Assessing the potential population-level impacts of HIV self-testing distribution among key populations in Cote d'Ivoire, Mali, and Senegal: a mathematical modelling analysis

Background: A third of people living with HIV (PLHIV) in Western Africa had an undiagnosed infection in 2020. In 2019-2021, the ATLAS programme has distributed a total of 380 000 HIV self-testing (HIVST) kits to key populations (KP) including female sex workers (FSW) and men who have sex with men (MSM), and their partners in Cote d'Ivoire, Mali and Senegal. We predicted the potential impact of ATLAS and of national HIVST scale-up strategies among KP. Methods: A deterministic model of HIV transmission was calibrated to country-specific empirical HIV and intervention data over time. We simulated scenarios reflecting 1) the actual ATLAS HIVST distribution only over 2019-2021 (~2% of all tests done in countries), and 2) ATLAS followed by a scale-up of HIVST distribution to KP (total of ~570 000 kits distributed each year). Impacts on HIV diagnosis, new HIV infections and deaths were derived using counterfactual scenarios without HIVST. Findings: ATLAS was predicted to substantially increase HIV diagnosis among KP by the end of 2021, especially among MSM in Mali (94.3 percentage point [pp] increase), and a 1.0pp increase overall. ATLAS might have averted a median of 706 new HIV infections among KP over 2019-2028 in the 3 countries combined, especially among MSM, and 1794 new HIV infections (0.4-3.3% of all new HIV infections across countries) and 591 HIV-related deaths overall. HIVST scale-up increased HIV diagnosis at the end of 2028 by around 8pp among FSW and 33pp among MSM in every country. Overall increases ranged from 1.0pp (Cote d'Ivoire) to 11.0pp (Senegal). HIVST scale-up may avert 3-5% of new HIV infections among FSW, 3-10% among FSW clients, and 20-28% among MSM across countries (and 2-16% overall), and avert 13-18% of HIV-related deaths among MSM over 2019-2028. Interpretation: Scaling-up HIVST distribution among KP in Western Africa may substantially attenuate disparities in access to HIV testing and help reduce HIV infections and deaths among KP and their partners. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This work was supported by Unitaid (Grant Number: 2018-23 ATLAS) through a collaborative agreement with Solthis. RS and MCB acknowledge funding from the MRC Centre for Global Infectious Disease Analysis (reference MR/R015600/1), jointly funded by the UK Medical Research Council (MRC) and the UK Foreign, Commonwealth & Development Office (FCDO), under the MRC/FCDO Concordat agreement and is also part of the EDCTP2 programme supported by the European Union. PV, MCB and MMG acknowledge funding from the Wellcome Trust (WT 226619/Z/22/Z). MMG research program is supported Tier 2 Canada Research Chairs. For the purpose of open access, the author has applied a Creative Commons Attribution (CC BY) license to any Author Accepted Manuscript version arising. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. 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, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors