Background: As the proportion of people diagnosed with HIV increases, the cost-effectiveness of any form of HIV testing declines, making it important to identify targeted strategies that offer value for money. Distribution of HIV self-tests (HIVSTs) to partners of HIV-negative female sex workers (FSW; partners-of-sex-workers) is feasible and can reach men at high risk of HIV.
Methods: We simulated 904 setting-scenarios for adult HIV epidemics and care programmes typical of southern Africa using a dynamic-transmission model, with projection 50 years from 2018. For each setting-scenario, we compared outcomes under continuation of current testing policy to those obtained by also providing HIVSTs to HIV-negative FSW to distribute to their partners (if age>18 and having condomless-sex). We assessed the epidemiological impact and cost/DALY averted. We assumed that ~90% of FSW would participate, that of these 70% will distribute HIVSTs to their partners, that 80% of partners-of-sex-workers testing positive with an HIVST would have confirmatory testing by a health care worker (HCW) within 1 year. We assumed a 3% annual discount rate, and cost-effectiveness threshold of US$500/DALY averted.
Results: In an adult population of 10 million in 2018, our assumptions result in 36,000 (median per 3 month;90% range:7,000-197,000) partners-of-sex-workers being eligible to receive HIVSTs, representing 0.4% of the adult population. The average number of HIVSTs distributed/year would be 175,000 with 62% of eligible men self-testing/year, of whom 28% first-time testers. The secondary distribution intervention would increase demand for HCW HIV tests by partners-of-sex-workers from ~10,000 to ~17,000 tests/year and HIV-positivity among all HCW tests from 31% to 54%. This intervention would increase the proportion of partners-of-sex-workers diagnosed from 40% to 68% and avert ~2000 HIV infections/year (3% of all new infections). Assuming a cost/partner-of-sex-worker HIV self-tested of US$5, our estimated ICER was US$164/DALY averted, well below the US$500/DALY threshold and robust to variations in timeframe (20 years), discount rate (10%) and rate of confirmation for positive HIVST (50%).
Conclusions: Given our assumed uptake of HIVST distribution by FSW, this is predicted to avert almost 3% of all HIV infections over the next 50 years, and likely to be cost-effective when delivered at US$5 per kit used.

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