Is digital innovation the key to enhancing HIV testing in high-prevalence regions? The article evaluates the cost-utility of digital HIV self-testing (HIVST) with digital supports in Malawi, South Africa, and Brazil. A Markov model compares the cost-effectiveness of digital HIVST to community-based and facility-based testing. Digital HIVST is cost-effective, especially for key populations with high HIV test-positivity rates. This approach improves linkage to care and ART initiation.

Key Insights on Digital HIV self-testing 

• Cost-Effectiveness: Digital HIV self-testing is cost-effective compared to facility-based testing. ICERs range from $769 to $17,839 per DALY averted.
• Linkage to Care: Linkage to care is crucial for cost-effectiveness. Required linkage rates vary from 20% to 48% by country.
• Digital Supports: Text messaging and online platforms boost digital HIVST uptake, especially among hard-to-reach groups.
• Country-Specific Outcomes: Cost-utility varies by country. Malawi has the lowest ICER, Brazil the highest, due to cost differences.
• Key Drivers: Cost-utility drivers include HIVST cost, test-positivity rates, care linkage, and ART initiation rates.

Relevance to Global HIV Strategies

The study aligns with global HIV goals set by the United Nations, which aim to enhance HIV diagnosis and care by 2030. These goals emphasise innovative strategies, such as HIVST, to increase testing uptake. Previous studies have shown that HIVST can be cost-effective with community supports. However, there is limited data on the cost-utility of digital HIVST approaches. This study follows WHO CHOICE guidelines and uses GDP-based willingness-to-pay thresholds, a common method in health economic evaluations.

Implications for Health Policy and Research

The findings suggest that digital HIVST is a highly cost-effective method for increasing HIV testing and improving care linkage, particularly in regions with high HIV prevalence and limited access to conventional testing. Policymakers should consider incorporating digital HIVST into their testing strategies, focusing on key populations with high rates of undiagnosed HIV. Strategies to enhance cost-utility include ensuring adequate linkage to care, negotiating reduced test costs, and leveraging digital technologies to improve accessibility. While digital HIVST offers many benefits, it may not suit all populations due to disparities in internet and device access. A balanced approach that combines digital and traditional methods is essential to ensure health equity.

Further research is needed to assess the long-term impact of HIVST on community HIV incidence and the cost-effectiveness of various digital strategies. Addressing limitations in current studies, such as the lack of dynamic transmission modeling and limited costing data for digital HIVST, is also vital.