Voluntary counseling and testing (VCT) for changing HIV-related risk behavior in developing countries

Trends in Sexual Health of Gay, Bisexual, and Other Men Who Have Sex with Men, and Transgender Individuals: Apps Driven Testing Program for HIV and Other STIs in Barcelona, Spain (2016-2023)

Gay, bisexual and other men who have sex with men (GBMSM) and transgender individuals face heightened risks of HIV and other sexually transmitted infections (STIs). Surveillance within these populations is critical, and community testing services play a pivotal role in preventing and controlling HIV and STIs. This study investigates the trends in HIV, syphilis and hepatitis C (HCV) infections among participants in an apps-driven rapid test program from 2016 to 2023 in Barcelona, Spain, examining associated factors. Trend analysis utilized Wilcoxon-type test and associated factors were determined through multivariate logistic analysis. The prevalence of new HIV diagnosis was 1.81% (CI 1.18-2.64), active syphilis was 3.37% (CI 2.46-4.50) and acute HCV was 0.40% (CI 0.11-1.02). While infection rates showed no significant changes, there was significant increasing in sex work and chemsex and decreasing in condom use. Additionally, a peak in dating apps use for sex and a specific reduction in number of sexual partners were observed in 2020. Factors associated with HIV diagnoses included migrant status (aOR = 11.19; CI 2.58-48.53) and inconsistent condom use during the previous 12 months (aOR = 3.12; CI 1.02-9.51). For syphilis, associated factors were migrant status (aOR = 2.46; CI 1.14-5.29), inconsistent condom use (aOR = 3.38; CI 1.37-8.36), and chemsex practice during the previous 12 months (aOR = 2.80; CI 1.24-6.30). Our findings emphasize the need for tailored interventions, including culturally sensitive outreach for migrants and comprehensive strategies addressing substance use in sexual contexts. Technological innovations and targeted educational initiatives could reduce the burden of HIV and STIs within the GBMSM and transgender communities, providing valuable insights for public health strategies.

Attitude and practice of secondary school students towards voluntary counselling and testing in Mwanza, North-West Tanzania

OBJECTIVES

Voluntary Counselling and Testing (VCT) has become popular in many parts of the world, especially in Africa, for people to learn about their HIV status and get motivation for positive sexual behaviour change. Our study explored the attitude and practice of secondary school students towards VCT.

METHODS

A cross-sectional descriptive study was conducted in Magu, Mwanza, North-West Tanzania. Recorded information included sex, factors promoting or hindering VCT attendance, reasons why attending VCT is necessary, awareness of VCT locations and source of information.

RESULTS

Of the 340 students interviewed, 93.2 % knew that VCT was necessary and had reasons such as getting Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) education, checking HIV status and getting advice if found to be HIV positive. The majority (74.4 %) knew the location of the VCT centres. However, only 20.3 % made use of the VCT services. Those who did not use VCT services had reasons such as time limitations, believing they were not infected and fear of being labelled HIV positive.

CONCLUSIONS

Our study shows that most secondary school students know that VCT is necessary and the locations of the VCT centres, but only a few use VCT services. More effort should be put into educating students and society on the importance of using VCT services.

Impact of armed conflicts on HIV treatment outcomes in sub-Saharan Africa: protocol for a systematic review and meta-analysis

INTRODUCTION

Armed conflicts have significant negative impacts on the entire healthcare system in general and HIV care system in particular. Sub-Saharan Africa is suffering from a disproportionate double burden of armed conflict and HIV infection. Nevertheless, the impact of the armed conflict on the HIV treatment outcomes in conflict settings in sub-Saharan Africa has not been thoroughly and systematically synthesised. This protocol outlines a review that aims to summarise the available evidence on the impact of armed conflict on HIV treatment outcomes in sub-Saharan Africa.

METHODS AND ANALYSIS

A systematic review of all quantitative studies that assess the impact of armed conflicts on HIV treatment outcomes will be conducted. The systematic search will start with a preliminary search of Google Scholar, followed by implementation of the full search strategy across five databases (MEDLINE, PubMed, CINAHL, SCOPUS and Web of Science) and the screening of titles and abstracts then relevant full texts. Bibliographies will be reviewed to identify additional relevant studies. We will include studies conducted in sub-Saharan Africa that were published in English between 1 January 2002 and 31 December 2022. Methodological validity of the included studies will be assessed using standardised critical appraisal instruments from the Joanna Briggs Institute (JBI) Meta-Analysis of Statistics Assessment and Review Instrument. Data will be extracted using standardised JBI instruments and analysed through narrative synthesis, and meta-analyses and regression. Heterogeneity will be assessed using I2 and Χ2 tests.

ETHICS AND DISSEMINATION

Since this study will not involve gathering primary data, formal ethical approval is not required. Journal publications, conference presentations and a media release will be used to share the study findings.

PROSPERO REGISTRATION NUMBER

CRD42022361924.

Assessing secular trends in HIV rapid diagnostic test uptake and positivity in Northeast Iran, a country in MENA region; ingredients for target-specific prevention policies

BACKGROUND

Iran is amongst the first three countries in Middle East and North Africa (MENA) region where two-thirds of region's new HIV infections are reported. HIV testing at the population level is key to interrupting the HIV transmission chain. The current study aimed to evaluate the history of HIV rapid diagnostic testing (HIV-RDT) and its correlates in northeast Iran.

METHODS

In this cross-sectional study, de-identified records of HIV-RDTs were extracted by the census method from the electronic health information system of 122 testing facilities between 2017 and 2021. Descriptive, bivariate, and multiple logistic regression analyses were performed to identify the factors associated with HIV-RDT uptake and risks and drivers of HIV-RDT positivity, separately among men and women.

RESULTS

Conducting 66,548 HIV-RDTs among clients with a mean age of 30.31 years, 63% female, 75.2% married, and 78.5% with high school education or below, yielded 312 (0.47%) positive results. Test uptake was comparatively low among men and the unmarried sub-population. Prenatal care and high-risk heterosexual intercourse were the most frequent reasons for taking HIV-RDT among women and men, respectively (76% and 61.2%). High-risk heterosexual contact, tattooing, mother-to-child transmission (MTCT), having a partner at risk of HIV infection, and injecting drugs were test seekers' most reported transmission routes. One-third of the newly-infected female clients were identified through prenatal testing. Multivariate analysis revealed older age at the time of testing (Adjusted Odd Ratio (AOR) = 1.03), divorce (AOR = 2.10), widowhood (AOR = 4.33), education level of secondary school (AOR = 4.67), and unemployment (AOR = 3.20) as significant demographic predictors of positive HIV-RDT (P-value < 0.05). However, clients' nationality, testing history, duration of HIV exposure, and reported reasons for taking HIV-RDT were not associated with the test result (P-value > 0.05).

CONCLUSION

Innovative strategies are required to scale up test uptake and positive yields among the key population in the region. The current evidence strongly suggests implementing gender-targeted strategies, according to the differences in demographic and behavioral risk between men and women.

Uptake of prevention of mother-to-child transmission cascade services in Burkina Faso between 2013 and 2020: are we on the right track?

BACKGROUND

The use of services to prevent mother-to-child transmission (PMTCT) of the human immunodeficiency virus (HIV) remains a serious challenge in sub-Saharan Africa. In the last decade, Burkina Faso has implemented numerous policies to increase the use of PMTCT services by pregnant women and their partners, as well as children. This study assesses trends in the uptake of PMTCT services in Burkina Faso from 2013 to 2020 in order to study the progress and gaps in achieving the national and international targets set for 2020.

METHODS

A repeated cross-sectional analysis was performed using data extracted from district health information software version 2. Percentages were computed for each PMTCT indicator and comparisons between the years were made using a chi-square test for trends with a significance threshold of 5%. Regions were not compared with each other.

RESULTS

The proportion of pregnant women who were tested and received their results significantly increased from 47.9% in 2013 to 84.6% in 2020 (p value < 0.001). Of the 13 regions in the country, only 1 region met the 95% national targets whereas, 6 regions met the 90% international targets for this indicator. The proportions of HIV-positive women receiving antiretroviral therapy (ART) increased from 90.8% in 2013 to 100% in 2020. In the same period, the proportion of exposed infants who received antiretroviral prophylaxis increased from 64.3% in 2013 to 86.8% in 2020. Only 3 regions reached the national and international targets for this indicator. A positive trend was also observed for the indicator related to screening at 2 months or later of exposed infants using Polymerase Chain Reaction (PCR) technic; with the rate rising from 7.4% in 2013 to 75.7% in 2020. However, for this indicator, the national and international targets were not achieved considering the national and regional settings. Concerning the women's partners, the proportion of those who tested for HIV increased from 0.9% in 2013 to 4.5% in 2020, with only 1 region that fully met the national target of 10% in 2020. The prevalence of HIV in this particular group was 0.5% in 2020.

CONCLUSIONS

PMTCT indicators show an increase from 2013 to 2020 but with a strong disparity between regions. National and international targets have not been achieved for any indicator; except for those related to women receiving ART. Strengthening strategies to effectively engage women and their partners on the use of PMTCT cascade services could help reduce mother-to-child transmission in Burkina Faso.

Condom-Related Stigma Scale among Men Who Have Sex with Men in China: Development and Psychometric Tests

Condom-related stigma is a frequently mentioned barrier to consistent condom use among men who have sex with men (MSM). Based on the concept and operational definition of condom-related stigma recently defined by our team, we developed the 20-item condom-related stigma scale (CRSS) and examined its psychometric properties among 433 MSM in China, following DeVellis's scale development guidelines. The content validity, convergent validity, empirical validity, factorial validity, scale score reliability, split-half reliability, and test-retest reliability for the CRSS were all assessed. The scale consists of four domains: perceived distrust, perceived potential HIV/STI risk, perceived embarrassment, and perceived violation of the traditional understanding of sexual intercourse. The CRSS has good validity (the scale-level content validity index was 0.99; the empirical validity was greater than 0.70) and high reliability (the Cronbach's alpha coefficient overall was 0.926; the split-half reliability overall was 0.795; the test-retest reliability overall was 0.950). This scale is recommended for assessing the level of condom-related stigma among Chinese MSM, which can serve as an evaluating indicator for safer-sex interventions to prevent HIV infection among the MSM population in a Chinese cultural context.

