Self-testing for HIV in low-income, high-incidence countries could save money, could improve outcomes . . . but it’s complicated, analysis finds

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Introducing self-testing in a country like Zimbabwe, where HIV incidence is high, resources to confront HIV are limited, and only about half the people who live with HIV know they have the virus, could save about $75 million over the next 20 years, with some health benefits, besides. That would make the self-testing more cost-effective than the current prevalent alternative which relies on health care workers, health care settings, and willingness on the part of the person being tested to overcome concerns about privacy, discrimination, and inconvenience, the authors of an analysis recently published in the Journal of Infectious Diseases say.

But the study, Assessment of the Potential Impact and Cost-effectiveness of Self-Testing for HIV in Low-Income Countries, by Valentina Cambiano of the University College of London and others, also concludes the variables that come with self testing are complicated enough that it could go the other way. It is a nuanced answer to questions surrounding the potential for self-tests to make a difference in both resources and numbers of people testing and knowing their status, at least since 2012 when the U.S. Food and Drug Administration approved OraQuick In-Home HIV Test for over-the-counter sales in the United States. Some questions,regarding the suitability of the tests to low income countries were offered in preliminary research in Kenya and Malawi suggesting the tests would be acceptable, used, and would not necessarily weaken chances of getting into care. While Oraquick self-testing kits are priced at $40 in the U.S., they are priced at about $3 per test in this analysis. While confirmatory tests would still be needed for positive results, the bulk of the savings would be realized by cutting out the cost of the middle-man — the health worker — from the cost of testing.

But here’s one of the variables: while testing delivered by health providers is estimated to be accurate in a negative result 98 percent of the time, and accurate in showing a positive result 100 percent of the time, self tests, according to the package insert are less reliable, with 92 percent accuracy on negative results and 99 percent accuracy on positive results. If that estimate is off, and self tests are less accurate (and the authors note that so far only one study has indicated that is the case), the consequences of that could add up to a less cost-effective scenario. Without good access to care, the benefits also drop.

And, an editorial by Benjamin Linas of Boston Medical Center and Boston University Schools of Medicine and Public Health accompanying the article on the study, points out, how the money saved by self-testing is then spent, also makes a difference in gains realized by the tests.

The authors of the study acknowledge all of these, and more, and conclude that their findings apply to the circumstances they assumed would be in place.



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