Comparison of HIV self-testing (HIVST) costs in Zambia: UNITAID PSI HIV SELF-TESTING AFRICA Comparison of HIV self-testing (HIVST) costs in Zambia: a question of scale and scope? Lawrence Mwenge, MSc Nurilign Ahmed, Linda Sande, Collin Mangenah, Marc d’Elbée, Sarah Kanema, Jason J. Ong, Mutinta Nalubamba, Sepiso Libamba, Hambweka Munkombwe, Pitchaya Indravudh, Euphemia Sibanda, Hendramoorthy Maheswaran, Cheryl Johnson, Karin Hatzold, Liz E. Corbett, Helen Ayles, Fern Terris-Prestholt 10th IAEN Pre-conference Amsterdam, 20-21 July 2018

Background Part of economic evaluation of STAR phase 1 implementation Implemented 3 distribution models in Zambia: Community-based distribution agents (CBDAs) Voluntary medical male circumcision (VMMC) Health facility (HF) models.

STUDY QUESTIONS What are the costs of delivering HIVST across three delivery approaches in Zambia: Community based, Facility based, and VMMC sites. Does the data suggest: Economies of Scale, or Economies of Scope? Consider implications for scale up

Methodology - Costing Full prospective economic costing from provider’s perspective Costing period: July 2016 - May 2017 in 16 communities Detailed top-down costing Supplemented by field observations to obtain allocation factors and opportunity costs Capital annualized (DR: 3%) All costs are presented in 2017 US$ Economies of scale Economies of scope Compare means and range in sites with 2 and 3 distribution approaches offered

Methodology - Setting 16 sites in four districts; Ndola (Copperbelt province) Kapiri Mposhi (Central province) Lusaka (Lusaka province) Choma (Southern province) District CBDA VMMC HF Ndola (4 sites) 4 Kapiri Mposhi (4 sites) 3 Lusaka (4 sites) 1 Choma (4 sites)

Results – HIVST kits distributed & costs STAR models distributed 127,804 HIVST kits; CDBA (81%) VMMC (9%) Health Facility (10%) Model HIVST Kits distributed Costs(US$) Total (US$) $/kit distributed CBDA 103,589 $1,508,109 $14.56 VMMC 11,330 $ 143,274 $12.65 Health Facility 12,885 $ 183,313 $14.23 CBDA distributor numbers: 138 in Malawi, 139 long-term in Zambia, & 1,009 short-term in Zimbabwe

Results – Cost components CBDA distributor numbers: 138 in Malawi, 139 long-term in Zambia, & 1,009 short-term in Zimbabwe

Results – economies of scale Economies of scale were present Where health facility model distributed less kits, UC appears higher Mean $14.23 Range $4-$42 No. of sites 16 CBDA distributor numbers: 138 in Malawi, 139 long-term in Zambia, & 1,009 short-term in Zimbabwe

…Results – economies of scale VMMC model shows similar pattern Mean $12.65 $14.23 Range $8-$25 $6-$36 No. of sites 8 16 CBDA distributor numbers: 138 in Malawi, 139 long-term in Zambia, & 1,009 short-term in Zimbabwe

…Results – economies of scale Strongly suggestive of economies of scale CBDA model had higher costs, but higher distribution, Mean $12.65 $14.56 $14.23 Range $8-$25 $6-$36 $4-$42 CBDA distributor numbers: 138 in Malawi, 139 long-term in Zambia, & 1,009 short-term in Zimbabwe

Results - Economies of Scope Due to high shared costs, expectation of economies of scope Mean $13.48 $14.88 Range $9-$23 $10-$37 n= 8

Results - Economics of Scope Due to high shared costs, expectation of economies of scope, but sample of sites small Mean $13.48 $14.88 Range $9-$23 $10-$37 n= 8

Conclusion Costs per kit distributed similar across 3 models $12-$15, but with very large variation by scale. Costs of conventional HTS in same sites: $4.24 Impact of static models constrained by client population size To reach large numbers need to step outside clinics. As saturation is reached, lessons from costing smaller scale sites expect unit costs to ↑ →Important consideration when planning scale up

Further research Analysis feeds into CE modelling to consider best combination of testing strategies in Zambia Ahmed, et al. Statistically test for econs of scope, scale & other drivers: → cost functions using pooled data across STAR countries See also: Mangenah – HIVST cross country cost analysis Poster Outside Ahmed – Systematic Review of HIV testing costs TEPEE613 D’Elbee – HIVST distribution preference Poster Outside Mwenge 2017 Cross country HTS costing PlosOne D’Elbee – Post testing linkage preferences 2018 AIDS

Thank you Acknowledgements The study was funded by Unitaid through PSI Participating sites Ministry of Health IAEN for funding this dissemination Thank you Contact Lawrence Mwenge Zambart Lawrence@zambart.org.zm