Voluntary testing for COVID-19: perceptions and utilization among the inhabitants of Saudi Arabia

Objectives

Voluntary testing (VT) plays a crucial role in the prevention and control of infectious diseases. The present study investigated the perceptions and utilization of VT services for coronavirus disease 2019 (COVID-19) among the inhabitants of Saudi Arabia.

Methods

In total, 3,510 adult participants from all provinces of Saudi Arabia were recruited via a national online survey.

Results

Of the 3,510 participants, 88.9% were aware of the testing services available to them and of those, more than half (59.5%) had used the VT services and 96.1% were satisfied with the services. Contact with a positive COVID-19 case was the top reason for accessing VT, while a lack of awareness about the availability of VT services was the top perceived limiting factor. A history of chronic health conditions, anxiety and/or depression, and previous symptoms suggestive of COVID-19 were found to be predictors of the utilization of VT services (OR 1.55, 95% CI 1.22−1.96; OR 1.48, 95% CI 1.16−1.88; OR 3.31, 95% CI 2.77−3.95; and OR 1.62, 95% CI 1.34−1.96; respectively), respectively.

Conclusion

The awareness of voluntary COVID-19 testing services was satisfactory among the Saudi Arabian population, but can be improved. Sociodemographic and health history predictors of the utilization of VT services were identified.

Socio-economic and demographic factors associated with never having tested for HIV among sexually active men across the four administrative regions of Uganda

BACKGROUND

HIV testing among men is paramount in the prevention, diagnosis, and treatment of HIV. There is limited literature in understanding the socio-economic and demographic factors associated with never having tested for HIV among sexually active men aged 15 - 54 across the four administrative regions of Uganda. The purpose of this study is to investigate the socio-economic and demographic factors associated with never having tested for HIV among sexually active men aged 15 - 54 across the four administrative regions in the country.

METHODS

The study used a cross-sectional research design to examine factors associated with never having tested for HIV among 4,168 sexually active men (15 - 54 years) across four administrative regions of Uganda using data from 2016 Uganda Demographic and Health Survey (UDHS). Frequency distributions, Pearson chi-square tests, and multivariable logistic regression were used to establish the association between never having tested for HIV among sexually active men (15 - 54 years) and selected independent variables across regions.

RESULTS

About 20% of sexually active men (15 - 54 years) never tested for HIV across regions of the country. The major correlates amidst variability of never testing for HIV among sexually active men across regions were; educational level and marital status. Age, religious status, wealth quintile, worked in the last 12 months, circumcised, and one sexual partner in the last 12 months were only correlates of never having tested for HIV among respondents in particular regions of the country.

CONCLUSION

Findings in the study suggest promotion of male education, and suggest further investigation into the relationship between HIV non-testing among sexually active men (15 - 54 years) and being married across regions of the country. The study also proposes appreciation of regional differences in the outcome of HIV non-testing and suggests that efforts be focused on addressing regional differences in order to attain high HIV testing among sexually active men (15 - 54 years) across regions of Uganda, and thus reduce HIV related morbidity and mortality.

Sex Differences in HIV Testing among Older Adults in Sub-Saharan Africa: A Systematic Review

Background

Despite being sexually active and engaging in risky sexual behaviours similar to young adults, older adults (50 years or older) are less likely to receive HIV testing, and disaggregated data are still scarce about HIV prevention and treatment in this vulnerable population in sub-Saharan Africa (SSA). This systematic review is aimed at examining sex differences in HIV testing and counseling (HTC) among older adults in SSA.

Methods

A systematic search of four databases, namely, MEDLINE (Ovid), EMBASE (Ovid), Web of Science, and Global Health, was conducted from 2000 to January 2020. The primary outcome of interest for this study was gender differences in HTC among older adults in SSA. Observational studies including cross-sectional, retrospective, and prospective cohort studies were included. Eligible studies must have reported sex differences in HIV testing uptake in a standard HTC service among older adults in SSA.

Results

From the database search, 4143 articles were identified. Five studies were ultimately included in the final review. Of the 1189 participants, 606 (51.1%) and 580 (48.9%) were female and male, respectively. The review findings suggested that both men and women preferred HTC providers that are the same sex as them with women additionally preferring a provider who is also of a similar age. Men and women differed in their pathways to getting tested for HIV. The review documented mixed results with regard to the associations between sex of older adults and uptake of HTC. Older adult HTC uptake data are limited in scope and coverage in sub-Saharan Africa.

Conclusion

This review revealed shortage of evidence to evaluate optimum HTC utilization among older adults. Few studies examined sex differences in HIV testing among older adults in the region. There is a need for stakeholders working in the area of HIV prevention and treatment to focus on older adult health utilization evidence organization, disaggregated by age and sex. Hence, high-quality research designs are needed on the topic in order to generate good quality evidence for targeted interventions to improve HTC among older adults in sub-Saharan Africa.

An HIV Narrative of Female Inmates With a Lifetime History of Mental Illness in Durban, South Africa

Introduction: South Africa (SA) has one of the highest prevalence rates of Human Immuno-deficiency Virus (HIV) globally, with women carrying a larger burden of the disease. Furthermore, female inmates have higher rates of HIV compared to their male counterparts, with an over-representation of mental illnesses among female inmates as well. Additionally, mental illnesses are highly prevalent in people living with HIV, with HIV and mental illness sharing a complex bidirectional relationship. This study, which forms part of a larger two-phased, mixed-methods study, describes the experiences of contracting and living with/being affected by HIV, among female inmates with a lifetime history of mental illness, in a South African setting. Method: This study was conducted at a correctional centre in Durban, KwaZulu-Natal, SA. Fourteen adult (18 years and older) female inmates, were purposively selected to participate in individual, in-depth semi-structured interviews. Participants had a lifetime history of mental illness, trauma and were either living with HIV, or affected by HIV. Women from diverse cultural backgrounds, who were fluent in English, were selected. This manuscript focuses on the description of the HIV component of the qualitative interviews only. Thematic analysis was used to analyse the data. Results: Themes related to contracting HIV included intimate partner betrayal, gender differences regarding sexual behaviour, fear associated with HIV and the importance of pre- and post-test HIV counselling. Themes related to living with/being affected by HIV included the challenges women experienced in their home community, which contrasted with their experience of living with HIV in the prison community, and the importance of accepting an HIV positive life. Conclusion: HIV is prevalent in the female inmate population at this correctional centre in SA. This study emphasises that whilst incarcerated, attempts should be made to educate, train, support and manage HIV in this population, thereby helping to curb the epidemic. Further research should aim at exploring such strategies. The study also underscores the importance of the continued need for HIV education in order to eradicate associated stigma and discrimination which are still prevalent in SA.

Uptake and correlates of chlamydia and gonorrhea testing among female sex workers in Southern China: a cross-sectional study

BACKGROUND

Female sex workers (FSW) are highly susceptible to chlamydia and gonorrhea infection. However, there is limited literature examining their testing uptake to date. This study aimed to assess the uptake and determinants of chlamydia and gonorrhea testing among FSW in Southern China.

METHODS

A cross-sectional study with convenience sampling was performed in five cities in Southern China. Data on socio-demographic characteristics, sexual behaviors, chlamydia and gonorrhea testing, and the utilization of health care services from participants were collected through face-to-face interviews. Univariate and multivariable logistic regressions were used to determine factors associated with chlamydia and gonorrhea testing, respectively.

RESULTS

Overall, 1207 FSWs were recruited, with the mean age of 30.7 ± 6.8 years and an average number of clients of 7.0 (4.0-10.0) per week. 65.4% participants constantly used condoms with clients during the past month. Only 7.5 and 10.4% had been tested for chlamydia and gonorrhea in the last year, respectively. Multivariable analysis indicated that FSW who worked at low tiers (adjusted Odds Ratio (aOR) = 2.36, 95%CI:1.23-10.14), had more clients in the last month (aOR = 1.03, 95%CI:1.01-1.05), used condoms consistently (aOR = 1.79, 95%CI:1.12-2.86), had STD symptoms (aOR = 4.09,95%CI:2.62-6.40), had been tested for HIV (aOR = 5.16, 95%CI:3.21-8.30) or syphilis (aOR = 6.90, 95%CI:4.21-11.22) in the last year were more likely to have chlamydia testing. In addition, FSW who had more clients in the past month (aOR = 1.02,95%CI:1.00-1.04), had STD symptoms (aOR = 3.33, 95%CI:2.03-5.46), had been tested for HIV (aOR = 3.94, 95%CI:2.34-6.65) and syphilis (aOR = 3.27, 95%CI:1.96-5.46) in the last year were more likely to have gonorrhea testing.

CONCLUSIONS

The testing rates of chlamydia and gonorrhea are low among Chinese FSW. Integrating chlamydia and gonorrhea testing into HIV testing promotion programs may help bridge the gap among FSW.

Sexual History Taking: Perspectives on Doctor-Patient Interactions During Routine Consultations in Rural Primary Care in South Africa

Background

Sexual history taking for risk behavior contributes to improving health outcomes in primary care. Giving the high numbers of people living with AIDS, every patient in South Africa should be offered an HIV test, which implies that a comprehensive sexual history must be taken.

Aim

To describe the optimal consultation process, as well as associated factors and skills required to improve disclosure of sexual health issues during a clinical encounter with a doctor in primary health care settings in North West province, South Africa.

Methods

This qualitative study, based on grounded theory, involved the video-recording of 151 consultations of adult patients living primarily with hypertension and diabetes. This article reports on the 5 consultations where some form of sexual history taking was observed. Patient consultations were analyzed thematically, which entailed open coding, followed by focused and verbatim coding using MaxQDA 2018 software. Confirmability was ensured by 2 generalist doctors, a public health specialist and the study supervisors.

Main Outcome Measure

Sexual history was not taken and patients living with sexual dysfunction were missed. If patients understand how disease and medication contribute to their sexual wellbeing, this may change their perceptions of the illness and adherence patterns.

Results

Sexual history was taken in 5 (3%) out of 151 consultations. Three themes emerged from these 5 consultations. In the patient-doctor relationship theme, patients experienced paternalism and a lack of warmth and respect. The consultation context theme included the seating arrangements, ineffective use of time, and privacy challenges due to interruptions and translators. Theme 3, consultation content, dealt with poor coverage of the components of the sexual health history.

