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During 2019–21, the AutoTest VIH, Libre d'accéder à la connaissance de son Statut (ATLAS) programme distributed around 380 000 HIV self-testing kits to key populations, including female sex workers, men who have sex with men, and their partners, in Côte d'Ivoire, Mali, and Senegal. We aimed to estimate the effects of the ATLAS programme and national scale-up of HIV self-test distribution on HIV diagnosis, HIV treatment coverage, HIV incidence, and HIV-related mortality.

Background: Calls for increased investment in sexually transmitted infection (STI) treatment across the developing world have been made to address the high disease burden and the association with HIV transmission. Goals: The goals of this study were to systematically review evidence on the cost of treating curable STIs and to explore its key determinants. Study: A search of published literature was conducted in PubMed and supplemented by reviews of gray literature. Studies were analyzed by broad focus. Regression analysis explored how intervention characteristics affect unit costs, accounting for differences in costing methods. Results: Fifty-three primary studies were identified, of which 62% used empirical data, 35% presented economic costs, and 22% presented full costs. The median STI treatment cost was $17.80. Clinics serving symptomatic patients were consistently cheaper than outreach services, services using syndromic management protocols had lower costs, and unit costs decreased with scale. Conclusions: The compiled cost data provide an evidence base that can be used to help inform resource planning.

Objective: The objective of this study is to estimate the annual costs of information, education, and communication (IEC), both community- and school-based; strengthened public and private sexually transmitted infections treatment; condom social marketing (CSM); and voluntary counseling and testing (VCT) implemented in Masaka, Uganda, over 4 years, and to explore how unit costs change with varying population use/uptake. Study: Total economic provider's costs and intervention outputs were collected annually to estimate annual unit costs between 1996 and 1999. Results: In early intervention years, uptake of all activities grew dramatically and continued to grow for public STI treatment, CSM, and VCT. Attendance at IEC performances started to drop in year 4. Unit costs dropped rapidly with increasing uptake of and participation in interventions. Conclusions: When implementing long-term community-based interventions, it is important to take into account that it takes time for communities to scale up their participation, since this can lead to large variations in unit costs.

Objective: To estimate annual costs of a multifaceted adolescent sexual health intervention in Mwanza, Tanzania, by input (capital and recurrent), component (in-school, community activities, youth-friendly health services, condom distribution), and phase (development, startup, trial implementation, scale-up). Study Design: Financial and economic providers' costs and intervention outputs were collected to estimate annual total and unit costs (1999-2001). The incremental financial budget projects funding requirements for scale-up within an integrated model. Results: The 3-year economic costs of trial implementation were $879,032, of which ~70% were for the school-based component. Costs of initial development and startup were relatively substantial (~21% of total costs); however, annual costs per school child dropped from $16 in 1999 to $10 in 2001. The incremental scale-up cost is ~1/5 of ward trial implementation running costs. Conclusions: Annual costs can reduce by almost 40% as project implementation matures. When scaled up, only an additional $1.54 is needed per pupil per year to continue the intervention.

Objective: The objective of this study was to estimate the cost-effectiveness of syndromic management, with and without periodic presumptive treatment (PPT), in averting sexually transmitted infections (STIs) and HIV in female sex workers (FSWs) participating in a hotel-based intervention in Johannesburg. Study Design: Financial and economic providers' costs were estimated. A mathematical model, fitted to epidemiologic data, projected the HIV and STIs averted by the intervention. Cost per HIV infection and DALY averted were estimated for different general population HIV prevalences. Results: Projections suggest 53 HIV infections were averted (July 2000-June 2001) and a 3.1% decrease in the FSW HIV incidence. Cost-effectiveness was $78 per DALY averted. Incremental cost of PPT was $31 per disability-adjusted life year (DALY) averted. Initiating the intervention at 15% general HIV prevalence would have improved cost-effectiveness by 35%. Expanding PPT coverage to mass-treat all FSWs (instead of Conclusion: The results highlight targeted interventions can be cost-effective at all stages of HIV epidemics and suggests PPT could improve the cost-effectiveness of targeted STI interventions.

HIV modelling and economic analyses have had a prominent role in guiding programmatic responses to HIV in sub-Saharan Africa. However, there has been little reflection on how the HIV modelling field might develop in future. HIV modelling should more routinely align with national government and ministry of health priorities, recognising their legitimate mandates and stewardship responsibilities, for HIV and other wider health programmes. Importance should also be placed on ensuring collaboration between modellers, and that joint approaches to addressing modelling questions, becomes the norm rather than the exception. Such an environment can accelerate translation of modelling analyses into policy formulation because areas where models agree can be prioritised for action, whereas areas over which uncertainty prevails can be slated for additional study, data collection, and analysis. HIV modelling should increasingly be integrated with the modelling of health needs beyond HIV, particularly in allocative efficiency analyses, where focusing on one disease over another might lead to worse health overall. Such integration might also enhance partnership with national governments whose mandates extend beyond HIV. Finally, we see a need for there to be substantial and equitable investment in capacity strengthening within African countries, so that African researchers will increasingly be leading modelling exercises. Building a critical mass of expertise, strengthened through external collaboration and knowledge exchange, should be the ultimate goal.

