摘要：Objectives. We evaluated the cost-effectiveness of fee-based and free testing strategies at an HIV voluntary counseling and testing (VCT) program integrated into a community-based AIDS service organization in Moshi, Tanzania. Methods. We waived the usual fee schedule during a 2-week free, advertised VCT campaign; analyzed the number of clients testing per day during prefree, free, and postfree testing periods; and estimated the cost-effectiveness of limited and sustained free testing strategies. Results. The number of clients testing per day increased from 4.1 during the prefree testing interval to 15.0 during the free testing campaign ( P <.0001) and remained significantly increased at 7.1 ( P <.0001) after resumption of the standard fees. HIV seroprevalence (16.7%) and risk behaviors were unchanged over these intervals. Modeled over 1 year, the costs per infection averted with the standard fee schedule, with a 2-week free VCT campaign, and with sustained free VCT year-round were $170, $105, and $92, respectively, and the costs per disability-adjusted life year gained were $8.72, $5.40, and $4.72, respectively. Conclusions. The provision of free VCT enhances both the number of clients testing per day and its cost-effectiveness in resource-limited settings. In sub-Saharan Africa, HIV voluntary counseling and testing (VCT) is a cost-effective method of reducing high-risk sexual behavior and preventing HIV transmission. A large multicenter study conducted in Kenya, Trinidad, and Tanzania demonstrated that VCT reduced unprotected sexual contact with a nonprimary partner by 35% among men and 39% among women (vs 13% and 17% reductions, respectively, among those who received health information only). 1 It has been estimated that VCT offered to 10000 Tanzanians would avert 895 HIV infections at a cost of $346 per infection averted and $17.78 per disability-adjusted life year (DALY) saved. 2 Universal voluntary testing with individual informed consent and confidentiality protection in Africa has been advocated. 3 , 4 The World Health Organization and Joint United Nations Programme on HIV/AIDS have recently endorsed moving from client-initiated requests for VCT to provider-initiated approaches. 5 In addition to promoting behavior change, VCT can serve as a point of referral for preventive services, including the prevention of mother-to-child transmission and as an entry point for treatment programs for sexually transmitted infections, prophylaxis of opportunistic infections, diagnosis and treatment of tuberculosis, 6 and, increasingly, initiation of highly active antiretroviral therapy, 7 thereby further enhancing its cost-effectiveness. Greater access to VCT has been facilitated through cheaper, rapid, and simple HIV testing kits, which reduce the cost per test performed. 8 Despite these considerations, VCT is vastly underutilized, particularly in poor countries, where the current overall coverage is estimated to be less than 1% to 10% of those at risk for HIV infection. 9 In a population-based nationally representative survey in Tanzania, approximately 7% of women and 12% of men reported ever having received an HIV test. 10 In the Kilimanjaro Region, even in a hospital setting, 44% of those found to be HIV infected in a systematic serosurvey were previously unaware of their infection. 11 Barriers to accessing VCT services include stigmatization (with abandonment and abuse being common, particularly among women who test positive), geographic accessibility, lack of social promotion, inefficient counseling and testing practices, and cost. 12 We describe a newly established VCT program in Moshi, Tanzania, designed to overcome many of these barriers and in particular focus on testing uptake before, during, and after a free VCT campaign.
