{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,15]],"date-time":"2026-01-15T23:10:35Z","timestamp":1768518635662,"version":"3.49.0"},"reference-count":27,"publisher":"BMJ","issue":"Suppl 4","license":[{"start":{"date-parts":[[2021,7,13]],"date-time":"2021-07-13T00:00:00Z","timestamp":1626134400000},"content-version":"unspecified","delay-in-days":12,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/3.0\/igo\/"}],"funder":[{"name":"Unitaid","award":["PO#8477-0-600"],"award-info":[{"award-number":["PO#8477-0-600"]}]},{"DOI":"10.13039\/100004440","name":"Wellcome Trust","doi-asserted-by":"publisher","award":["WT091769"],"award-info":[{"award-number":["WT091769"]}],"id":[{"id":"10.13039\/100004440","id-type":"DOI","asserted-by":"publisher"}]},{"name":"BMGF","award":["OPP1189095"],"award-info":[{"award-number":["OPP1189095"]}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Glob Health"],"accepted":{"date-parts":[[2021,4,27]]},"published-print":{"date-parts":[[2021,7]]},"abstract":"<jats:sec>\n                  <jats:title>Introduction<\/jats:title>\n                  <jats:p>As countries approach the UNAIDS 95-95-95 targets, there is a need for innovative and cost-saving HIV testing approaches that can increase testing coverage in hard-to-reach populations. The HIV Self-Testing Africa-Initiative distributed HIV self-test (HIVST) kits using unincentivised HIV testing counsellors across 31 public facilities in Malawi, South Africa, Zambia and Zimbabwe. HIVST was distributed either through secondary (partner\u2019s use) distribution alone or primary (own use) and secondary distribution approaches.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>We evaluated the costs of adding HIVST to existing HIV testing from the providers\u2019 perspective in the 31 public health facilities across the four countries between 2018 and 2019. We combined expenditure analysis and bottom-up costing approaches. We also carried out time-and-motion studies on the counsellors to estimate the human resource costs of introducing and demonstrating how to use HIVST for primary and secondary use.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>A total of 41\u2009720 kits were distributed during the analysis period, ranging from 1254 in Zimbabwe to 27\u2009678 in Zambia. The cost per kit distributed through the primary distribution approach was $4.27 in Zambia and $9.24 in Zimbabwe. The cost per kit distributed through the secondary distribution approach ranged from $6.46 in Zambia to $13.42 in South Africa, with a wider variation in the average cost at facility-level. From the time-and-motion observations, the counsellors spent between 20% and 44% of the observed workday on HIVST. Overall, personnel and test kit costs were the main cost drivers.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusion<\/jats:title>\n                  <jats:p>The average costs of distributing HIVST kits were comparable across the four countries in our analysis despite wide cost variability within countries. We recommend context-specific exploration of potential efficiency gains from these facility-level cost variations and demand creation activities to ensure continued affordability at scale.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1136\/bmjgh-2021-005191","type":"journal-article","created":{"date-parts":[[2022,1,7]],"date-time":"2022-01-07T00:45:53Z","timestamp":1641516353000},"page":"e005191","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":17,"title":["Costs of integrating HIV self-testing in public health facilities in Malawi, South Africa, Zambia and Zimbabwe"],"prefix":"10.1136","volume":"6","author":[{"given":"Linda Alinafe","family":"Sande","sequence":"first","affiliation":[{"name":"Faculty of Public Health and Policy, Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK"},{"name":"Public Health Group, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Katleho","family":"Matsimela","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Health Economics and Epidemiology Research Office, Johannesburg, South Africa"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lawrence","family":"Mwenge","sequence":"additional","affiliation":[{"name":"Health Economics Unit, Zambart, Lusaka, Zambia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0733-0622","authenticated-orcid":false,"given":"Collin","family":"Mangenah","sequence":"additional","affiliation":[{"name":"Centre for Sexual Health, HIV\/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Augustine Talumba","family":"Choko","sequence":"additional","affiliation":[{"name":"Public Health Group, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Marc","family":"d'Elb\u00e9e","sequence":"additional","affiliation":[{"name":"Faculty of Public Health and Policy, Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mohammed","family":"Majam","sequence":"additional","affiliation":[{"name":"University of the Witwatersrand, Ezintsha, Johannesburg, South