Approaches that allow easy access to pre-exposure prophylaxis (PrEP), such as over-the-counter provision at pharmacies, could facilitate risk-informed PrEP use and lead to lower HIV incidence, but their cost-effectiveness is unknown. We aimed to evaluate conditions under which risk-informed PrEP use is cost-effective.

ObjectivesSelf-testing for STIs such as HIV and syphilis may empower sexual minorities and expand uptake of STI testing. While much is known about HIV self-testing (HIVST), less is known about syphilis self-testing, particularly in low-income settings. The objective of this study is to determine context-specific facilitators and barriers for self-testing and to assess the usability of syphilis self-testing in Zimbabwe among men who have sex with men (MSM).MethodsThis mixed methods study was conducted in Harare as part of a larger syphilis self-testing trial. The study included in-depth interviews (phase I) followed by usability testing and a second interview (phase II). In-depth interviews were conducted with MSM and key informants prior to syphilis self-testing. The same MSM then used the syphilis self-test, quantitatively assessed its usability and participated in a second in-depth interview. Phase I data were analysed using a thematic approach, guided by an adapted social ecological model conceptual framework. Phase II interviews were analysed using rapid assessment procedure methodology, and usability was assessed using a pre-established index, adapted from existing HIVST scales.ResultsTwenty MSM and 10 key informants were recruited for phase I in-depth interviews, and 16 of these MSM participated in phase II by completing a syphilis self-test kit. Facilitating factors for self-testing included the potential for increased privacy, convenience, autonomy, and avoidance of social and healthcare provider stigma. Barriers included the fear to test and uncertainty about linkage to care and treatment. Data from the Usability Index suggested high usability (89.6% on a 0–100 scale) among the men who received the self-test.ConclusionsMSM in Zimbabwe were willing to use syphilis self-test kits and many of the barriers and facilitators were similar to those observed for HIVST. Syphilis self-testing may increase syphilis test uptake among sexual minorities in Zimbabwe and other low-income and middle-income countries.

Early HIV diagnosis reduces morbidity, mortality, the probability of onward transmission, and their associated costs, but might increase cost because of earlier initiation of antiretroviral treatment (ART). We investigated this trade-off by estimating the cost-effectiveness of HIV screening in primary care.

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There are inefficiencies in current approaches to monitoring patients on antiretroviral therapy in sub-Saharan Africa. Patients typically attend clinics every 1 to 3 months for clinical assessment. The clinic costs are comparable with the costs of the drugs themselves and CD4 counts are measured every 6 months, but patients are rarely switched to second-line therapies. To ensure sustainability of treatment programmes, a transition to more cost-effective delivery of antiretroviral therapy is needed. In contrast to the CD4 count, measurement of the level of HIV RNA in plasma (the viral load) provides a direct measure of the current treatment effect. Viral-load-informed differentiated care is a means of tailoring care so that those with suppressed viral load visit the clinic less frequently and attention is focussed on those with unsuppressed viral load to promote adherence and timely switching to a second-line regimen. The most feasible approach to measuring viral load in many countries is to collect dried blood spot samples for testing in regional laboratories; however, there have been concerns over the sensitivity and specificity of this approach to define treatment failure and the delay in returning results to the clinic. We use modelling to synthesize evidence and evaluate the cost-effectiveness of viral-load-informed differentiated care, accounting for limitations of dried blood sample testing. We find that viral-load-informed differentiated care using dried blood sample testing is cost-effective and is a recommended strategy for patient monitoring, although further empirical evidence as the approach is rolled out would be of value. We also explore the potential benefits of point-of-care viral load tests that may become available in the future.This article has not been written or reviewed by Nature editors. Nature accepts no responsibility for the accuracy of the information provided.

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Many people with HIV are undiagnosed. Early diagnosis saves lives and reduces onward transmission. We assessed whether an education programme promoting rapid HIV testing in general practice would lead to increased and earlier HIV diagnosis.

BackgroundPOEMS syndrome is a rare cause of neuropathy misdiagnosed as Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP) in 60% of cases. Ineffective CIDP directed therapy is expensive, introduces risk of complications, and often results in disease progression. Vascular endothelial growth factor (VEGF) is a sensitive and specific biomarker in the diagnosis of POEMS syndrome costing approximately £50. Introducing early directed screening with VEGF more accurately distinguishes POEMS syndrome from CIDP than the current standard of care (SOC).Methods100 cases from the UCLH POEMS database were selected. We grouped patients according to diagnostic pathway and compared health outcomes. We conducted a model-based cost-effectiveness analysis to compare diagnostic outcomes and costs of the current SOC with intervention pathways using VEGF screening. We used a study cohort of 1,250 patients with polyneuropathy (UK incidence) and conducted costing from a health-services perspective.ResultsTreatments associated with POEMS misdiagnosis led to a total healthcare expenditure in our cohort of £808,550-£1,111,756 over 20 years, with an average cost-per-POEMS-syndrome-patient misdiagnosed of£14,701-£20,214. Our intervention pathway which introduces VEGF screening into the current SOC results in 4 additional early POEMS diagnoses per year and a cost-saving of almost £40,000 through avoidance of non-POEMS directed therapy and related hospital costs.ConclusionVEGF testing should be routine for patients presenting with an acquired demyelinating neu- ropathy. This will improve early diagnosis of POEMS syndrome, enable effective therapy and reduce cos8ts5.stephen.keddie@nhs.net