JMIR Publications

ABSTRACT

Background:

Index case testing (ICT) is an effective strategy for HIV case finding, but implementation in low-and middle-income countries (LMICs) is often limited by cost and logistics. Traditional ICT training—centralized and in-person—is costly, disrupts service delivery, and varies in quality.

Objective:

This study evaluates the cost-effectiveness of a blended learning package designed to build healthcare worker (HCW) capacity for ICT, combining tablet-guided teaching and practice sessions, phone-based feedback, and tablet-guided continuous quality improvement (CQI compared with standard of care (SOC) training.

Methods:

The PRACTICE cluster-randomized trial included 33 clusters in Southern Malawi from May 2022 to September 2023, randomized 2:1 to SOC (n=22) or SOC plus blended learning intervention (n=11). Our cost-effectiveness analysis from the health system perspective used micro-costing, time-and-motion assessments, and observed trial outcomes. The decision tree model estimated total program costs, contact testing outcomes, and incremental cost-effectiveness ratios (ICERs) per contact tested and per person living with HIV (PWH) diagnosed across one year of implementation. Sensitivity analyses assessed parameter uncertainty, and a scenario analysis modeled a nationwide scale-up under a decentralized, Ministry of Health (MOH)-led approach.

Results:

Our model simulated 100,000 index clients as eligible for contact elicitation over one year across two districts (50,000 per arm). The enhanced ICT arm yielded 891 additional contacts tested, and 54 more HIV diagnoses. The ICERs were $125 per contact tested and $2,045 per PWH diagnosed; excluding training development costs reduced these to $69 and $1,136, respectively. Nationwide scale-up under an MOH-led model further reduced ICERs to $43 per contact tested and $698 per PWH diagnosed. Probabilistic sensitivity analyses showed the enhanced strategy was cost-effective in most simulations.

Conclusions:

The blended learning strategy improved ICT delivery and HIV case finding. The decentralized, government-led scale-up substantially reduced costs, and may be an efficient case-finding strategy particularly in Malawi’s mature epidemic. Blended learning packages provide a scalable, system-integrated, cost-effective approach that could strengthen health worker capacity across other service delivery areas in low-resource settings. Clinical Trial: Clinicaltrials.gov identifier: NCT05343390.