Africa"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Cyprian","family":"Mostert","sequence":"additional","affiliation":[{"name":"Faculty of Health Sciences, University of the Witwatersrand, Wits Reproductive Health and HIV Institute, Johannesburg, South Africa"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Inonge","family":"Matamwandi","sequence":"additional","affiliation":[{"name":"Health Economics Unit, Zambart, Lusaka, Zambia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1754-1076","authenticated-orcid":false,"given":"Euphemia Lindelwe","family":"Sibanda","sequence":"additional","affiliation":[{"name":"Centre for Sexual Health and HIV\/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Cheryl","family":"Johnson","sequence":"additional","affiliation":[{"name":"HIV Department, WHO, Geneva, Switzerland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Karin","family":"Hatzold","sequence":"additional","affiliation":[{"name":"Population Services International, Cape Town, South Africa"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Helen","family":"Ayles","sequence":"additional","affiliation":[{"name":"Zambart, Lusaka, Zambia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Frances M","family":"Cowan","sequence":"additional","affiliation":[{"name":"Centre for Sexual Health HIV\/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe"},{"name":"Liverpool School of Tropical Medicine, Liverpool, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Elizabeth Lucy","family":"Corbett","sequence":"additional","affiliation":[{"name":"Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8870-6504","authenticated-orcid":false,"given":"Melissa","family":"Neuman","sequence":"additional","affiliation":[{"name":"MRC International Statistics and Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hendramoorthy","family":"Maheswaran","sequence":"additional","affiliation":[{"name":"Imperial College London, London, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Gesine","family":"Meyer-Rath","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Health Economics and Epidemiology Research Office, Johannesburg, South Africa"},{"name":"Center for Global Health and Development, Boston University School of Public Health, Boston, Massachusetts, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Fern","family":"Terris-Prestholt","sequence":"additional","affiliation":[{"name":"Department of Global Health & Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK"},{"name":"Joint United Nations Programme on HIV\/AIDS, Geneva, Switzerland"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2021,7,18]]},"reference":[{"key":"2025072913400625000_6.Suppl_4.e005191.1","unstructured":"UNAIDS . Understanding fast\u2010track: accelerating action to end the AIDS epidemic by 2030. Geneva: UNAIDS, 2015."},{"key":"2025072913400625000_6.Suppl_4.e005191.2","unstructured":"UNAIDS . Unaids data 2019. Geneva: UNAIDS, 2019."},{"key":"2025072913400625000_6.Suppl_4.e005191.3","doi-asserted-by":"crossref","first-page":"S203","DOI":"10.1097\/QAD.0000000000001516","article-title":"'I will choose when to test, where I want to test': investigating young people's preferences for HIV self-testing in Malawi and Zimbabwe","volume":"31 Suppl 3","author":"Indravudh","year":"2017","journal-title":"AIDS"},{"key":"2025072913400625000_6.Suppl_4.e005191.4","doi-asserted-by":"crossref","first-page":"27","DOI":"10.1080\/09540121.2018.1479032","article-title":"Costs of accessing HIV testing services among rural Malawi communities","volume":"30","author":"Sande","year":"2018","journal-title":"AIDS Care"},{"key":"2025072913400625000_6.Suppl_4.e005191.5","doi-asserted-by":"publisher","DOI":"10.1186\/s12916-016-0577-7"},{"key":"2025072913400625000_6.Suppl_4.e005191.6","unstructured":"UNAIDS . Ending AIDS: progress towards the 90-90-90 targets. Global AIDS update, 2017."},{"key":"2025072913400625000_6.Suppl_4.e005191.7","unstructured":"World Health Organization . Guidelines on HIV self-testing and partner notification: supplement to consolidated guidelines on HIV testing services. World Health Organization, 2016."},{"key":"2025072913400625000_6.Suppl_4.e005191.8","doi-asserted-by":"crossref","DOI":"10.1002\/jia2.25244","article-title":"HIV self-testing: breaking the barriers to uptake of testing among men and adolescents in sub-Saharan Africa, experiences from STAR demonstration projects in Malawi, Zambia and Zimbabwe","volume":"22 Suppl 1","author":"Hatzold","year":"2019","journal-title":"J Int AIDS Soc"},{"key":"2025072913400625000_6.Suppl_4.e005191.9","doi-asserted-by":"publisher","DOI":"10.1136\/sextrans-2011-050199"},{"key":"2025072913400625000_6.Suppl_4.e005191.10","unstructured":"UNAIDS . Unaids terminology guidelines. Geneva, Switzerland: UNAIDS, 2015."