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Introduction To ensure there is adequate investment into diagnostics, an understanding of the magnitude of impact and return on investment is necessary. We, therefore, sought to understand the health and economic impacts of the molecular diagnostic programme in South Africa, to deepen the understanding of the broad value of diagnostics and guide future healthcare investments.Methods We calculated the 10-year (where data were available) total cost and disability-adjusted life-years (DALYs) averted associated with molecular testing for tuberculosis diagnosis (2013–2022), HIV viral load monitoring (2013–2022), early infant diagnosis of HIV infection (2013–2022) and SARS-CoV-2 testing (2020–2022), based on the actual number of molecular tests conducted in South Africa for the respective time periods. We then calculated the economic value associated with those health gains and subsequent return on investment.Results Since the inception of the molecular diagnostics programme in South Africa, approximately 4.3 million DALYs (uncertainty range (UR): 2.8–5.8 million) have been averted as a direct consequence of this programme. This has generated an estimated US$28.3 billion in economic value due to these health gains (UR$18.4–UR$38.7 billion). The return on investment varied by specific diagnostic test (20.3 (UR 15.2–25.4) for tuberculosis, 7.7 (UR 1.6–13.9) for HIV viral load testing, 63.0 (UR 63.0–65.5) for early infant diagnosis of HIV and 2.5 (UR 0.7–4.6) for SARS-CoV-2), for an average of 13.9 (UR 9.0–18.9) for the entire molecular diagnostics programme or US$13.9 of value for each UR$1 invested.Conclusions The molecular diagnostics programme in South Africa generated a significant amount of health gains and economic value associated with these health gains. The return on investment rivals other high-impact public health interventions such as childhood vaccination. The molecular diagnostics programme in South Africa is highly impactful and will continue to be an excellent investment in South African public health expenditure.

The objective of this scoping review is to understand the cost-effectiveness of current and future tools/strategies for screening and diagnosis of tuberculosis (TB) infection and disease. To this end, PubMed, EMBASE and SCOPUS were used to identify any English language reports on the cost-effectiveness of TB infection/disease screening/diagnostic strategies published between 1 January 2017 and 7 October 2023. Studies included high-burden/risk TB populations, compared diagnostic/screening methods and conducted a cost-effectiveness/economic evaluation. We stratified the included articles in four groups (cost-effectiveness of diagnosing TB disease/infection and cost-effectiveness of screening for TB disease/infection). A full-text review was conducted, and relevant costing data extracted. Of the 2417 articles identified in the initial search, 112 duplicates were removed, and 2305 articles were screened for title and abstract. 23 full articles were reviewed, and 17 fulfilled all inclusion criteria. While sputum smear microscopy (SSM) has been the primary method of diagnosing TB disease in high-burden countries, the current body of literature suggests that SSM is likely to be the least cost-effective tool for the diagnosis of TB disease. Further scale-up with molecular diagnostics, such as GeneXpert and Truenat, was shown to be broadly cost-effective, with a multitest approach likely to be cost-effective for both screening and diagnosis. There is an urgent need to increase access and remove barriers to implementation of diagnostics that have been repeatedly shown to be cost-effective, as well as to develop new diagnostic and screening technologies/strategies to address current barriers to scale-up.

Objectives To determine the most epidemiologically effective and cost-effective school-based SARS-CoV-2 antigen-detection rapid diagnostic test (Ag-RDT) self-testing strategies among teachers and students.Design Mathematical modelling and economic evaluation.Setting and participants Simulated school and community populations were parameterised to Brazil, Georgia and Zambia, with SARS-CoV-2 self-testing strategies targeted to teachers and students in primary and secondary schools under varying epidemic conditions.Interventions SARS-CoV-2 Ag-RDT self-testing strategies for only teachers or teachers and students—only symptomatically or symptomatically and asymptomatically at 5%, 10%, 40% or 100% of schools at varying frequencies.Outcome measures Outcomes were assessed in terms of total infections and symptomatic days among teachers and students, as well as total infections and deaths within the community under the intervention compared with baseline. The incremental cost-effectiveness ratios (ICERs) were calculated for infections prevented among teachers and students.Results With respect to both the reduction in infections and total cost, symptomatic testing of all teachers and students appears to be the most cost-effective strategy. Symptomatic testing can prevent up to 69·3%, 64·5% and 75·5% of school infections in Brazil, Georgia and Zambia, respectively, depending on the epidemic conditions, with additional reductions in community infections. ICERs for symptomatic testing range from US$2 to US$19 per additional school infection averted as compared with symptomatic testing of teachers alone.Conclusions Symptomatic testing of teachers and students has the potential to cost-effectively reduce a substantial number of school and community infections.

Places of worship serve as a venue for both mass and routine gathering around the world, and therefore are associated with risk of large-scale SARS-CoV-2 transmission. However, such routine gatherings also offer an opportunity to distribute self-tests to members of the community to potentially help mitigate transmission and reduce broader community spread of SARS-CoV-2. Over the past four years, self-testing strategies have been an impactful tool for countries' response to the COVID-19 pandemic, especially early on to mitigate the spread when vaccination and treatment options were limited. We used an agent-based mathematical model to estimate the impact of various strategies of symptomatic and asymptomatic self-testing for a fixed percentage of weekly routine gatherings at places of worship on community transmission of SARS-CoV-2 in Brazil, Georgia, and Zambia. Testing strategies assessed included weekly and bi-weekly self-testing across varying levels of vaccine effectiveness, vaccine coverage, and reproductive numbers to simulate developing stages of the COVID-19 pandemic. Self-testing symptomatic people attending routine gatherings can cost-effectively reduce the spread of SARS-CoV-2 within places of worship and the community, resulting in incremental cost-effectiveness ratios of $69-$303 USD. This trend is especially true in contexts where population level attendance at such gatherings is high, demonstrating that a distribution approach is more impactful when a greater proportion of the population is reached. Asymptomatic self-testing of attendees at 100% of places of worship in a country results in the greatest percent of infections averted and is consistently cost-effective but remains costly. Budgetary needs for asymptomatic testing are expensive and likely unaffordable for lower-middle income countries (520-1550x greater than that of symptomatic testing alone), promoting that strategies to strengthen symptomatic testing should remain a higher priority.