Using HIV Self-testing to Increase the Affordability of Community-based HIV Testing Services

Marc d'Elbée; Molemo Charles Makhetha; Makhahliso Jubilee; Matee Taole; Cyril Nkomo; Albert Machinda; Mphotleng Tlhomola; Linda A. Sande; Gabriela B. Gomez Guillen; Elizabeth L. Corbett; Cheryl C. Johnson; Karin Hatzold; Gesine Meyer-Rath; Fern Terris-Prestholt


AIDS. 2020;34(14):2115-2123. 

In This Article

Abstract and Introduction


Objectives: This study estimates the costs of community-based HIV testing services (HTS) in Lesotho and assesses the potential efficiency gains achieved by adding HIV self-testing (HIVST) and then self-testing booths.

Design: Micro-costing analysis using longitudinal data from a real-world intervention.

Methods: We collected data prospectively on provider's costs and programmatic outcomes over three time periods of approximately 8 months each, between May 2017 and April 2019. The scope of services was extended during each period as follows: HTS only, HTS and HIVST, HTS and HIVST with individual HIVST booths wherein clients were encouraged to self-test on-site followed by on-site confirmative testing for those with reactive self-test. For each implementation period, we estimated the full financial and economic implementation costs, the incremental costs of adding HIVST onto conventional HTS and the cost per HIV positive case identified.

Results: Costs per HIV-positive case identified increased between period 1 (US$956) and period 2 (US$1249) then dropped in period 3 (US$813). Full versus incremental cost analyses resulted in large differences in the magnitude of costs, attributable to methods rather than resource use: for example, in period 3, the average full and incremental cost estimates for HTS were US$34.3 and US$23.5 per person tested, and for HIVST were US$37.7 and US$14.0 per kit provided, respectively.

Conclusion: In Lesotho, adding HIVST to community-based HTS improves its overall affordability for HIV-positive case finding. The reporting of both full and incremental cost estimates increase transparency for use in priority setting, budgeting and financial planning for scale-up.


Lesotho has the second highest HIV burden in the world at a prevalence of 25.6% (30.4% among women and 20.8% among men) and an annual incidence of 1.1% among adults in 2017.[1] In recent years, the country made considerable progress towards the United Nation's 90-90-90 targets [by 2020, 90% of all people living with HIV will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral treatment (ART) and 90% of all people receiving ART will have viral suppression].[2] In 2017, among the estimated 306 000 people living with HIV (PLHIV), 81% are reporting knowledge of status, 92% of those are on ART and of those who are on ART, 88% are virally suppressed.[1]

Nationally, the total number of people tested for HIV increased from 221 616 in 2009 to 1 109 345 in 2017, while the proportion of new HIV-positive diagnosed out of all those tested (HIV yield rate) decreased from 18 to 4% over the same period.[3] Population Services International (PSI), a global nongovernmental health organization (NGO), provides most community-based HIV testing services (HTS) in Lesotho,[4] including door-to-door and mobile outreach services. In 2015, community-based index testing, which is HTS for sexual partners and biological children of people diagnosed with HIV, was added to PSI services under the CID-LINK project, achieving an average HIV yield rate of 4.2% with 79% of linkage to care among those diagnosed between May 2015 and November 2017.[5]

Yet, achieving the first 90 target called for innovative methods to reach undertested groups, notably men and young people (aged 15–24 years) among whom awareness of HIV-positive status was only 76.6 and 67.6%, respectively.[1,3,6,7] Following demonstrated success elsewhere in southern Africa, the Lesotho Ministry of Health (MOH) added HIV self-testing (HIVST) to the HTS strategy in 2017 with technical support and funding provided by the STAR (HIV Self-Testing AfRica) Initiative.[8–13]

Provision of multiple services delivered jointly alongside conventional HTS has the theoretical potential to achieve economies of scope,[14,15] through efficiency gains that reflect sharing of overheads, common fixed costs or through joint learning by staff for services provision or demand creation.[16,17] In particular, HIV self-testing can increase total testing numbers, but may also increase the programme's technical efficiency when provided alongside standard testing services if more people are diagnosed at a given cost.[18] However, relatively few data exist on how costs change over time during implementation of national HTS[12,19] or whether new testing modalities have succeeded in increasing a programme's efficiency.

The objective of this study was to estimate the costs of community-based HTS implementation in Lesotho before and after integration of HIVST. We aim to investigate potential efficiency gains from the addition of self-testing and from continuous programme development.