Conclusion

Overall, sexual dysfunction in patients was totally overlooked and risk for HIV was not explored, which had a negative effect on patients’ quality of life and long-term health outcomes. The study provided detailed information on the complexity of sexual history taking during a routine consultation and is relevant to primary health care in a rural setting. Pretorius D, Couper I, Mlambo M. Sexual History Taking: Perspectives on Doctor-Patient Interactions During Routine Consultations in Rural Primary Care in South Africa. Sex Med 2021;9:100389.

Implementation of HPV-based screening in Burkina Faso: lessons learned from the PARACAO hybrid-effectiveness study

BACKGROUND

Cervical cancer screening in sub-Saharan countries relies on primary visual inspection with acetic acid (VIA). Primary human papillomavirus (HPV)-based screening is considered a promising alternative. However, the implementation and real-life effectiveness of this strategy at the primary-care level in limited-resource contexts remain under explored. In Ouagadougou, Burkina Faso, free HPV-based screening was implemented in 2019 in two primary healthcare centers. We carried out a process and effectiveness evaluation of this intervention.

METHODS

Effectiveness outcomes and implementation indicators were assessed through a cohort study of screened women, observations in participating centers, individual interviews with women and healthcare providers and monitoring reports. Effectiveness outcomes were screening completeness and women's satisfaction. Logistic regression models and concurrent qualitative analysis explored how implementation variability, acceptability by women and the context affected effectiveness outcomes.

RESULTS

After a 3-month implementation period, of the 350 women included in the cohort, 94% completed the screening, although only 26% had their screening completed in a single visit as planned in the protocol. The proportion of highly satisfied women was higher after result disclosure (95%) than after sampling (65%). A good understanding of the screening results and recommendations increased screening completeness and women's satisfaction, while time to result disclosure decreased satisfaction. Adaptations were made to fit healthcare workers' workload.

CONCLUSION

Free HPV-based screening was successfully integrated within primary care in Ouagadougou, Burkina Faso, leading to a high level of screening completeness despite the frequent use of multiple visits. Future implementation in primary healthcare centers needs to improve counseling and reduce wait times at the various steps of the screening sequence.

Trends in demographic and clinical characteristics and initiation of antiretroviral therapy among adult patients enrolling in HIV care in the Central Africa International epidemiology Database to Evaluate AIDS (CA-IeDEA) 2004 to 2018

INTRODUCTION

The Central Africa International epidemiology Database to Evaluate AIDS (CA-IeDEA) is an open observational cohort study investigating impact, progression and long-term outcomes of HIV/AIDS among people living with HIV (PLWH) in Burundi, Cameroon, Democratic Republic of Congo (DRC), Republic of Congo (ROC) and Rwanda. We describe trends in demographic, clinical and immunological characteristics as well as antiretroviral therapy (ART) use of patients aged > 15 years entering into HIV care in the participating CA-IeDEA site.

METHODS

Information on sociodemographic characteristics, height, weight, body mass index (BMI), CD4 cell count, WHO staging and ART status at entry into care from 2004 through 2018 were extracted from clinic records of patients aged > 15 years enrolling in HIV care at participating clinics in Burundi, Cameroon, DRC, ROC and Rwanda. We assessed trends in patient characteristics at enrolment in HIV care including ART initiation within the first 30 days after enrolment in care and calculated proportions, means and medians (interquartile ranges) for the main variables of interest.

RESULTS

Among 69,176 patients in the CA-IeDEA cohort, 39% were from Rwanda, 24% from ROC, 18% from Cameroon, 14% from Burundi and 5% from DRC. More women (66%) than men enrolled in care and subsequently initiated ART. Women were also younger than men (32 vs. 38 years, P < 0.001) at enrolment and at ART initiation. Trends over time show increases in median CD4 cell count at enrolment from 190 cells/µL in 2004 to 334 cells/µL in 2018 at enrolment. Among those with complete data on CD4 counts (60%), women had a higher median CD4 cell count at care entry than men (229 vs. 249 cells/µL, P < 0.001). Trends in the proportion of patients using ART within 30 days of enrolment at the participating site show an increase from 16% in 2004 to 75% in 2018.

CONCLUSIONS

Trends from 2004 to 2018 in the characteristics of patients participating in the CA-IeDEA cohort highlight improvements at entry into care and subsequent ART initiation including after the implementation of Treat All guidelines in the participating sites.

HIV incidence and associated risk factors in female spouses of men who inject drugs in Pakistan

Introduction

Female sexual partners of men who inject drugs (MWID) living with HIV are at risk of HIV transmission. HIV prevalence estimates among non-drug using female sex partners of MWID are scarce, with no studies documenting HIV incidence. We investigated HIV prevalence and incidence among female spouses of MWID registered at Nai Zindagi Trust (NZT), Pakistan, between 2012 and 2019.

Methods

NZT registration and service provision data for female spouses who participated in HIV testing and counselling calculated HIV prevalence and incidence using the person years (PY) method. Cox proportional hazards models identified factors associated with incident infection.

Results

Overall HIV prevalence among female spouses of MWID was 8.5%. Among 3478 HIV-negative female spouses, 109 incident infections were observed, yielding an incidence rate of 1.5/100PY (95% CI 1.2–1.8). Independent predictors of incident infection were registration in Punjab province (AHR 1.73 95% CI 1.13–2.68, p = 0.012) and 1–5 years of education (AHR 1.89 95% CI 1.22–2.93, p = 0.004). Knowledge of HIV at registration was protective against infection (AHR 0.51, 95% CI 0.26–0.99, p = 0.047), along with a MWID spouse who had initiated antiretroviral therapy (ART) (AHR 0.25, 95% CI 0.16–0.38, p < 0.001), while incident infection was inversely associated with number of children (≥ 5 children AHR 0.44 95% CI 0.22–0.88, p = 0.022).

Conclusions

Additional efforts are needed to reduce HIV transmission among female spouses of MWID, including targeted provision of HIV education and access to HIV screening. Interventions that target MWID are also required, including evidence-based drug treatment and access to ART, including support to maximize adherence. Finally, consideration should be given to making HIV pre-exposure prophylaxis available to female spouses at high risk of HIV transmission, particularly young women and those whose husbands are not receiving, or have difficulty adhering to, ART.

Willingness to use HIV prevention methods among vaccine efficacy trial participants in Soweto, South Africa: discretion is important

BACKGROUND

Despite multiple available HIV prevention methods, the HIV epidemic continues to affect South Africa the most. We sought to understand willingness to use actual and hypothetical HIV prevention methods among participants enrolled in a preventative HIV vaccine efficacy trial in Soweto, South Africa.

METHODS

We conducted a qualitative study with 38 self-reporting HIV-uninfected and consenting 18-35 year olds participating in the HVTN 702 vaccine efficacy trial in Soweto. Using a semi-structured interview guide, five focus group discussions (FGDs) were held, stratified by age, gender and sexual orientation. The FGDs were composed of: (i) 10 heterosexual women aged 18-24 years; (ii) 9 heterosexual and bisexual women aged 25-35 years; (iii & iv) heterosexual men aged 25-35 years with 7 in both groups; and (v) 5 men aged 18-35 years who have sex with men. FGDs were audio-recorded, transcribed verbatim, translated into English and analysed using thematic analysis.

RESULTS

We present five main themes: (i) long-lasting methods are preferable; (ii) condoms are well-known but not preferred for use; (iii) administration route of HIV prevention method is a consideration for the user; (iv) ideal HIV prevention methods should blend into the lifestyle of the user; and the perception that (v) visible prevention methods indicate sexual indiscretion.

CONCLUSIONS

The participants' candour about barriers to condom and daily oral pre-exposure prophylaxis (PrEP) use, and expressed preferences for long-lasting, discreet, lifestyle-friendly methods reveal a gap in the biomedical prevention market aiming to reduce sexually acquired HIV in South Africa. Product developers should consider long-acting injectable formulations, such as vaccines, passive antibodies and chemoprophylaxis, for HIV prevention technologies. Future innovations in HIV prevention products may need to address the desire for the method to blend easily into lifestyles, such as food-medication formulations.

Sexual behaviour change following HIV testing services: a systematic review and meta-analysis

INTRODUCTION

Learning one's HIV status through HIV testing services (HTS) is an essential step toward accessing treatment and linking to preventive services for those at high HIV risk. HTS may impact subsequent sexual behaviour, but the degree to which this varies by population or is true in the setting of contemporary HIV prevention activities is largely unknown. As part of the 2019 World Health Organization Consolidated Guidelines on HTS, we undertook a systematic review and meta-analysis to determine the effect of HTS on sexual behaviour.

METHODS

We searched nine electronic databases for studies published between July 2010 and December 2019. We included studies that reported on at least one outcome (condom use [defined as the frequency of condom use or condom-protected sex], number of sex partners, HIV incidence, STI incidence/prevalence). We included studies that prospectively assessed outcomes and that fit into one of three categories: (1) those evaluating more versus less-intensive HTS, (2) those of populations receiving HTS versus not and (3) those evaluating outcomes after versus before HTS. We conducted meta-analyses using random-effects models.

RESULTS AND DISCUSSION

Of 29 980 studies screened, 76 studies were included. Thirty-eight studies were randomized controlled trials, 36 were cohort studies, one was quasi-experimental and one was a serial cross-sectional study. There was no significant difference in condom use among individuals receiving more-intensive HTS compared to less-intensive HTS (relative risk [RR]=1.03; 95% CI: 0.99 to 1.07). Condom use was significantly higher after receiving HTS compared to before HTS for individuals newly diagnosed with HIV (RR = 1.65; 95% CI: 1.36 to 1.99) and marginally significantly higher for individuals receiving an HIV-negative diagnosis (RR = 1.63; 95% CI: 1.01 to 2.62). Individuals receiving more-intensive HTS reported fewer sex partners at follow-up than those receiving less-intensive HTS, but the finding was not statistically significant (mean difference = -0.28; 95% CI: -3.66, 3.10).

CONCLUSIONS

Our findings highlight the importance of using limited resources towards HTS strategies that focus on early HIV diagnosis, treatment and prevention services rather than resources dedicated to supplementing or enhancing HTS with additional counselling or other interventions.

