Optimizing the location of point-of-care infant HIV testing devices in Zimbabwe to maximize impact and value: A modeling analysis.

BACKGROUND

Early HIV diagnosis in infants is essential for timely antiretroviral therapy (ART) initiation, but requires virologic testing - often performed in centralized laboratories, which can delay results and treatment initiation. Point-of-care (POC) testing delivers same-day results, facilitating prompt diagnosis and treatment, but availability is limited in low-resource settings. We aimed to optimally locate POC machines to improve life expectancy (LE) and net health benefit (NHB) for infants born to people with HIV in Zimbabwe.

METHODS

We linked the validated CEPAC-Pediatric HIV microsimulation model, populated with detailed subnational programmatic data, with a location-optimization model for 122 clinics in Matabeleland South's 7 districts. Simulating two testing strategies - conventional laboratory-based and POC machine-based - we projected: 30-day result-return, 30-day ART initiation for children with HIV (CWH), LE, HIV-related healthcare costs, and NHB. We maximized LE or NHB for infants tested at 6-10 weeks old.

FINDINGS: With 17 POC devices in current locations, a projected 43.8% of tested infants would receive HIV test results, with 41.6% of CWH starting ART within 30 days. Undiscounted LE would be 67.85 years (25.91 among CWH), with average discounted lifetime costs of $202/infant. Optimizing locations to maximize LE would retain 6 devices in current locations and move 11 to new sites, leading to projected 52.6% 30-day result-return, 50.0% 30-day ART initiation, and 67.88 years LE (27.04 among CWH), costing $211/infant. Maximizing NHB with a willingness-to-pay threshold ≥ $1,164 (66% of Zimbabwe's GDP per capita) would render the same optimal locations as maximizing LE. Additional optimally-located machines would further improve LE. Ensuring one machine per district while maximizing LE would require one additional machine and would increase 30-day result-return (to 53.3%), ART initiation (to 50.6%), and LE (to 67.88 years, 27.11 for CWH), costing $212/infant.

INTERPRETATION: Data-driven optimization of POC machine location could improve HIV detection and increase life expectancy and net health benefit for infants undergoing HIV testing in Zimbabwe.