Feasibility and economic costs of syphilis self-testing to expand test uptake among gay, bisexual and transgender men: results from a randomised controlled trial in Zimbabwe
Open accessAbstract
Background: Access to syphilis testing and treatment is frequently limited for men who have sex with men (MSM). A two-armed randomised controlled trial compared feasibility and costs of facility-based syphilis testing with self-testing among MSM in Zimbabwe. Methods: This randomised controlled trial was conducted in Harare, with participants randomised 1:1. Syphilis self-testing was offered in community-based settings. The primary outcome was the relative proportion of individuals taking up testing. Total incremental economic provider and user costs, and cost per client tested, diagnosed and treated were assessed using ingredients-based costing in 2020 US$. Results: A total of 100 men were enrolled. The two groups were similar in demographics. The mean age was 26 years. Overall, 58% (29/50) and 74% (37/50) of facility- and self-testing arm participants, respectively, completed syphilis testing. A total of 28% of facility arm participants had a reactive test, with 50% of them returning for confirmatory testing yielding 28% reactivity. In the self-testing arm, 67% returned for confirmatory testing, with a reactivity of 16%. Total provider costs were US$859 and US$736, and cost per test US$30 and US$15 for respective arms. Cost per reactive test was US$107 and US$123, and per client treated US$215 and US$184, respectively. The syphilis test kit was the largest cost component. Total user cost per client per visit was US$9. Conclusion: Syphilis self-testing may increase test uptake among MSM in Zimbabwe. However, some barriers limit uptake including lack of self-testing and poor service access. Bringing syphilis testing services to communities, simplifying service delivery and increasing self-testing access through community-based organisations are useful strategies to promote health-seeking behaviours among MSM.
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The systematic review included 12 publications of about seven different studies, of which two were RCTs.
“Overall, the review included 12 publications of about seven different studies (61-72), of which two were RCTs (64, 66).”
Uptake could potentially be higher when offering dual HIV/syphilis self-testing versus self-testing only for syphilis.
“Some evidence from these two RCTs suggested that uptake could potentially be higher when offering dual HIV/syphilis self-testing versus self-testing only for syphilis (64, 66).”
Several studies showed that most participants were able to correctly self-test.
“Several studies showed that most participants were able to correctly self-test (62, 64, 66-69).”
Linkage to further testing after a reactive syphilis test result may be higher when using dual HIV/syphilis self-tests compared with self-tests for syphilis alone.
“However, linkage to further testing after a reactive syphilis test result may be higher when using dual HIV/syphilis self-tests compared with self-tests for syphilis alone (64).”
No social harm or adverse events were identified or reported in the RCT publications.
“No social harm or adverse events were identified or reported in the RCT publications (64, 66).”
In two RCTs and pooled analysis, there was little to no difference between self-testing and standard testing in proportion with reactive syphilis result.
“In the same two RCTs (64, 66), there appeared to be little to no difference between these groups, and the same was true in the pooled analysis combining data from both studies (64, 66).”
In both China and Zimbabwe, cost per person tested with syphilis self-tests or dual HIV/syphilis self-tests was less than half the cost of standard syphilis testing.
“In both China and Zimbabwe, the cost per person tested with syphilis self-tests or dual HIV/syphilis self-tests was less than half the cost of standard syphilis testing (64, 66).”
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- Authors
- Nhamo, D., Mangenah, C., Chapwanya, G., Mamvuto, T., Mahaka, I., Sri-Pathmanathan, C., Ferrand, R. A., Kranzer, K., Terris-Prestholt, F., Marks, M., & Tucker, J. D.
- Affiliations
- University of KwaZulu-Natal (ZA)
- Liverpool School of Tropical Medicine (GB)
- APangaea Zimbabwe AIDS Trust (PZAT), Harare, Zimbabwe.
- London School of Hygiene & Tropical Medicine (GB)
- GDepartment of Global Health and Development, London School of Hygiene and Tropical Medicine (LSHTM), London, UK.
- University of North Carolina at Chapel Hill (US)
- Corresponding author
- Nhamo, Definate
- ORCID
- Venue
- Sexual Health
- Publisher
- CSIRO Publishing
- Published
- 2023-09-05
- Volume
- 20
- Issue
- 6
- Pages
- 514-522
- ISSN
- 1448-5028 (ISSN-L)
- 1449-8987
- OpenAlex
- W4386433041
- Cited by
- 5
- References
- 19
- Citations by year
- 2026: 3 · 2025: 2
- FWCI
- 0.89
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- Sexual Health (publishedVersion, cc-by-nc-nd)
- PubMed (publishedVersion)
- LSTM Online Archive (Liverpool School of Tropical Medicine) (acceptedVersion)
- LSHTM Research Online (London School of Hygiene and Tropical Medicine) (acceptedVersion)
- Carolina Digital Repository (University of North Carolina at Chapel Hill) (submittedVersion, cc-by-nc-nd)
- Warwick Research Archive Portal (University of Warwick) (submittedVersion)
- UNC Libraries
- Funders
- Medical Research Council (MR/T003995/1)
- Topics
- Health Sciences › Medicine › Physiology › Syphilis Diagnosis and Treatment
- Health Sciences › Medicine › Infectious Diseases › HIV/AIDS Research and Interventions
- Life Sciences › Immunology and Microbiology › Microbiology › Reproductive tract infections research
- Keywords
- syphilis, self-testing, men who have sex with men, cost analysis, community-based testing, health-seeking behavior, Zimbabwe, HIV prevention
- MeSH terms
- Sexual and Gender Minorities, Self-Testing, Adult, Feasibility Studies, Female, Health Promotion, Humans, Male, Syphilis, Zimbabwe, HIV Infections, Homosexuality, Male, Transgender Persons
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