HIV This Week

Menzies N, Abang B, Wanyenze R, Nuwaha F, Mugisha B, Coutinho A, Bunnell R, Mermin J, Blandford JM. The costs and effectiveness of four HIV counselling and testing strategies in Uganda. AIDS. 2009;23(3):395-401.

HIV counselling and testing is a key intervention for HIV control, and new strategies have been developed for expanding coverage in developing countries. Menzies and colleagues compared costs and outcomes of four HIV counselling and testing strategies in Uganda. A retrospective cohort of 84 323 individuals received HIV counselling and testing at one of four Ugandan HIV counselling and testing programmes between June 2003 and September 2005. Strategies assessed were stand-alone; hospital-based; household-member; and door-to-door. The authors collected data on client volume, demographics, prior testing and HIV diagnosis from project monitoring systems, and cost data from project accounts and personnel interviews. Strategies were compared in terms of costs and effectiveness at reaching key population groups. Household-member and door-to-door HIV counselling and testing strategies reached the largest proportion of previously untested individuals (>90% of all clients). Hospital-based HIV counselling and testing diagnosed the greatest proportion of HIV-infected individuals (27% prevalence), followed by stand-alone HIV counselling and testing (19%). Household-member HIV counselling and testing identified the highest percentage of discordant couples; however, this was a small fraction of total clients (<4%). Costs per client (2007 USD) were $19.26 for stand-alone, $11.68 for hospital-based, $13.85 for household-member, and $8.29 for door-to-door- HIV counselling and testing. All testing strategies had relatively low per client costs. Hospital-based HIV counselling and testing most readily identified HIV-infected individuals eligible for treatment, whereas home-based strategies more efficiently reached populations with low rates of prior testing and HIV-infected people with higher CD4 cell counts. Multiple HIV counselling and testing strategies with different costs and efficiencies can be used to meet the UNAIDS/WHO call for universal HIV counselling and testing access by 2010.

Editors’ note: This useful cost-effectiveness study of four different HIV counselling and testing strategies that a national HIV programme might consider demonstrates the value of each in a generalized epidemic. More than 30 per cent (range 30.7-48.1 per cent) of all people found HIV-positive had advanced immunosuppression (CD4+ count <200 cells/μl) regardless of testing strategy. Door-to-door strategies reached previously untested people cheaply in this country where in 2007 less than a quarter of people had ever been tested. These data indicate that a variety of testing strategies, providing choices for individuals, couples, and communities, can work in complementary fashion to accomplish the goals of increasing knowledge of serostatus and facilitating earlier treatment initiation.