Facility-based HIV self-testing strategies may substantially increase number of men and youth tested for HIV in Malawi: results from a data-driven individual-based model

Background Malawi is rapidly closing the gap in achieving the UNAIDS 95-95-95 targets, with 90% of people living with HIV in Malawi aware of their status. As we approach epidemic control, interventions to improve coverage will become more costly. There is therefore an urgent need to identify innovative and low-cost strategies to maintain and increase testing coverage without diverting resources from other HIV services. Methods A data-driven individual-based model was parameterized with data from a community-representative survey (sociodemographic, health service utilization, HIV testing history) of men and youth in Malawi (data collected 08/2019). 79 different strategies for the implementation of HIV self-testing (HIVST) and provider-initiated-testing-and-counselling at the outpatient department (OPD) were evaluated. Outcomes included percent of men/youth tested for HIV in a 12-month period, cost-effectiveness, and human resource requirements. Testing yield was assumed to be constant across the scenarios. Findings Facility-based HIVST offered year-round resulted in the greatest increase in proportion of men and youth tested in the OPD (from 45% to 72%-83%), was considered cost-saving for HIVST kit priced at $1.00, and generally reduced required personnel as compared to the status quo. At higher HIVST kit prices, and more relaxed eligibility criteria, all scenarios that considered year-round HIVST in the OPD remained on the cost-effectiveness frontier. Interpretation Facility-based HIVST is a cost-effective strategy to increase the proportion of men/youth tested for HIV and decreases the human resource requirements for HIV testing in the OPD-providing additional health care worker time for other priority health care activities. Funding FCDO; USAID ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement The Foreign, Commonwealth and Development Office of the United Kingdom of Great Britain and Northern Ireland funded the study (grant number: 300380), as well as United States Agency for International Development (Cooperative agreement). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The National Health Sciences Review Committee of Malawi (number 2338) and the University of California Los Angeles Institutional Review Board (number 20-001606) approved study activities All necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes Underlying model input data are available upon request.