},{"key":"2025072913400625000_6.Suppl_4.e005191.11","doi-asserted-by":"crossref","first-page":"e276","DOI":"10.1016\/S2214-109X(19)30534-0","article-title":"Effect of facility-based HIV self-testing on uptake of testing among outpatients in Malawi: a cluster-randomised trial","volume":"8","author":"Dovel","year":"2020","journal-title":"Lancet Glob Health"},{"key":"2025072913400625000_6.Suppl_4.e005191.12","unstructured":"Ahmed N , Mwenge L , Sande L . Cost analysis of differentiated HIV Self-Tsting kits distribution in Zambia. Boston, Massachusetts: Conference on Retroviruses and Opportunistic Infections, 2018."},{"key":"2025072913400625000_6.Suppl_4.e005191.13","doi-asserted-by":"crossref","DOI":"10.1002\/jia2.25255","article-title":"Economic cost analysis of door-to-door community-based distribution of HIV Self-Test kits in Malawi, Zambia and Zimbabwe","volume":"22 Suppl 1","author":"Mangenah","year":"2019","journal-title":"J Int AIDS Soc"},{"key":"2025072913400625000_6.Suppl_4.e005191.14","doi-asserted-by":"crossref","unstructured":"D\u2019elb\u00e9e M , Makhetha MC , Jubilee M . Using HIV self-testing to increase the affordability of community-based HIV testing services: a longitudinal analysis in Lesotho. AIDS 2020.","DOI":"10.1097\/QAD.0000000000002664"},{"key":"2025072913400625000_6.Suppl_4.e005191.15","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0210497","article-title":"The per-patient costs of HIV services in South Africa: systematic review and application in the South African HIV investment case","volume":"14","author":"Meyer-Rath","year":"2019","journal-title":"PLoS One"},{"key":"2025072913400625000_6.Suppl_4.e005191.16","unstructured":"Choko AT , Fielding K , Johnson CC . Partner-delivered HIV Self-Test kits with and without incentivized linkage versus clinic invitation letters among antenatal care Attendees and newly diagnosed HIV-positive patients in Malawi: a pragmatic three arm open-label facility-randomized trial, 2020."},{"key":"2025072913400625000_6.Suppl_4.e005191.17","unstructured":"Reserve bank of Malawi . Reserve bank of Malawi-exchange rates, 2021. Available: https:\/\/www.rbm.mw\/Statistics\/MajorRates"},{"key":"2025072913400625000_6.Suppl_4.e005191.18","unstructured":"Bank of Zambia . Average exchange rates, 2021."},{"key":"2025072913400625000_6.Suppl_4.e005191.19","unstructured":"South African Reserve Bank . Selected historical rates, 2021. Available: https:\/\/www.resbank.co.za\/en\/home\/what-we-do\/statistics\/key-statistics\/selected-historical-rates"},{"key":"2025072913400625000_6.Suppl_4.e005191.20","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0185740","article-title":"Costs of facility-based HIV testing in Malawi, Zambia and Zimbabwe","volume":"12","author":"Mwenge","year":"2017","journal-title":"PLoS One"},{"key":"2025072913400625000_6.Suppl_4.e005191.21","unstructured":"Drummond MF , Sculpher MJ , Claxton K . Methods for the economic evaluation of health care programmes. Oxford university press, 2015."},{"key":"2025072913400625000_6.Suppl_4.e005191.22","doi-asserted-by":"crossref","unstructured":"Botha A , Booi V , eds. mHealth implementation in South Africa. 2016 IST-Africa Week Conference. IEEE, 2016.","DOI":"10.1109\/ISTAFRICA.2016.7530667"},{"key":"2025072913400625000_6.Suppl_4.e005191.23","doi-asserted-by":"publisher","DOI":"10.1136\/sextrans-2015-052039"},{"key":"2025072913400625000_6.Suppl_4.e005191.24","doi-asserted-by":"publisher","DOI":"10.1136\/sextrans-2012-050544"},{"key":"2025072913400625000_6.Suppl_4.e005191.25","doi-asserted-by":"crossref","first-page":"147","DOI":"10.1016\/j.socscimed.2016.01.013","article-title":"Does integration of HIV and sexual and reproductive health services improve technical efficiency in Kenya and Swaziland? an application of a two-stage semi parametric approach incorporating quality measures","volume":"151","author":"Obure","year":"2016","journal-title":"Soc Sci Med"},{"key":"2025072913400625000_6.Suppl_4.e005191.26","unstructured":"Mahtani K , Spencer EA , Sackett Catalogue of Bias Collaboration . Hawthorne bias Catalogue of bias 2017, 2017. Available: https:\/\/catalogofbias.org\/biases\/hawthorne-effect\/"},{"key":"2025072913400625000_6.Suppl_4.e005191.27","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0146694","article-title":"Innovation in evaluating the impact of integrated service-delivery: the integra indexes of HIV and reproductive health integration","volume":"11","author":"Mayhew","year":"2016","journal-title":"PLoS One"}],"container-title":["BMJ Global Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjgh-2021-005191","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,7,29]],"date-time":"2025-07-29T20:40:16Z","timestamp":1753821616000},"score":1,"resource":{"primary":{"URL":"https:\/\/gh.bmj.com\/lookup\/doi\/10.1136\/bmjgh-2021-005191"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,7]]},"references-count":27,"journal-issue":{"issue":"Suppl 4","published-online":{"date-parts":[[2021,7,18]]},"published-print":{"date-parts":[[2021,7]]}},"alternative-id":["10.1136\/bmjgh-2021-005191"],"URL":"https:\/\/doi.org\/10.1136\/bmjgh-2021-005191","relation":{},"ISSN":["2059-7908"],"issn-type":[{"value":"2059-7908","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,7]]}}}