Optimal HIV testing strategies for South Africa: a model-based evaluation of population-level impact and cost-effectiveness

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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).

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Most cited references 40

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Quantifying the burden of disease: the technical basis for disability-adjusted life years.

C J Murray (1994)

Detailed assumptions used in constructing a new indicator of the burden of disease, the disability-adjusted life year (DALY), are presented. Four key social choices in any indicator of the burden of disease are carefully reviewed. First, the advantages and disadvantages of various methods of calculating the duration of life lost due to a death at each age are discussed. DALYs use a standard expected-life lost based on model life-table West Level 26. Second, the value of time lived at different ages is captured in DALYs using an exponential function which reflects the dependence of the young and the elderly on adults. Third, the time lived with a disability is made comparable with the time lost due to premature mortality by defining six classes of disability severity. Assigned to each class is a severity weight between 0 and 1. Finally, a three percent discount rate is used in the calculation of DALYs. The formula for calculating DALYs based on these assumptions is provided.

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Low male partner participation in antenatal HIV counselling and testing in northern Tanzania: implications for preventive programs.

S Msuya, E Mbizvo, A. Hussain … (2008)

This study aimed to describe the prevalence and predictors for male partner participation in HIV voluntary counselling and testing (VCT) at two primary healthcare clinics in Moshi urban, Tanzania as well as the effect of partner participation on uptake of HIV perinatal interventions. Pregnant women (n = 2654) in their third trimester, participating in a prevention of mother to child tranmission (PMTCT) program between June 2002 and March 2004 were encouraged to inform and invite their partners for HIV-VCT. Trained nurses conducted pre-test counselling, interviews, clinical examinations and blood sampling from the participating women and their partners. Test results were presented and post-test counselling was conducted individually or in couples, depending on the wishes of the participants. Three-hundred-and-thirty-two male partners (12.5%) came for HIV-VCT. A high proportion (131; 40%) came after the woman had delivered. HIV-seropositive women whose partners attended were three times more likely to use Nevirapine prophylaxis, four times more likely to avoid breastfeeding and six times more likely to adhere to the infant feeding method selected than those whose partners didn't attend. Women were more likely to bring their partner for VCT if they collected their own test results, were living with their partner, had a high monthly income and had expressed at enrolment the intention to share HIV results with their partner. Although PMTCT programs are presumably a good entry point for male involvement in prevention of sexual and perinatal HIV transmission, this traditional clinic-based approach reaches few men. Given the positive influence male participation has on the acceptance of perinatal interventions, a different approach for promoting male participation in VCT is urgently required. Within PMTCT programs, counseling should emphasize the advantages of partner participation to encourage women to inform and convince male partners to come for VCT. Also, promotion of couple VCT outside antenatal settings in male friendly and accessible settings should be given priority.

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Male antenatal attendance and HIV testing are associated with decreased infant HIV infection and increased HIV-free survival.

Adam R. Aluisio, Barbra Richardson, Rose Bosire … (2011)

To investigate the relationship between male involvement in prevention of mother-to-child HIV transmission services and infant HIV acquisition and mortality, a prospective cohort study was undertaken between 1999 and 2005 in Nairobi, Kenya. HIV-infected pregnant women were enrolled and followed with their infants for 1 year with infant HIV DNA testing at birth, 1, 3, 6, 9, and 12 months postpartum. Women were encouraged to invite male partners for prevention counseling and HIV testing. Among 456 female participants, 140 partners (31%) attended the antenatal clinic. Eighty-two (19%) of 441 infants tested were HIV infected by 1 year of age. Adjusting for maternal viral load, vertical transmission risk was lower among women with partner attendance compared with those without [adjusted hazard ratio (aHR) = 0.56, 95% confidence interval (CI): 0.33 to 0.98; P = 0.042] and among women reporting versus not reporting previous partner HIV testing (aHR = 0.52, 95% CI: 0.32 to 0.84; P = 0.008). The combined risk of HIV acquisition or infant mortality was lower with male attendance (aHR = 0.55; 95% CI: 0.35 to 0.88; P = 0.012) and report of prior male HIV testing (aHR = 0.58; 95% CI: 0.34 to 0.88; P = 0.01) when adjusting for maternal viral load and breastfeeding. Including men in antenatal prevention of mother-to-child HIV transmission services with HIV testing may improve infant health outcomes.

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Author and article information

Contributors

Leigh F. Johnson:

ORCID: http://orcid.org/0000-0002-2717-011X

Leigh.Johnson@uct.ac.za

Journal

Journal ID (nlm-ta): Sci Rep

Journal ID (iso-abbrev): Sci Rep

Title: Scientific Reports

Publisher: Nature Publishing Group UK (London )

ISSN (Electronic): 2045-2322

Publication date (Electronic): 2 September 2019

Publication date PMC-release: 2 September 2019

Publication date Collection: 2019

Volume: 9

Electronic Location Identifier: 12621

Affiliations

[1 ]ISNI 0000 0004 1937 1151, GRID grid.7836.a, Centre for Infectious Disease Epidemiology and Research, , University of Cape Town, ; Cape Town, South Africa

[2 ]ISNI 0000 0004 1937 1135, GRID grid.11951.3d, Health Economics and Epidemiology Research Office, , University of the Witwatersrand, ; Johannesburg, South Africa

[3 ]ISNI 0000 0004 1937 1135, GRID grid.11951.3d, Department of Medicine, Faculty of Health Sciences, , University of the Witwatersrand, ; Johannesburg, South Africa

[4 ]ISNI 0000 0004 1936 7558, GRID grid.189504.1, Department of Global Health, , Boston University School of Public Health, ; Boston, USA

Author information

Leigh F. Johnson http://orcid.org/0000-0002-2717-011X

Article

Publisher ID: 49109

DOI: 10.1038/s41598-019-49109-w

PMC ID: 6718403

PubMed ID: 31477764

SO-VID: 75183549-5bf7-4039-835a-0ad825ecd2d5

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Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/.

History

Date received : 1 May 2019

Date accepted : 19 August 2019

Funding

Funded by: HIV Modelling Consortium, USAID/PEPFAR

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ScienceOpen disciplines: Uncategorized

Keywords: hiv infections,diagnosis,applied mathematics

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ScienceOpen disciplines: Uncategorized

Keywords: hiv infections, diagnosis, applied mathematics

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Optimal HIV testing strategies for South Africa: a model-based evaluation of population-level impact and cost-effectiveness

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Most cited references 40

Quantifying the burden of disease: the technical basis for disability-adjusted life years.

Low male partner participation in antenatal HIV counselling and testing in northern Tanzania: implications for preventive programs.

Male antenatal attendance and HIV testing are associated with decreased infant HIV infection and increased HIV-free survival.

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Cited by 29

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