Prevalence of and factors associated with advanced HIV disease among newly diagnosed people living with HIV in Guangdong Province, China

INTRODUCTION

A high proportion of people living with HIV (PLHIV) present for care with advanced HIV disease (AHD), which is detrimental to "90-90-90" targets to end AIDS by 2030. This study aimed to explore the prevalence of and factors related to AHD among newly diagnosed PLHIV in Guangdong Province, China.

METHODS

Newly diagnosed PLHIV were recruited from six cities in Guangdong Province from May 2018 to June 2019. AHD was defined as an initial CD4 count <200 cells/µL or an AIDS-defining event within one month of HIV diagnosis. Data from a questionnaire and the national HIV surveillance system were used to explore the potential factors related AHD.

RESULTS

A total of 400 of 997 newly diagnosed PLHIV were defined as having AHD with a proportion of 40.1%. After adjusting for statistically significant variables in univariate analysis, multivariable logistic regressions showed that individuals aged 30 to 39 years (adjusted odds ratio (aOR) = 1.77, 95% confidence interval (CI): 1.13 to 2.79) and ≥50 years (aOR = 1.98, 95% CI: 1.15 to 3.43) were at a higher risk of AHD than those aged 18 to 29 years. Participants diagnosed by voluntary counselling and testing (VCT) clinics were less likely to have AHD (aOR = 0.67, 95% CI: 0.48 to 0.94) than those diagnosed at medical facilities. Participants who had ever considered HIV testing (aOR = 0.66, 95% CI: 0.45 to 0.98) and who had high social support (aOR = 0.73, 95% CI: 0.55 to 0.97) were at a lower risk of AHD, whereas participants who had HIV-related symptoms within one year before diagnosis were at a higher risk of AHD (aOR = 2.09, 95% CI: 1.58 to 2.77). The most frequent reason for active HIV testing was "feeling sick" (42.4%, 255/601), and the main reason for never considering HIV testing was "never thinking of getting HIV" (74.0%, 542/732).

CONCLUSIONS

Low-risk perception and a lack of awareness of HIV-related symptoms resulted in a high proportion of AHD in Guangdong Province, especially among the elderly, those diagnosed at medical facilities and those with low social support. Strengthening AIDS education and training programmes to scale up HIV testing through provider-initiated testing and counselling in medical facilities and VCT could facilitate early HIV diagnosis.

Willingness to use HIV self-test kits and willingness to pay among urban antenatal clients in Cote d'Ivoire and Tanzania: a cross-sectional study

Objectives

To generate evidence on willingness to use HIV self‐test kits and willingness to pay among antenatal care clients in public and private facilities in Cote d’Ivoire and Tanzania.

Methods

Cross‐sectional survey data were collected from 414 clients recruited from 35 high‐volume facilities in Cote d’Ivoire and from 385 clients in 33 high‐volume facilities in Tanzania. Surveys covered willingness to use HIV self‐test kits, prices clients were willing to pay, advantages and disadvantages and views on specific qualities of HIV self‐tests. Market data on availability of proxy self‐testing products (e.g. pregnancy and malaria tests) and attitudes of pharmacists towards HIV self‐test kits were collected from 51 pharmacies in Cote d’Ivoire and 59 in Tanzania.

Results

Willingness to use HIV self‐test kits was 65% in Cote d’Ivoire and 69% in Tanzania. Median ideal prices women would pay ranged from USD 1.77 in Cote d’Ivoire to USD 0.87 in Tanzania. Proxy self‐test kits were available in pharmacies, and interest was high in stocking HIV self‐test kits.

Conclusions

Implications for national HIV self‐test policy and planning include keeping prices low, providing psychological and HIV counselling, and ensuring linkage to HIV care and treatment services. Private pharmacies will play a key role in providing access to HIV self‐test kits.

Facilitators, Barriers, and Outcomes of Self-Initiated HIV Testing: An Integrative Literature Review

BACKGROUND AND PURPOSE

HIV testing is an essential tool for identifying people at risk for HIV infection and linking those who are infected to care. Despite the recommendation for routine HIV testing for people who are vulnerable to HIV infection, healthcare professionals experience difficulties initiating discussions related to sexual health and recommending HIV testing. Healthcare professionals not offering HIV testing is a frequently reported reason for delays in testing. Self-initiated HIV testing is understudied and vital to improving HIV testing rates, treatment, and the process of HIV prevention. The main aim of this integrative literature review is to identify facilitators, barriers, and outcomes of self-initiated HIV testing.

METHOD

A search of PubMed, CINAHL, PsycINFO, EBSCO host, and Google Scholar, revealed 31 studies that met the inclusion criteria.

RESULTS

Self-initiated HIV testing is voluntarily requested and completed by individuals either using self-testing kits or in a setting that provides HIV testing. Perception of susceptibility to HIV infection, privacy, access to HIV testing sites or self-testing kits, and knowledge related to HIV infection and testing, were some of the salient facilitators and barriers to self-initiated HIV testing. Findings from our review indicate several benefits to self-initiated HIV testing, including early identification of acute HIV infection, increased likelihood for the uptake of HIV prevention interventions, and a reduction in sexual risk behaviors.

IMPLICATION FOR PRACTICE

Nursing initiatives geared toward promoting self-initiated HIV testing will lead to prompt diagnoses and linkages to treatment which will further improve nursing care and a variety of health outcomes.

The state of the evidence for voluntary home-based human immunodeficiency virus counseling and testing in the community: A proposed model for evidence translation

BACKGROUND

Home-based voluntary human immunodeficiency virus (HIV) counseling and testing (HBVCT) plays a significant role in reducing HIV-related risk-taking behaviors. Adopting evidence-based interventions is essential, but few conceptual models exist to guide the development, implementation, and evaluation of these interventions.

AIMS

Our proposed model for evidence translation based on evidence review describes the implementation process of HBVCT in the community.

MATERIALS AND METHODS

Our study adopted the translating research into practice model, which incorporates information needs about the implementation, planning, and execution required for consideration by clinicians. Thirteen systematic reviews published in the English language from January 1, 2000 to February 9, 2020 were retrieved and reviewed from four electronic databases and journals, including EMBASE, PubMed, JBI Database of Systematic Reviews and Implementation Reports, and Cochrane Library.

RESULTS

The analysis of the review papers based on the phenomenon of interest, results, and the population revealed some distinctions in the number of socioecological levels used by this evidence synthesis. These levels of factors include individual, interpersonal, organizational, community, and public policies. HBVCT is an essential component of HIV prevention programs and a critical entry point for adequate care and treatment.

DISCUSSION

This collaborative model demonstrates the application of research to a real-world health care setting.

Perceived Knowledge of HIV-Negative Status Increases Condom Use Among Female Sex Workers in Zambian Transit Towns

Knowledge of HIV status is a necessary pre-condition for most HIV interventions, including treatment as well as biomedical and behavioral prevention interventions. We used data from a female sex worker (FSW) cohort in three Zambian transit towns to understand the effect that knowledge of HIV status has on FSWs' HIV risk-related sexual behaviors with clients. The cohort was formed from an HIV self-testing trial that followed participants for 4 months. Participants completed three rounds of data collection at baseline, 1 month, and 4 months where they reported their perceived knowledge of HIV status, number of clients on an average working night, and consistent condom use with clients. We measured the effect of knowledge of HIV status on participants' sexual behaviors by using linear regression models with individual fixed effects. The majority of the 965 participants tested for HIV at least once during the observation period (96%) and changed their knowledge of HIV status (79%). Knowledge of HIV status did not affect participants' number of clients, but it did affect their consistency of condom use. Compared with unknown HIV status, knowledge of HIV-negative status significantly increased participants' consistent condom use by 8.1% points [95% confidence interval (CI): 2.7–13.4, p = 0.003] and knowledge of HIV-positive status increased participants' consistent condom use by 6.1% points (95% CI: −0.1 to 12.9, p = 0.08); however, this latter effect was not statistically significant. FSWs in Zambia engaged in safer sex with clients when they learned their HIV status. The expansion of HIV testing programs may serve as a behavioral HIV prevention measure among FSWs.

Individual and partner characteristics associated with HIV testing and counseling uptake among individuals 50 years or older in Tanzania

HIV prevention efforts have historically focused on people aged 15–49 years, despite mounting evidence of risk behavior and increased disease burden among older adults. We analyzed survey data from 600 adults aged ≥50 years in the Rombo District of Tanzania. Logistic regression models were performed to evaluate individual and partner-level factors associated with HIV testing and counseling (HTC) uptake. In this sample, more than half of participants were sexually active and condom use was rare, but only 57% had ever been tested for HIV. Ten were HIV infected (1.7%); this prevalence was approximately one-third that observed among the general population in Tanzania (4.7%). Individual factors associated with increased HTC uptake included younger age, female gender, greater educational attainment, and having health insurance. Partner factors associated with increased HTC uptake included lower partner age and higher partner education. This population demonstrated substantial HIV risk, warranting tailored interventions to raise awareness and increase HTC uptake.

Adverse childhood experiences, sexual debut and HIV testing among adolescents in a low-income high HIV-prevalence context

OBJECTIVES

To investigate whether adverse childhood experiences are important determinants of sexual debut and HIV testing.

DESIGN

Adolescents (age 10-16; N = 2089) from rural Malawi were interviewed in 2017-2018 for the baseline wave of a longitudinal study of childhood adversity and HIV risk.

METHODS

Respondents were interviewed in their local language. Surveys captured 13 lifetime childhood adversities (using the Adverse Childhood Experience - International Questionnaire); sexual debut; and previous HIV testing. We used multivariate regression models to test whether adversity, measured both cumulatively and separately, predicted HIV risk.

RESULTS

For each additional adversity, there was a significant rise in the odds of sexual debut (odds ratio 1.13, confidence interval 1.07-1.20) and HIV testing (odds ratio 1.10, confidence interval 1.04-1.16).

CONCLUSION

Preventing HIV among all young people necessitates a paradigm shift that recognizes the importance of early life social determinants in structuring HIV risk.

