South Africa started distributing HIV self-test (HIVST) kits in 2017 in order to close remaining gaps in achieving the first 95 of the United Nations’ 95-95-95 targets across all population groups. We analysed the ability of HIVST to reach rarely or never tested employees and the cost of distributing HIVST kits to rural workplaces compared to urban industries.
Distribution was targeted to small- and medium-sized workplaces with a predominantly male workforce and low baseline HIV testing in the mining, construction, manufacturing, security, petroleum and agriculture sectors in two predominantly rural and one urban province in South Africa and included both primary distribution (to employees) and secondary distribution (for their sexual partners). We used multivariate regression of the frequency of past testing to compare the probabilities of reaching never or infrequently tested populations with primary distribution in rural vs. urban workplaces. The cost of both primary and secondary distribution was analysed from the provider perspective and included the economic cost of the kit ($2, the current ex-works cost under an agreement with the manufacturer), freight, company sensitisation and HIVST demonstration, distribution and follow-up by peer educators.
Between Nov. 2017 and Aug. 2018, the programme distributed 123,727 self-test kits in 2,313 companies (69% and 31% through primary and secondary distribution, resp.). The industries with the highest number of primary kits distributed were agriculture, construction, mining and petroleum in the rural provinces, and mining and construction in the urban province. Uptake was 85% across industries, and in men was twice that of women. 13% of test kits were distributed to employees who had never tested, and 38% to those who had last tested more than 12 months ago. The probability of self-test uptake in infrequently and never tested populations was three times higher in rural workplaces (Table 1) and especially high in never tested employees aged <25 and in infrequently tested employees aged 25-34. The average cost of distributing HIVST in rural agricultural workplaces and urban industries was 4.30 USD vs. 4.35 USD, with 56% due to the cost of the kits (incl. freight), followed by distribution staff (32%), sensitisation (5%) and travel (3%).
HIVST distribution at the workplace leads to improved HIV testing coverage especially in underserved rural populations, at a similar cost to urban populations.