Moving to HIV self-care would be better and cheaper for Africa

A recent study in The Lancet Global Health found that offering more self-administered HIV services would improve results and save costs of care. It modelled the effects of self-care policies in comparison to current strategies across Africa.

The research by the Institute for Global Health, University College London, and others came about in response to the recent funding crisis of HIV services that has particularly affected African countries. 

A key proposed strategy for addressing this is increasing enabled self-care, which means several HIV services being provided directly to patients by community-based health workers (CHWs) and local pharmacies. That includes free HIV self-tests, pre-exposure prophylaxis (PrEP), post-exposure prophylaxis (PEP), and antiretroviral therapy (ART).

This paper considers how to best use the available funds in smarter and more effective ways. Self-care would lean on available resources, like CHWs and pharmacies, and the community’s own capabilities, to reduce the reliance on clinical staff and facilities.

Essentially, the paper considers how to best deal with the difficult funding situation, instead of only focusing on how to increase funding. It relies on various data, like the availability of self-testing, that point towards the promise of this overall strategy. 

To test the idea, the researchers used an established mathematical model called HIV Synthesis, which was created by a team led by Professor Andrew Phillips, who is also the lead author on this research paper. 

They simulated HIV epidemics in 1000 scenarios, which represented various parameters or characteristics that occur across east, central, southern, and west Africa. They ran this model multiple times with the current HIV service provision, as well as for what would happen if self-care policies were in place. It simulated outcomes for this hypothetical population, such as how many might use prevention services, acquire HIV or die from AIDS. 

The model used 100,000 people above the age of 15 and simulated scenarios between the beginning of the HIV epidemic in 1989 and 2076. “We chose a 50-year time horizon to capture the full effects of the policies,” the paper explains.

The model updated the characteristics of the simulated population regularly, such as how many had primary condomless sex partners and their HIV test history. 

Over several runs, and while keeping a margin of uncertainty, the study found significant positives from transitioning to a system more focused on self-care. 

In the scenario where current service provision is continued, health-care worker testing would continue, while access to self-testing would be limited. However, in the second scenario, health-care workers would only be used for confirmatory testing, while self-testing would be widely available from CHWs and pharmacies. This more than doubled the rate of adults testing for HIV per three months from 5% to 12.7%. 

In the current service provision scenario, there would be no PEP, with oral PrEP primarily available through existing clinics. Under self-care, both would be available from pharmacies and CHWs. As a result, the proportion of PEP and PrEP users in the population increased from 0.7% to 1.2%.

The self-care scenario would extend ART access beyond existing clinics so that pharmacies and CHWs could also offer single-pill daily tenofovir–lamivudine–dolutegravir (TLD) access. This would slightly increase the number of diagnosed people on ART, from 96% to 97%. 

Both scenarios share the strategies that viral load monitoring would focus on symptomatic people only, voluntary male medical circumcision would be discontinued, and free condoms would be available. 

Overall, the authors predicted that more self-care structures would reduce HIV incidence significantly by 27%. The self-care-based approach also lowered HIV deaths by a median 18% in the next decade. The greatest benefits would be for people who did not previously have access to PrEP or testing. Over the 50-year time horizon, the policies would help around 34,000 disability-adjusted life-years be avoided. 

Beyond these benefits, the results showed a significant cost saving in the vast majority of settings. “The mean undiscounted annual cost per adult in the population per year across setting scenarios was $12,” the paper says, noting that settings with particularly high HIV prevalence were particularly likely to save. Overall, this would result in a saving of around US$6 million, or a 7% decrease in programme costs. 

The paper acknowledges that some services, like testing, PrEP and PEP, could be moved over to self-care, while others like ART are best suited to a complementary strategy using both self-care and clinic services. The model was aimed at making a realistic prediction that could shift burden of care away from overstretched human resources towards other important tasks. 

The paper also acknowledges that this kind of transition to self-care would only be successful if the needed tools and drugs were readily available and came with accessible and comprehensive educational materials. 

Commentary from Dr Dvora Joseph Davey from the David Geffen School of Medicine at the University of California appeared in the same journal issue. In it, she calls the paper’s study “a timely and policy-relevant proposition.” 

She emphasises the importance of this theory for resource-strained environments, because it includes simplified and scalable HIV care delivery models. But she also takes note that successful implementation, especially for key populations, would be crucial in making an impact. 

As Davey explains, “at stake is not only the trajectory of HIV incidence and mortality but also the future architecture of HIV service delivery.” 

Reference

Phillips AN et al. Sustaining progress in HIV care in Africa with a transition to enabled self-care: a modelling study. The Lancet Global Health 14: 103943, 2026 (open access).

DOI: 10.1016/S2214-109X(26)00088-4

Image credit: 'Waiting at the dispensary'. A dispensary at a clinic in Mukono, Uganda. Available at Flickr under a Creative Commons licence CC BY-NC-ND 2.0.