Attitudes Toward Long-Term Use of Antiretroviral Therapy Among HIV-Infected Pregnant Women in Moshi, Tanzania: A Longitudinal Study

Adherence to antiretroviral therapy (ART) during pregnancy and the postpartum period is necessary to prevent vertical HIV transmission and to secure the long-term health of an HIV-infected woman. Health behavior theory suggests that patients' attitudes towards medication can predict their medication-taking behaviour. This study sought to understand how women's attitudes towards ART changes between the pregnancy and postpartum periods, and the factors associated with these attitudes. The study enrolled 200 pregnant women living with HIV. Structured surveys were administered during pregnancy and at three and 6 months postpartum. Overall, attitudes towards ART were stable over time. More positive attitudes towards ART were associated with HIV acceptance, lower levels of depression, and lower levels of shame. Counselling interventions are needed to help HIV-infected women accept their status and reduce shameful emotions. Depression screening and treatment should be integrated into PMTCT services. This study emphasizes the importance of early attention to attitudes towards ART, in order to establish a trajectory of sustained care engagement.

Perceptions among transgender women of factors associated with the access to HIV/AIDS-related health services in Yogyakarta, Indonesia

Access to HIV/AIDS-related health services among transgender women living with HIV is still a major public health issue in many developing countries, and Indonesia is not an exception. However, reportedly compared to other settings in the country, transgender women in Yogyakarta have a good access to the HIV-related health services. This study aimed to explore perceptions among transgender women living with HIV, locally known as waria, of factors supportive of their access to the services in Yogyakarta, Indonesia. A qualitative inquiry using in-depth interview method was conducted from December 2017 to February 2018 to collect the data from a selection of waria living with HIV (n = 29) recruited using both purposive and snowball sampling techniques. Data analysis employed a thematic approach which was guided by the framework analysis for qualitative data. The findings indicated several health service system-related determinants supportive of waria’s access to HIV/AIDS-related health services. These included the availability of the services, the simplicity and convenience of accessibility to the services and the comfort felt by the participants while accessing the services. Health professionals’ positive attitudes during healthcare provision, social relationships between waria and health professionals, proximity to healthcare facilities, free access to the services, and information sessions on HIV infection and prevention were also reported to enable participants’ access to the services. These findings call to efforts and strengthening of HIV health service system to support and provide equal access to HIV/AIDS-related services including to all Indonesians living with HIV, but more so for transgender women and other high-risk groups such as sex workers and their clients and men who have sex with men.

Characteristics of stakeholder involvement in systematic and rapid reviews: a methodological review in the area of health services research

OBJECTIVE

Engaging stakeholders in reviews is considered to generate more relevant evidence and to facilitate dissemination and use. As little is known about stakeholder involvement, we assessed the characteristics of their engagement in systematic and rapid reviews and the methodological quality of included studies. Stakeholders were people with a particular interest in the research topic.

DESIGN

Methodological review.

SEARCH STRATEGY

Four databases (Medline, Embase, Cochrane database of systematic reviews, databases of the University of York, Center for Reviews and Dissemination (CRD)) were searched based on an a priori protocol. Four types of reviews (Cochrane and non-Cochrane systematic reviews, rapid and CRD rapid reviews) were retrieved between January 2011 and October 2015, pooled by potential review type and duplicates excluded. Articles were randomly ordered and screened for inclusion and exclusion criteria until 30 reviews per group were reached. Their methodological quality was assessed using AMSTAR and stakeholder characteristics were collected.

RESULTS

In total, 57 822 deduplicated citations were detected with potential non-Cochrane systematic reviews being the biggest group (56 986 records). We found stakeholder involvement in 13% (4/30) of Cochrane, 20% (6/30) of non-Cochrane, 43% (13/30) of rapid and 93% (28/30) of CRD reviews. Overall, 33% (17/51) of the responding contact authors mentioned positive effects of stakeholder involvement. A conflict of interest statement remained unmentioned in 40% (12/30) of non-Cochrane and in 27% (8/30) of rapid reviews, but not in Cochrane or CRD reviews. At most, half of non-Cochrane and rapid reviews mentioned an a priori study protocol in contrast to all Cochrane reviews.

CONCLUSION

Stakeholder engagement was not general practice, except for CRD reviews, although it was more common in rapid reviews. Reporting factors, such as including an a priori study protocol and a conflict of interest statement should be considered in conjunction with involving stakeholders.

HIV prevention among youth: A randomized controlled trial of voluntary counseling and testing for HIV and male condom distribution in rural Kenya

OBJECTIVE

Voluntary Counseling and Testing for HIV (VCT) and increasing access to male condoms are common strategies to respond to the HIV/AIDS pandemic. Using biological and behavioral outcomes, we compared programs to increase access to VCT, male condoms or both among youth in Western Kenya with the standard available HIV prevention services within this setting.

DESIGN

A four arm, unblinded randomized controlled trial.

METHODS

The sample includes 10,245 youth aged 17 to 24 randomly assigned to receive community-based VCT, 150 male condoms, both VCT and condoms, or neither program. All had access to standard HIV services available within their communities. Surveys and blood samples for HSV-2 testing were collected at baseline (2009-2010) and at follow up (2011-2013). VCT was offered to all participants at follow up. HSV-2 prevalence, the primary outcome, was assessed using weighted logistic regressions in an intention-to-treat analysis.

RESULTS

For the 7,565 respondents surveyed at follow up, (effective tracking rate = 91%), the weighted HSV-2 prevalence was similar across groups (control group = 10.8%, condoms only group = 9.1%, VCT only group = 10.2%, VCT and condoms group = 11.5%). None of the interventions significantly reduced HSV-2 prevalence; the adjusted odds ratios were 0.87 (95% CI: 0.61-1.25) for condoms only, 0.94 (95% CI: 0.64-1.38) for VCT only, and 1.12 (95% CI: 0.79-1.58) for both interventions. The VCT intervention significantly increased HIV testing (adj OR: 3.54, 95% CI: 2.32-5.41 for VCT only, and adj OR: 5.52, 95% CI: 3.90-7.81 for condoms and VCT group). There were no statistically significant effects on risk of HIV, or on other behavioral or knowledge outcomes including self-reported pregnancy rates.

CONCLUSION

This study suggests that systematic community-based VCT campaigns (in addition to VCT availability at local health clinics) and condom distribution are unlikely on their own to significantly reduce the prevalence of HSV-2 among youth.

Is knowledge of HIV status associated with sexual behaviours? A fixed effects analysis of a female sex worker cohort in urban Uganda

INTRODUCTION

Female sex workers (FSWs) have strong economic incentives for sexual risk-taking behaviour. We test whether knowledge of HIV status affects such behaviours among FSWs.

METHODS

We used longitudinal data from a FSW cohort in urban Uganda, which was formed as part of an HIV self-testing trial with four months of follow-up. Participants reported perceived knowledge of HIV status, number of clients per average working night, and consistent condom use with clients at baseline, one month, and four months. We measured the association between knowledge of HIV status and FSWs' sexual behaviours using linear panel regressions with individual fixed effects, controlling for study round and calendar time.

RESULTS

Most of the 960 participants tested for HIV during the observation period (95%) and experienced a change in knowledge of HIV status (71%). Knowledge of HIV status did not affect participants' number of clients but did affect their consistent condom use. After controlling for individual fixed effects, study round and calendar month, knowledge of HIV-negative status was associated with a significant increase in consistent condom use by 9.5 percentage points (95% CI 5.2 to 13.5, p < 0.001), while knowledge of HIV-positive status was not associated with a significant change in consistent condom use (2.5 percentage points, 95% CI -8.0 to 3.1, p = 0.38).

CONCLUSIONS

In urban Uganda, FSWs engaged in safer sex with clients when they perceived that they themselves were not living with HIV. Even in communities with very high HIV prevalence, the majority of the population will test HIV-negative. Our results thus imply that expansion of HIV testing programmes may serve as a behavioural HIV prevention measure among FSWs.

Uptake and correlates of HIV testing among men in Malawi: evidence from a national population-based household survey

BACKGROUND

HIV testing is one of the key strategies in the HIV/AIDS prevention and control programmes. However, studies examining utilization of this service by men in Malawi are limited. The aim of this study was to assess the uptake and determinants of HIV testing among men in Malawi.

METHODS

Secondary data analysis was conducted on cross-sectional household data for 7478 men aged 15 to 54 years drawn from the 2015-16 Malawi Demographic and Health Survey. Descriptive statistics, bivariate and multivariable logistic regression analyses were performed to identify the socio-demographic, behavioral and health service related factors that are associated with HIV testing service utilisation by men in Malawi. All analyses were performed using the complex sample analysis procedure of the Statistical Package for the Social Sciences version 22.0 to account for the multistage sampling used in Demographic Health Survey.

RESULTS

Overall, 69.9% of the participants had ever been tested for HIV. The results indicate that age, region of residence, marital status, covered by health insurance, education and age at first sexual debut are significant predictors of HIV testing among men in Malawi. In particular, men who were in the age group 30-39 years (AOR = 3.00; 95% CI = 2.35-3.82), married (AOR = 3.03; 95% CI = 2.51-3.65), those with secondary or above education (AOR = 3.02; 95% CI = 2.33-3.91), and those who had health insurance (AOR = 1.66; 95% CI = 1.05-2.63) were likely to utilise HIV testing service than their counterparts.

CONCLUSION

The findings suggest that HIV testing services and programmes need to target younger unmarried men aged 15-19, men with low level or no education and expand HIV testing services to the central and southern regions of Malawi. Targeting the undiagnosed men living with HIV in a timely manner is a crucial and necessary step not only for achieving the UNAIDS' 90-90-90 targets but for individuals to benefit from antiretroviral treatment and to sustainably reduce population-level HIV transmission.

The impact and cost-effectiveness of community-based HIV self-testing in sub-Saharan Africa: a health economic and modelling analysis

INTRODUCTION

The prevalence of undiagnosed HIV is declining in Africa, and various HIV testing approaches are finding lower positivity rates. In this context, the epidemiological impact and cost-effectiveness of community-based HIV self-testing (CB-HIVST) is unclear. We aimed to assess this in different sub-populations and across scenarios characterized by different adult HIV prevalence and antiretroviral treatment programmes in sub-Saharan Africa.

