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IntroductionGlobally, there are approximately 58 million people with chronic hepatitis C virus infection (HCV) but only 20% have been diagnosed. HCV self-testing (HCVST) could reach those who have never been tested and increase access and uptake of HCV testing services. We compared cost per HCV diagnosis or cure for HCVST versus facility-based HCV testing services.MethodsWe used a decision analysis model with a one-year time horizon to examine the key drivers of economic cost per diagnosis (viraemic infection) or cure following the introduction of HCVST in China (men who have sex with men), Georgia (men 40-49 years), Viet Nam (people who inject drugs, PWID), and Kenya (PWID). HCV antibody (HCVAb) prevalence ranged from 1%-60% across settings. Model parameters in each setting were informed by HCV testing and treatment programmes, HIV self-testing programmes, and expert opinion. In the base case, we assume a reactive HCVST is followed by a facility-based rapid diagnostic test (RDT) and then nucleic acid testing (NAT). We assumed oral-fluid HCVST costs of $5.63/unit ($0.87-$21.43 for facility-based RDT), 62% increase in testing following HCVST introduction, 65% linkage following HCVST, and 10% replacement of facility-based testing with HCVST based on HIV studies. Parameters were varied in sensitivity analysis. Outcomes are reported in 2019 US dollars ($).ResultsCost per HCV viraemic diagnosis without HCVST ranged from $35 (Viet Nam) to $361 (Kenya). With HCVST, diagnosis increased resulting in incremental cost per diagnosis of $104 in Viet Nam, $163 in Georgia, $587 in Kenya, and $2,647 in China. Differences were driven by HCVAb prevalence. Switching to blood-based HCVST ($2.25/test), increasing uptake of HCVST and linkage to facility-based care and NAT testing, or proceeding directly to NAT testing following HCVST, reduced the cost per diagnosis. The baseline incremental cost per cure was lowest in Georgia ($1,418), similar in Viet Nam ($2,033), and Kenya ($2,566), and highest in China ($4,956).ConclusionsHCVST increased the number of people tested, diagnosed, and cured, but at higher cost. Introducing HCVST is more cost-effective in populations with high prevalence.Key messagesWhat is already known on this topicA recent systematic review of the impact and cost of Hepatitis C virus (HCV) self-testing (HCVST) found no prior evaluations of the cost or cost-effectiveness of HCVST. Indirect evidence can be inferred from studies of HIV self-testing (HIVST), which support the affordability and cost-effectiveness of self-testing in low and middle-income (LMIC) settings in Asia and sub-Saharan Africa. Other recent studies related to HCVST demonstrate the feasibility and usability of HCVST in various LMIC settings.What this study addsThis study is the first to evaluate the cost or cost-effectiveness of HCVST. With quality-assured HCVST coming onto the market in the near future, we build on the best available evidence on potential costs for HCV testing and treatment from four LMIC settings in general and key population groups with HCVAb prevalence ranging from 1% - 60%, and show it is likely to be cost-effective (depending on willingness to pay threshold) particularly where prevalence is high.How this study might affect research, practice or policyThe results of this study indicate that introducing HCVST will help countries diagnose and treat more people with HCV and contribute to achieving elimination goals faster. However, such gains will require additional investment on top of the standard of care. Targeting HCVST toward populations and settings with high HCV burden will be the most affordable option for countries. Efforts to reduce HCV treatment costs, optimize HCVST delivery and linkage services are needed to achieve greatest public health impact of offering this new approach.

ObjectivesKey populations, including sex workers, men who have sex with men, and people who inject drugs, have a high risk of HIV and sexually transmitted infections (STIs). We assessed the health and economic impacts of different HIV and syphilis testing strategies among three key populations in Viet Nam using a dual HIV/syphilis rapid diagnostic test (RDT).SettingWe used the Spectrum AIDS Impact Model to simulate the HIV epidemic in key populations in Viet Nam and evaluated five testing scenarios. We used a 15-year time horizon and all costs are from the provider’s perspective.ParticipantsWe include the entire population of Viet Nam in the model.InterventionsWe model five testing scenarios among key populations: 1) annual testing with an HIV rapid diagnostic test (RDT), 2) annual testing with a dual RDT, 3) biannual testing using dual RDT and HIV RDT, 4) biannual testing using HIV RDT, and 5) biannual testing using dual RDTs.Primary and secondary outcome measuresThe primary outcome is incremental cost-effectiveness ratios (ICERS). Secondary outcomes include HIV and syphilis cases and costs for each proposed intervention.ResultsAnnual testing using a dual HIV/syphilis RDT was cost saving and averted 3,206 HIV cases and treated 7,719 syphilis cases compared to baseline over 15 years. Biannual testing using one dual test and one HIV RDT, or two dual tests both averted an additional 875 HIV cases and were cost-effective ($1,024 and $2,518 per DALY averted, respectively). Annual or biannual HIV testing using HIV RDTs and separate syphilis tests were more costly and less effective than using one or two dual RDTs.ConclusionsAnnual or biannual HIV and syphilis testing using dual RDTs among key populations can be cost-effective and support countries in reaching global reduction goals for HIV and syphilis.STRENGTHS AND LIMITATIONS OF THIS STUDYStrength: Our model presents novel cost-effectiveness estimates for the use of dual HIV/syphilis testing in key populations that can inform health plannersStrength: We include five testing scale up scenarios using both HIV RDT and dual HIV/syphilis RDTStrength: Our model is informed by demographic, behavioral, and biological data from government sources, surveys, surveillance, publicly available reports, databases, and peer-reviewed literatureLimitation: We made some assumptions regarding the timing and uptake of HIV and syphilis testing among key populations that may be inaccurate.Limitation: Our model assumes that increased syphilis testing and treatment will not impact syphilis prevalence, however, it is unknown whether increased testing will reduce or increase syphilis prevalence.

BackgroundHIV testing and counseling is a key component of HIV prevention and the entry point into the treatment cascade, which improves for individual clinical outcomes and reduces onward HIV transmission. Current guidelines recommend at least annual testing for key populations. More frequent testing could provide health benefits, but these additional services increase the program the cost-effectiveness is not well-evaluated.MethodsWe used a compartmental mathematical model to simulate the health and economic impact of HIV testing one to four times per year for men who have sex with men, people who inject drugs, and female sex workers in Viet Nam. Model outcomes included costs, HIV infections, HIV-related deaths, and disability-adjusted life years (DALYs) associated with each scenario. We used an opportunity cost-based cost-effectiveness threshold of US $2,255 per DALY averted, discounted costs and health benefits at 3% annually, and used a time horizon from 2021 to 2030 to calculate incremental cost-effectiveness ratios (ICERs).ResultsCompared to the baseline scenario, more frequent HIV testing was estimated to incrementally avert 10.2%, 5.2%, 3.0%, and 1.6% discounted infections for one-, two-, three-, and four-tests per year, respectively. ICERs associated with each scenario ranged from $464, $1,190, $1,762, and $2,727 per DALY averted for one-, two-, three-, and four-tests per year, respectively.ConclusionsIncreased HIV testing frequency for key populations was projected to avert HIV incidence, mortality, and disability in Viet Nam and was cost-effective. Settings with a similar context should consider strategies on how to optimize retesting among key populations.