The cost and value of hiv testing in Malawi
- 1. The Cost and Value of HIV Testing in Malawi CENTSWebinarPart 3: Costingand Value forMoney for HIV testing AndreasJahn, MD PhD ThokozaniKalua,MD Departmentof HIV and AIDS, MOH, Malawi I-TECH,University of Washington,Seattle
- 2. Evolution of HIV Testing Strategy: early 2000s • “Know your status”,“positiveliving” , HTC(with a big “C”) • Perceived preventioneffect • “Asking God when you will die” • Task-shifting:Health SurveillanceAssistants(HSA) delivered99% of testing • Vulnerableto competingtasks common service disruptions • HIV Testing week campaigns • Tackle stigma, reachingthe hard-to-reach,HIV service“mainstreaming” • Disruption of health services,unaccountedcommodities,stock-outs • HTC as a home for any budget / grant with “HIV label” • Proliferation of projectswith poorly targeted testing logistics and reporting challenges • The eternal window-period “pit-stop” testing • ART only for advanced HIV • Introduction of ART significant increasein demand for testing
- 4. • Annual cycle for HTS outputs • Campaign peaks followed by troughs • Introduction of dedicated lay cadre (HIV Diagnostic Assistants) led to massive sustained increase in PITC coverage • Almost linear decline in “yield” of new diagnoses • Surprisingly similar number of new positives identified each quarter
- 5. Proxy Linkage from Diagnosis to ART (Program Data) WHO Stage3/4 CD4 <250 CD4 <350 Option B+ CD4<500Option B+ Universal ART
- 6. 9.7% 0.9% 0% 2% 4% 6% 8% 10% 12% 14% 2000 2005 2010 2015 2020 Adults 15+ Children HIV Prevalence (Spectrum 2018)
- 7. 9.7% 2.4% 0.9% 0.3% 0% 2% 4% 6% 8% 10% 12% 14% 2000 2005 2010 2015 2020 Adults 15+ Adults 15+ not yet diagnosed Children Children not yet diagnosed HIV Prevalence (Spectrum 2018)
- 8. How to target by age / sex? Who is missed? 120,000 100,000 80,000 60,000 40,000 20,000 0 20,000 40,000 60,000 80,000 100,000 120,000 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+ Males, on ART, VLS Males, on ART, non-VLS Males, not on ART Females, on ART, VLS Females, on ART, non-VLS Females, not on ART
- 9. Optima Model • Preliminary results • Not yet endorsed • Unexpected findings challenges
- 11. Emerging HTS Challenges Repeat positives • Many undisclosed:hints from ART referral registers, PHIA • 3 Groups: never started ART – interrupted ART – currently on ART • Probably different proportions of repeat positivesby HTS mode / location • Very difficult to make formal adjustments • Key data gap for cost-effectiveness/ allocative efficiency • Self-testing may complicateclassification further Rapid adjustments for HTS strategy needed • “Pockets”of undiagnosed PLHIV are rapidly exhausted • Undiagnosed are increasingly recently infected
- 12. Emerging HTS Challenges Prioritizingtesting modes • Maintaininghigh PITC coverageat health facilities ethical imperativefor MOH • Huge draw on resources Accurate cost data • Commodity cost – easy • Programmatic cost – challenging • Comprehensiveexpendituredata by mode – (almost) impossible Economiesof scale? • No simple linear / multiplicativeassociation between budgetinputand HIV diagnosis outputs • Focuson new on ART / total alive on ART as HTS programimpact