METHODS

The synthesis model was used to address this aim. Three sub-populations were considered for CB-HIVST: (i) women having transactional sex (WTS); (ii) young people (15 to 24 years); and (iii) adult men (25 to 49 years). We assumed uptake of CB-HIVST similar to that reported in epidemiological studies (base case), or assumed people use CB-HIVST only if exposed to risk (condomless sex) since last HIV test. We also considered a five-year time-limited CB-HIVST programme. Cost-effectiveness was defined by an incremental cost-effectiveness ratio (ICER; cost-per-disability-adjusted life-year (DALY) averted) below US$500 over a time horizon of 50 years. The efficiency of targeted CB-HIVST was evaluated using the number of additional tests per infection or death averted.

RESULTS

In the base case, targeting adult men with CB-HIVST offered the greatest impact, averting 1500 HIV infections and 520 deaths per year in the context of a simulated country with nine million adults, and impact could be enhanced by linkage to voluntary medical male circumcision (VMMC). However, the approach was only cost-effective if the programme was limited to five years or the undiagnosed prevalence was above 3%. CB-HIVST to WTS was the most cost-effective. The main drivers of cost-effectiveness were the cost of CB-HIVST and the prevalence of undiagnosed HIV. All other CB-HIVST scenarios had an ICER above US$500 per DALY averted.

CONCLUSIONS

CB-HIVST showed an important epidemiological impact. To maximize population health within a fixed budget, CB-HIVST needs to be targeted on the basis of the prevalence of undiagnosed HIV, sub-population and the overall costs of delivering this testing modality. Linkage to VMMC enhances its cost-effectiveness.

Behavioral changes following HIV seroconversion during the historical expansion of HIV treatment in the United States

OBJECTIVES

To identify the ways in which HIV seroconversion impacts subsequent health behaviors in the context of evolving HIV treatment technologies.

DESIGN

Prospective cohort study.

METHODS

We assessed changes in health and HIV risk behaviors following HIV seroconversion both before and after HIV treatment access (i.e. HAART) in the United States by drawing from the Multicenter AIDS Cohort Study, which collected data from men who have sex with men (MSM) (n = 4616) in four US cities from 1984 to 2008. Longitudinal regression analyses with individual fixed effects accounted for time-invariant, unobservable determinants of risk behaviors. Further analyses assessed the sensitivity of our results to controlling for indicators of physical and mental health (e.g. CD4 cell count, depression) and differential attrition by higher risk individuals.

RESULTS

Among those who seroconverted during observation (n = 558), HIV seroconversion was associated with reduced odds of subsequent engagement in sex with at least two partners [adjusted odds ratio [adjusted odds ratio (aOR): 0.371; confidence interval (CI): 0.263-0.523], insertive anal sex with at least two partners (aOR: 0.360; CI: 0.219-0.591), and heavy drinking (aOR: 0.704; CI: 0.508-0.977). Seroconversion after HAART availability and treatment initiation was associated with further reduced odds of engaging in these behaviors. CD4 cell count, depression, and attrition did not change these results.

CONCLUSION

Specific health and HIV risk behaviors declined following seroconversion, especially with treatment availability and utilization. These positive behavior changes following HIV seroconversion provide evidence for continued investment in the HIV care continuum, including support for HIV testing and engagement in clinical care and treatment.

The Evidence Project risk of bias tool: assessing study rigor for both randomized and non-randomized intervention studies

BACKGROUND

Different tools exist for assessing risk of bias of intervention studies for systematic reviews. We present a tool for assessing risk of bias across both randomized and non-randomized study designs. The tool was developed by the Evidence Project, which conducts systematic reviews and meta-analyses of behavioral interventions for HIV in low- and middle-income countries.

METHODS

We present the eight items of the tool and describe considerations for each and for the tool as a whole. We then evaluate reliability of the tool by presenting inter-rater reliability for 125 selected studies from seven published reviews, calculating a kappa for each individual item and a weighted kappa for the total count of items.

RESULTS

The tool includes eight items, each of which is rated as being present (yes) or not present (no) and, for some items, not applicable or not reported. The items include (1) cohort, (2) control or comparison group, (3) pre-post intervention data, (4) random assignment of participants to the intervention, (5) random selection of participants for assessment, (6) follow-up rate of 80% or more, (7) comparison groups equivalent on sociodemographics, and (8) comparison groups equivalent at baseline on outcome measures. Together, items (1)-(3) summarize the study design, while the remaining items consider other common elements of study rigor. Inter-rater reliability was moderate to substantial for all items, ranging from 0.41 to 0.80 (median κ = 0.66). Agreement between raters on the total count of items endorsed was also substantial (κw = 0.66).

CONCLUSIONS

Strengths of the tool include its applicability to a range of study designs, from randomized trials to various types of observational and quasi-experimental studies. It is relatively easy to use and interpret and can be applied to a range of review topics without adaptation, facilitating comparability across reviews. Limitations include the lack of potentially relevant items measured in other tools and potential threats to validity of some items. To date, the tool has been applied in over 30 reviews. We believe it is a practical option for assessing risk of bias in systematic reviews of interventions that include a range of study designs.

Gender Disparities in Receipt of HIV Testing Results in Six Sub-Saharan African Countries

Purpose: Receipt of HIV testing results is vital for individuals to know their status and make decisions that would improve their access to HIV prevention, treatment, and care. The objective of this study is to determine the association of HIV testing and receipt of results with three key exposure variables (HIV stigma, HIV knowledge, and media use) stratified by gender and country. Methods: Data from a random sample of adults aged 15-49 years from Burundi, Ethiopia, Kenya, Rwanda, Tanzania, and Uganda were abstracted from country-specific Demographic and Health Surveys or AIDS Indicators Surveys. Individuals were asked questions regarding demographics, socioeconomic status, sexual behaviors/attitudes, HIV knowledge, HIV stigma, and media-consumption. Weighted logistic regression was used to determine the association between receipt of HIV testing with key risk factors stratified by gender and country. Results: Gender disparities in HIV testing and receipt of results, HIV stigma, and HIV knowledge remain high. More women have recently tested for HIV and received their results than men. HIV stigma was associated with decreased recent HIV testing in all six countries for women, and for men except in Ethiopia, Tanzania, and Uganda. HIV knowledge was positively related to recent testing in all countries, except Uganda for women and Kenya and Tanzania for men. In Burundi and Rwanda, women had more HIV knowledge than men, while in Kenya, Ethiopia, Tanzania, and Uganda, men had more HIV knowledge than women. Conclusion: Given the importance of HIV testing for effective management of HIV in sub-Saharan Africa, it is crucial for these countries to exchange information on gender-specific policies and strategies that have the most impact on increasing HIV knowledge and decreasing HIV stigma.

HIV test uptake and related factors amongst heterosexual drug users in Shandong province, China

BACKGROUND

In China, the mode of HIV transmission and the types and routes of drug use have changed in the past decade. HIV testing amongst drug users needs further improvement.

METHODS

Interviewer-administered questionnaires were used for data collection amongst 600 heterosexual drug users from the community and a municipal detention centre, where criminal suspects are supervised. Descriptive statistics, univariate analysis and multilevel logistic regression analysis were used to identify the factors associated with HIV testing amongst heterosexual drug users. All participants were screened HIV and sexually transmitted infections.

RESULTS

Amongst 600 participants, 554 (92.3%) were methamphetamine users, and 155 (25.8%) underwent HIV testing in the past year. Multivariate analysis results revealed that drug users who were single (adjusted odds ratio(AOR) = 1.923, 95% confidence interval(CI) = 1.189-3.109), had less knowledge of HIV (AOR = 1.706, 95% CI = 1.074-2.711), used only one kind of drug (AOR = 2.649, 95% CI = 1.155-6.077), used drug via a non-injection route (AOR = 2.121, 95% CI = 1.103-4.078), did not receive free condoms (AOR = 2.307, 95% CI = 1.129-4.715) and who did not receive free publicity material from health workers in the past year (AOR = 2.828, 95% CI = 1.757-4.552) were less likely to undergo HIV testing. A total of 594 participants underwent HIV and syphilis screening in this survey. Amongst these participants, 2 (0.3%) were HIV antibody positive, and 88 (14.8%) showed positive results in both non-treponemal test (rapid plasma regain test) and treponemal test (Treponema pallidum particle agglutination test) for the first time.

CONCLUSIONS

The rate of HIV test uptake amongst heterosexual drug users in China remains low. Thus, more specific interventions are urgently needed to improve the utilisation of HIV testing amongst heterosexual drug users, particularly amongst non-injection drug users in China.

Covariates of high-risk sexual behaviour of men aged 50 years and above in sub-Saharan Africa

Since the advent of HIV/AIDS, sexuality studies in sub-Saharan Africa (SSA) have focused mainly on the sexual behaviour of the younger generation (15-49 years) and little has been done to understand the sexual behaviour of those a 50 years and above. The objective of this study is therefore to examine the covariates of high-risk sexual behaviour among men aged 50 years plus within the SSA region. Data from Demographic and Health Surveys of 10 SSA countries were pooled together and a sample of 5394 men aged 50 years plus who have ever had sex was analysed. Findings show that in SSA, a large proportion of men aged 50 years plus (74%) were sexually active and a substantial proportion of these men engaged in unsafe sexual behaviours, such as having multiple sexual partners and unprotected sex. The multivariate logistic regression analysis showed that involvement with multiple sexual partners was significantly associated with older age, urban residence, religion, having primary or secondary education, and ever taken an HIV test. Condom use at last sex was significantly associated with age at first sex, multiple sexual partners, level of education and ever been tested for HIV. These results suggest that HIV prevention and intervention programmes should also target older men as they are also sexually active and at risk of being infected because of unsafe sexual practices.

The Relationship Between Risk Perception and Frequency of HIV Testing Among Men Who Have Sex with Men and Transgender Women, Lima, Peru

HIV infections in Peru are concentrated among men who have sex with men (MSM) and transgender women (TW). HIV testing rates among them remain low, delaying entrance into care. We assessed the prevalence of frequent HIV testing (at least every 6 months) and associated factors among 310 MSM and TW who attend sexual health clinics in Lima, Peru, and who reported that they were HIV seronegative or unaware of their status. Only 39% of participants tested frequently, and 22% had never tested; 29% reported that they were at low or no risk for acquiring HIV. Reporting low or no risk for acquiring HIV was associated with frequent testing (adjusted prevalence ratio [aPR] = 1.53, 95% CI 1.13-2.08); those reporting unprotected anal sex were less likely to test frequently (aPR = 0.66, 95% CI 0.50-0.87). HIV prevalence was 12% and did not vary by risk perception categories. This at-risk population tests infrequently and may not understand the risk of having unprotected sex.

