The Cost and Intermediate Cost-Effectiveness of a Randomized Control Trial Delivering U=U Messaging to Increase HIV Testing Among South African Men.

backgroundSouth African men have lower HIV testing uptake than their female counterparts, leading to lower antiretroviral treatment (ART) uptake and higher HIV-related mortality. A recent cluster-randomized trial in a high HIV prevalence area in Cape Town showed that relaying the "undetectable equals untransmittable" (U=U) message to South African men increased their HIV testing uptake compared to issuing standard testing invitations. We conducted an economic analysis based on this trial to inform decision-making regarding implementing U=U messaging in routine public-sector HIV care.

methodsWe analyzed the mean cost of the U=U intervention and its intermediate cost-effectiveness over the control arm. Costs were estimated from trial expenditure data in 2020 South African rand (ZAR), converted using March 2020 US$ exchange rates. Shared trial costs were allocated to each arm based on participant volume or days of operation; capital costs, including the creation of the U=U message via human-centered design workshops, were annualized over 8 years. In a second scenario, trial cost was adjusted for potential implementation in routine care.

resultsPeer promoters delivered 504 U=U invitations to test for HIV over 7 intervention days and 544 standard invitations over 5 control days in March 2020. Compared with standard invitations, men who received U=U messaging had 60% increased odds of getting tested for HIV. The average trial cost was $5.40 per U=U message delivered ($2.35 after adjustment for routine implementation), $388.47 per person testing HIV-positive ($168.99 adjusted), and $906.44 per person initiating ART ($394.31 adjusted). Within trial costs, staff, overhead, and research costs were the largest allocations, with each accounting for 20% to 30% of total costs. After routine implementation adjustment, the costs of message creation via human-centered design workshops, personnel (peer promoters, research staff), and supplies were the largest allocations. Cost of U=U messaging per person confirmed HIV-positive and initiating ART was lower than conventional HIV testing messaging and at the lower end of cost ranges of HIV self-test distribution models targeted at men ($62 to $7,936 per person confirmed positive and $117 to $8,198 per person initiating ART) established in previous work.

conclusionDelivering tailored U=U messaging can increase HIV testing and ART uptake among men while saving costs over standard untargeted HIV testing messaging and other HIV self-test distribution models.