics* / Q000706:statistics & numerical data; D059026:Diagnostic Self Evaluation; D005260:Female; D015658:HIV Infections / Q000175:diagnosis* / Q000191:economics* / Q000453:epidemiology / Q000628:therapy; D006679:HIV Seropositivity / Q000175:diagnosis / Q000191:economics / Q000453:epidemiology / Q000628:therapy; D015497:HIV-1 / Q000276:immunology; D017048:Health Care Costs / Q000706:statistics & numerical data; D006268:Health Facilities / Q000191:economics* / Q000706:statistics & numerical data; D006801:Humans; D008295:Malawi / Q000453:epidemiology; D008297:Male; D008403:Mass Screening / Q000191:economics / Q000379:methods; D008875:Middle Aged; D011788:Quality of Life; D012698:Serologic Tests / Q000191:economics / Q000706:statistics & numerical data; D059039:Standard of Care / Q000191:economics / Q000706:statistics & numerical data; D055815:Young Adult