Barriers to HIV testing among male clients of female sex workers in Indonesia

BACKGROUND

Frequent engagement of men in sexual encounters with female sex workers (FSWs) without using condoms places them at a high risk for HIV infection. HIV testing has been noted to be among important strategies to prevent HIV transmission and acquisition. However, it is known that not all men willingly undertake an HIV test as a way to prevent HIV transmission and/or acquisition. This study aimed to identify barriers to accessing HIV testing services among men who are clients of FSWs (clients) in Belu and Malaka districts, Indonesia.

METHODS

A qualitative inquiry employing face to face open ended interviews was conducted from January to April 2017. The participants (n = 42) were clients of FSWs recruited using purposive and snowball sampling techniques. Data were analysed using a qualitative data analysis framework.

RESULTS

Findings indicated three main barriers of accessing HIV testing services by clients. These included: (1) personal barriers (lack of knowledge of HIV/AIDS and HIV testing availability, and unwillingness to undergo HIV testing due to low self-perceived risk of HIV and fear of the test result); (2) health care service provision barriers (lack of trust in health professionals and limited availability of medication including antiretroviral (ARV)); and (3) social barriers (stigma and discrimination, and the lack of social supports).

CONCLUSIONS

These findings indicated multilevelled barriers to accessing HIV testing services among participants, who are known to be among key population groups in HIV care. Actions to improve HIV/AIDS-related health services accessibility are required. The dissemination of the knowledge and information on HIV/AIDS and improved available of HIV/AIDS-related services are necessary actions to improve the personal levelled barriers. System wide barriers will need improved practices and health policies to provide patients friendly and accessible services. The societal levelled barriers will need a more broad societal approach including raising awareness in the community and enhanced discussions about HIV/AIDS issues in order to normalise HIV in the society.

Age-Related Differences in Socio-demographic and Behavioral Determinants of HIV Testing and Counseling in HPTN 043/NIMH Project Accept

Youth represent a large proportion of new HIV infections worldwide, yet their utilization of HIV testing and counseling (HTC) remains low. Using the post-intervention, cross-sectional, population-based household survey done in 2011 as part of HPTN 043/NIMH Project Accept, a cluster-randomized trial of community mobilization and mobile HTC in South Africa (Soweto and KwaZulu Natal), Zimbabwe, Tanzania and Thailand, we evaluated age-related differences among socio-demographic and behavioral determinants of HTC in study participants by study arm, site, and gender. A multivariate logistic regression model was developed using complete individual data from 13,755 participants with recent HIV testing (prior 12 months) as the outcome. Youth (18-24 years) was not predictive of recent HTC, except for high-risk youth with multiple concurrent partners, who were less likely (aOR 0.75; 95% CI 0.61-0.92) to have recently been tested than youth reporting a single partner. Importantly, the intervention was successful in reaching men with site specific success ranging from aOR 1.27 (95% CI 1.05-1.53) in South Africa to aOR 2.30 in Thailand (95% CI 1.85-2.84). Finally, across a diverse range of settings, higher education (aOR 1.67; 95% CI 1.42, 1.96), higher socio-economic status (aOR 1.21; 95% CI 1.08-1.36), and marriage (aOR 1.55; 95% CI 1.37-1.75) were all predictive of recent HTC, which did not significantly vary across study arm, site, gender or age category (18-24 vs. 25-32 years).

HIV Testing Services in Africa: Are They Sustainable?

HIV testing services (HTS) are an essential component of a national response to the HIV epidemic, and in lower and middle income countries, at least 150 million persons are tested annually. HIV testing is necessary to identify persons in need of antiretroviral treatment, which has been documented to be highly effective not only for treatment but also for prevention of HIV transmission to both adults and children. An assessment of the recent literature on sustainability of health and HIV services suggests that organizational performance, flexibility, and integration with other health interventions contribute to sustainability of HIV services and programs. This article describes the experiences of two HIV testing service providers in Uganda and Zambia as well as the track record of services to prevent mother-to-child HIV transmission to illustrate the factors of performance, flexibility, adaptability, and integration which are key to the sustainability of HIV testing services.

The History of the HIV/AIDS Epidemic in Africa

HIV testing of African immigrants in Belgium showed that HIV existed among Africans by 1983. However, the epidemic was recognized much later in most parts of sub-Saharan Africa (SSA) due to stigma and perceived fear of possible negative consequences to the countries' economies. This delay had devastating mortality, morbidity, and social consequences. In countries where earlier recognition occurred, political leadership was vital in mounting a response. The response involved establishment of AIDS control programs and research on the HIV epidemiology and candidate preventive interventions. Over time, the number of effective interventions has grown; the game changer being triple antiretroviral therapy (ART). ART has led to a rapid decline in HIV-related morbidity and mortality in addition to prevention of onward HIV transmission. Other effective interventions include safe male circumcision, pre-exposure prophylaxis, and post-exposure prophylaxis. However, since none of these is sufficient by itself, delivering a combination package of these interventions is important for ending the HIV epidemic as a public health threat.

Reaching the 'first 90': Gaps in coverage of HIV testing among people living with HIV in 16 African countries

BACKGROUND

UNAIDS has recently proposed a set of three ambitious targets that, if achieved, are predicted to end the AIDS epidemic by 2030. The targets, known as 90-90-90, call for 90% of people living with HIV (PLHIV) to know their status, 90% of PLHIV to receive antiretroviral therapy, and 90% of those on antiretroviral therapy to achieve viral suppression by the year 2020. We examine the first of these targets, focusing on sub-Saharan Africa, the region of the world most affected by HIV, to measure the proportion of PLHIV estimated to know their HIV status, and to identify background and behavioral characteristics significantly associated with gaps in ever testing among PLHIV.

METHODS AND FINDINGS

We analyze cross-sectional population-based data from the Demographic and Health Surveys (DHS) and AIDS Indicator Surveys (AIS) fielded since 2010 in 16 sub-Saharan African countries where voluntary serological testing was recently conducted: Burkina Faso, Cameroon, Chad, Cote d'Ivoire, Ethiopia, Gabon, Lesotho, Malawi, Namibia, Rwanda, Sierra Leone, Tanzania, Togo, Uganda, Zambia, and Zimbabwe. Survey response rates averaged 95.0% (range 89.3-99.5%), while consent to serotesting averaged 94.9% (range 88.7-99.6%). This study, which includes more than 14,000 respondents living with HIV, finds that 69% of PLHIV in the average study country have ever been tested for HIV (range 34-95%). Based on timing of the last test and on ART coverage, we estimate that 54% of PLHIV in the average country are aware of their status (range 26-84%). Adjusted logistic regression finds that men (median adjusted odds ratio [AOR] = 0.38), adults with less than primary education (median AOR = 0.31), and adolescents (median AOR = 0.32) are consistently less likely to have ever been tested for HIV than women, adults with secondary and above education, and adults age 30-39, respectively. In most countries unadjusted logistic regression also finds significant gaps in testing among the poorest groups and those reporting never having had sex.

CONCLUSION

The fact that an average of 54% of PLHIV in these 16 countries are estimated to know their status reflects encouraging progress. However, not only is this average far short of the 90% target set by UNAIDS for 2020, but it also implies that in the average study country nearly one-half of PLHIV are unable to access lifesaving care and treatment because they are unaware that they are HIV-positive. Several gaps in HIV testing coverage exist, particularly among adolescents, the least educated, and men. While the need to target demographic groups at greatest risk of HIV continues, additional interventions focused on reaching men and on reaching socially vulnerable populations such as adolescents, the poorest, and the least educated are essential.

Frequent HIV Testing: Impact on HIV Risk Among Chinese Men Who Have Sex with Men

BACKGROUND

The HIV epidemic continues to expand among men who have sex with men (MSM) in China. The NIMH Project Accept/HPTN 043 trial suggested a borderline significant trend toward HIV incidence reduction among persons with higher testing rates.

METHODS

We assessed HIV testing histories and infection status among a community-based Beijing MSM. HIV serostatus was lab confirmed. We ascertained demographic/behavioral factors through questionnaire-based interviews. Associations of previous HIV testing with odds of current HIV infection were assessed, seeking improved like-with-like risk comparisons through multivariable logistic regression analysis with propensity score adjustment and restricted cubic spline modeling.

RESULTS

Among 3588 participants, 12.7% were HIV infected; 70.8% reported having ever tested for HIV. Compared with MSM who never tested, those ever testing had a 41% reduction in the odds of being HIV positive [adjusted odds ratio (aOR): 0.59; 95% confidence interval (CI): 0.48 to 0.74. Higher HIV testing frequencies were associated with a decreasing trend in the odds of being infected with HIV vs. a referent group with no previous testing [>6 tests (aOR: 0.27; 95% CI: 0.18 to 0.41); 4-6 (aOR: 0.55; 95% CI: 0.39 to 0.78); 2-3 (aOR: 0.61; 95% CI: 0.45 to 0.82); P for trend <0.001]. The multivariable-adjusted model with restricted cubic spline of HIV testing frequency showed a higher frequency of previous HIV testing associated with lower odds of HIV infection, particularly among men with ≥10 lifetime male sexual partners.

CONCLUSIONS

Using risk probability adjustments to enable less biased comparisons, frequent HIV testing was associated with a lower HIV odds among Chinese MSM.

What works - reaching universal HIV testing: lessons from HPTN 071 (PopART) trial in Zambia

Objective:

To determine the uptake of home-based HIV counselling and testing (HCT) in four HPTN 071 (PopART) trial communities (implementing a ‘full’ combination HIV prevention package that includes universal HIV testing and treatment) in Zambia. We also explore factors associated with uptake of HCT in these communities.

Design:

HPTN 071 (PopART) is a three-arm community-randomized trial in 12 communities in Zambia and nine communities in South Africa evaluating the impact of a combination HIV prevention package, including universal HIV testing and treatment, on HIV incidence.

Methods:

Using a door-to-door approach that includes systematically revisiting households, individuals were offered participation in the intervention, and verbal consent was obtained. Data were analysed for the first 18 months of the intervention, December 2013 to June 2015 for individuals 18 years and older.

Results:

Among 121 130 enumerated household members, 101 102 (83.5%) accepted the intervention. HCT uptake was 72.2% (66 894/92 612), similar by sex but varied across communities. HCT uptake was associated with younger age, sex, community, being symptomatic for TB and sexually transmitted infections and longer time since previous HIV test. Knowledge of HIV status due to the intervention increased by 36% overall and by 66% among HIV positive participants; the highest impact was among 18–24 years old.

Conclusion:

Overall acceptance of HIV-testing through offering a door-to-door-based combination HIV prevention package was 72.2%. The intervention increased knowledge of HIV status from ∼50 to ∼90%. However, challenges still remain and a one-off intervention is unlikely to be successful but will require repeated visits and multiple strategies.

Prevalence of HIV testing and counseling and associated factors among secondary school students in Botswana

BACKGROUND

The World Health Organization recommends HIV testing and counseling (HTC) for all adolescents living in countries with generalized HIV epidemics. In Botswana, HIV prevalence among adolescents 15-19 years is 3.7% and among pregnant adolescents is 10%. We describe the proportion and characteristics of secondary school students who have accessed HTC.

METHODS

A multistage sample survey was conducted among students in Botswana's public secondary schools in 2010. The survey was self-administered using a personal digital assistant device. The HTC rate was estimated using self-reported history of HIV testing.

RESULTS

Of 1,632 participants, 52% were girls, 43% aged below 16 years, and 27% had ever had sexual intercourse. Most (81%) students knew where to get tested for HIV. Overall, 2.2% of students were HIV positive by self-report. The HTC rate was 23% overall, 34% among students who had ever had sexual intercourse, and 45% among students who had sexual intercourse in the past 12 months. Being pregnant or having made someone pregnant and having had sexual intercourse in the past 12 months were associated with having been tested for HIV among students who had ever had sexual intercourse.

DISCUSSION

Overall, the HTC rate was low, and the self- reported HIV prevalence was high among secondary students in Botswana. Most sexually active students have never been tested for HIV. Health communications efforts for adolescents that increase demand for HTC, routine opt-out HIV testing in healthcare facilities, and school-based HIV testing are needed as part of a national HIV prevention strategy.

Uptake of HIV testing in Burkina Faso: an assessment of individual and community-level determinants

Background

Previous studies have highlighted a range of individual determinants associated with HIV testing but few have assessed the role of contextual factors. The objective of this paper is to examine the influence of both individual and community-level determinants of HIV testing uptake in Burkina Faso.

Methods

Using nationally representative cross-sectional data from the 2010 Demographic and Health Survey, the determinants of lifetime HIV testing were examined for sexually active women (n = 14,656) and men (n = 5680) using modified Poisson regression models.

Results

One third of women (36%; 95% Confidence Interval (CI): 33–37%) reported having ever been tested for HIV compared to a quarter of men (26%; 95% CI: 24–27%). For both genders, age, education, religious affiliation, household wealth, employment, media exposure, sexual behaviors, and HIV knowledge were associated with HIV testing. After adjustment, women living in communities where the following characteristics were higher than the median were more likely to report uptake of HIV testing: knowledge of where to access testing (Prevalence Ratio [PR] = 1.41; 95% CI: 1.34–1.48), willing to buy food from an infected vendor (PR = 2.06; 95% CI: 1.31–3.24), highest wealth quintiles (PR = 1.18; 95% CI: 1.10–1.27), not working year-round (PR = 0.90; 95% CI: 0.84–0.96), and high media exposure (PR = 1.11; 95% CI: 1.03–1.19). Men living in communities where the proportion of respondents were more educated (PR = 1.23; 95% CI: 1.07–1.41) than the median were more likely to be tested.

Conclusions

This study shed light on potential mechanisms through which HIV testing could be increased in Burkina Faso. Both individual and contextual factors should be considered to design effective strategies for scaling-up HIV testing.

Should trained lay providers perform HIV testing? A systematic review to inform World Health Organization guidelines

New strategies for HIV testing services (HTS) are needed to achieve UN 90-90-90 targets, including diagnosis of 90% of people living with HIV. Task-sharing HTS to trained lay providers may alleviate health worker shortages and better reach target groups. We conducted a systematic review of studies evaluating HTS by lay providers using rapid diagnostic tests (RDTs). Peer-reviewed articles were included if they compared HTS using RDTs performed by trained lay providers to HTS by health professionals, or to no intervention. We also reviewed data on end-users' values and preferences around lay providers preforming HTS. Searching was conducted through 10 online databases, reviewing reference lists, and contacting experts. Screening and data abstraction were conducted in duplicate using systematic methods. Of 6113 unique citations identified, 5 studies were included in the effectiveness review and 6 in the values and preferences review. One US-based randomized trial found patients' uptake of HTS doubled with lay providers (57% vs. 27%, percent difference: 30, 95% confidence interval: 27-32, p < 0.001). In Malawi, a pre/post study showed increases in HTS sites and tests after delegation to lay providers. Studies from Cambodia, Malawi, and South Africa comparing testing quality between lay providers and laboratory staff found little discordance and high sensitivity and specificity (≥98%). Values and preferences studies generally found support for lay providers conducting HTS, particularly in non-hypothetical scenarios. Based on evidence supporting using trained lay providers, a WHO expert panel recommended lay providers be allowed to conduct HTS using HIV RDTs. Uptake of this recommendation could expand HIV testing to more people globally.

Prevalence of condomless anal intercourse and recent HIV testing and their associated factors among men who have sex with men in Hangzhou, China: A respondent-driven sampling survey

Men who have sex with men (MSM) are a large high-risk population for HIV infection in recent years in China. A cross-sectional survey was conducted in Hangzhou, China, to determine rates of condomless anal intercourse (CAI), recent HIV testing (in the recent year) and associated factors using respondent-driven sampling. Questionnaires using face-to-face interviews were employed to collect data on sexual risk behaviors and HIV testing. Five hundred eleven MSM were recruited, of which 459 (89.8%) had anal intercourse in the past 6 months. Of these 459 participants, 457 (99.6%) answered whether they had taken an HIV test in the recent year, so only their data were analyzed. Weighted data were analyzed using bivariate and multivariate logistic regression analysis. The CAI rate with male partners in the past 6 months was 43.7% (95% confidence interval [CI], 34.0-51.5%), while the rate of condomless vaginal intercourse (CVI) was 21.6% (95% CI, 15.6-32.3%). The prevalence of recent HIV testing was 56.8% (95% CI, 48.7-66.5%), while the prevalence of HIV and syphilis were 8.8% and 6.5%, respectively. Multivariate analysis indicated that CAI was associated with earlier homosexual debut, suicidal inclinations, childhood sexual abuse, HIV testing in the recent year, and lower estimate of HIV prevalence. Recent HIV testing was associated with homosexual debut age, engaging in CAI with male partners in the past 6 months, having oral sex in the past 6 months, self-perceived higher likelihood of HIV infection, knowing about antiretroviral therapy for HIV/AIDS, receiving AIDS/sexually transmitted infection (STI) interventions in the past year, and syphilis infection. Given high prevalence of HIV and syphilis, high levels of CAI and CVI, and low HIV testing rate, the results indicated high risk of HIV infection and transmission among MSM. HIV prevention interventions should target MSM with early homosexual debut and psychosocial health problems, while HIV/AIDS education among MSM should focus on increasing knowledge of HIV risk, estimated HIV prevalence and antiretroviral therapy, and improving risk perception of HIV acquisition.

Can Policy Interventions Affect HIV-Related Behaviors? A Systematic Review of the Evidence from Low- and Middle-Income Countries

In their response to HIV, many countries have adopted and enacted policies to reduce transmission and increase HIV-related service use. Theoretically, policy-level interventions for HIV prevention have the potential to improve health behavior outcomes. These policy interventions vary in their scale, from relatively minor changes in clinical policy to major national legal initiatives. Assessing the effectiveness of HIV policy interventions is a challenging undertaking. While many policies exist and guide HIV programmes, relatively few have specifically been evaluated for their effects on reducing HIV risk taking or increasing HIV health-seeking behaviors. Thus, questions on the effectiveness of policy interventions to prevent HIV and change HIV-related risk behaviors remain largely unanswered. To address this current gap in the literature, we systematically reviewed the existing evidence on the effect of HIV policy interventions on changing HIV-related behaviors in low-and middle-income countries.

Uptake contexts and perceived impacts of HIV testing and counselling among adults in East and Southern Africa: A meta-ethnographic review

INTRODUCTION

HIV testing and counselling (HTC) interventions are key to controlling the HIV epidemic in East and Southern Africa where HTC is primarily delivered through voluntary counselling and testing (VCT), provider initiated testing and counselling (PITC), and home-based counselling and testing (HBVCT). Decision making processes around uptake of HTC models must be taken into account when designing new interventions. Counselling in HTC aims to reduce post-test risk taking behaviour and to link individuals to care but its efficacy is unclear. This meta-ethnography aims to understand the contexts of HTC uptake in East and Southern Africa and to analyse the perceived impacts of counselling-based interventions in relation to sexual behaviour and linkage to care.

METHODS

We conducted a systematic literature review of studies investigating HTC in East and Southern Africa from 2003 -April 2014. The search and additional snowballing identified 20 studies that fit our selection criteria. These studies were synthesised through a thematic framework analysis.

RESULTS

Twenty qualitative and mixed-methods studies examining impacts of HTC models in East and Southern Africa were meta-synthesised. VCT decisions were made individually while HBVCT decisions were located in family and community units. PITC was associated with coercion from healthcare providers. Low quality counselling components and multiple-intersecting barriers faced by individuals mean that counselling in HTC was not perceived to be effective in reducing post-test risk behaviour and had limited perceived effect in facilitating linkage to care.

CONCLUSION

HBVCT is associated with minimal stigma and should be considered as an area of priority. Counselling components in HTC interventions were effective in transmitting information about HIV and sexual risk, but were perceived as ineffective in addressing the broader personal circumstances preventing sexual behaviour change and modulating access to care.