The impact of rapid HIV home test use with sexual partners on subsequent sexual behavior among men who have sex with men

Understanding experiences of potential harm among MSM (cis and trans) using HIV self-testing in the SELPHI randomised controlled trial in England and Wales: a mixed-methods study

BACKGROUND

The potential of HIV self-testing (HIVST) to cause harm is a concern hindering widespread implementation. The aim of this paper is to understand the relationship between HIVST and harm in SELPHI (An HIV Self-testing Public Health Intervention), the largest randomised trial of HIVST in a high-income country to date.

METHODS

10 111 cis and trans men who have sex with men (MSM) recruited online (geolocation social/sexual networking apps, social media), aged 16+, reporting previous anal intercourse and resident in England or Wales were first randomised 60/40 to baseline HIVST (baseline testing, BT) or not (no baseline testing, nBT) (randomisation A). BT participants reporting negative baseline test, sexual risk at 3 months and interest in further HIVST were randomised to three-monthly HIVST (repeat testing, RT) or not (no repeat testing, nRT) (randomisation B). All received an exit survey collecting data on harms (to relationships, well-being, false results or being pressured/persuaded to test). Nine participants reporting harm were interviewed in-depth about their experiences in an exploratory substudy; qualitative data were analysed narratively.

RESULTS

Baseline: predominantly cis MSM, 90% white, 88% gay, 47% university educated and 7% current/former pre-exposure prophylaxis (PrEP) users. Final survey response rate was: nBT=26% (1056/4062), BT=45% (1674/3741), nRT=41% (471/1147), RT=50% (581/1161).Harms were rare and reported by 4% (n=138/3691) in exit surveys, with an additional two false positive results captured in other study surveys. 1% reported harm to relationships and to well-being in BT, nRT and RT combined. In all arms combined, being pressured or persuaded to test was reported by 1% (n=54/3678) and false positive results in 0.7% (n=34/4665).Qualitative analysis revealed harms arose from the kit itself (technological harms), the intervention (intervention harms) or from the social context of the participant (socially emergent harms). Intervention and socially emergent harms did not reduce HIVST acceptability, whereas technological harms did.

DISCUSSION

HIVST harms were rare but strategies to link individuals experiencing harms with psychosocial support should be considered for HIVST scale-up.

TRIAL REGISTRATION NUMBER

ISRCTN20312003.

Geospatial Prioritization to Reach Hispanic or Latino and Other Priority Populations Through HIV Home Testing Services

CONTEXT

Hispanic or Latino men who have sex with men (HLMSM) are disproportionately affected by the HIV/AIDS epidemic in New York State (NYS) and nationally. In 2019, HLMSM comprised 13% of all new diagnoses and 21% of new diagnoses among men who have sex with men (MSM) in NYS excluding New York City. HIV home testing programs are effective methods for increasing HIV testing.

OBJECTIVE

This pilot sought to determine whether the NYS HIV Home Test Giveaway (HHTG) can effectively reach priority populations, specifically HLMSM/transgender/gender nonconforming persons who have sex with men, to increase uptake of HIV home testing services and identify new HIV infections.

DESIGN/SETTING

We recruited participants using media campaigns linked to a brief self-administered eligibility survey. Eligible participants provided their e-mail address to receive a code for a free HIV home test and were sent a self-administered follow-up survey 4 to 11 weeks after eligibility survey completion.

PARTICIPANTS

The 2018 and 2019 NYS HHTG reached 1214 and 1340 participants, respectively. A total of 606 participants in 2018 and 736 participants in 2019 were eligible to receive the HHTG home test kit.

MAIN OUTCOME MEASURES

HHTG utilization and test results.

RESULTS

Hispanic or Latino persons participated at higher rates (34.8% and 25.4% in 2018 and 2019, respectively) than the percentage of Hispanic men in prioritized zip codes (15.7% and 15.6% in 2018 and 2019, respectively). The majority of participants who received HHTG test kits used them to test themselves (87.5% in 2018 and 90.6% in 2019). Across both rounds, 4 participants reported new HIV-positive results, for a seropositivity rate of approximately 1%.

CONCLUSION

Geospatial prioritization was successful in reaching Hispanic or Latino priority populations for HIV testing. HIV self-testing programs such as the HHTG are beneficial methods to reach priority populations for state and national Ending the HIV Epidemic initiatives.

The Impact of Providing Free HIV Self-testing on Sexual Risk Behaviors Among Men who have Sex with Men in Hunan, China: A Randomized Controlled Trial

HIV self-testing (HIVST) increases testing frequency among men who have sex with men (MSM). However, its impact on sexual risk behaviors is unclear. In a randomized controlled trial conducted in Hunan Province, China, HIV-negative MSM were randomized to receive one of two interventions for one year: (1) facility-based HIV testing, or (2) facility-based HIV testing augmented with free HIVST. From April to June 2018, 230 MSM were enrolled. They self-reported sexual behaviors every 3 months for 12 months. Among 216 MSM with follow-ups (intervention: 110; control: 106), adjusting for potential confounders in Generalized Estimating Equation models, there were no statistically significant differences in consistent condom use with male partners (regular/casual) or female partners, nor on number of male or female sexual partners. Provision of free HIVST kits does not increase risky sex and should be included in comprehensive HIV prevention packages, particularly for sexual minority men in China.

Willingness to receive the COVID-19 vaccine among HIV positive men who have sex with men in China: a cross-sectional study

BACKGROUND

People living with HIV(PLWH) are deemed more vulnerable to the SARS-CoV-2 infection than the uninfected population. Vaccination is an effective measure for COVID-19 control, yet, little knowledge exists about the willingness of men who have sex with men (MSM) living with HIV in China to be vaccinated.

METHODS

This cross-sectional study evaluated the willingness of MSM living with HIV to receive COVID-19 vaccination in six cities of Guangdong, China, from July to September 2020. Factors associated with willingness to receive COVID-19 vaccination using multivariable logistic regression.

RESULTS

In total, we recruited 944 HIV-positive MSM with a mean age of 29.2 ± 7.7 years. Of all participants, 92.4% of them were willing to receive the COVID-19 vaccine. Participants who were separated, divorced, or widowed (adjusted OR: 5.29, 95%CI: 1.02-27.48), had an annual income higher than 9,000 USD (adjusted OR: 1.70, 95%CI: 1.01-2.86), had ever taken an HIV self-test (adjusted OR: 1.78, 95%CI: 1.07-2.95), had ever disclosed sexual orientation to a doctor/nurse (adjusted OR: 3.16, 95%CI: 1.33-7.50), had ever disclosed sexual orientation to others besides their male partners (adjusted OR: 2.18, 95%CI: 1.29-3.69) were more willing to receive the vaccine. Sex with a female partner in the past six months decreased the likelihood of willingness to receive the vaccine (adjusted OR: 0.40, 95%CI: 0.17-0.95). Economic burden, worry that my health condition could not bear the risk of receiving COVID-19 vaccines, and concern that the vaccination would affect the immune status and antiretroviral therapy were the main reasons for unwillingness to receive vaccination.

CONCLUSION

Our study showed that HIV-positive MSM had a high willingness to receive the COVID-19 vaccination. Targeted interventions such as health education should be conducted among MSM with HIV infection to enhance COVID-19 vaccine uptake.

Engagement in Care Among Newly Diagnosed HIV-Positive Gay, Bisexual, and Other Men Who Have Sex With Men in the United States: Results From the Together 5,000 Study

One-quarter of gay, bisexual, and other men who have sex with men (GBMSM) with diagnosed HIV are not engaged in HIV care. Between 2018 and 2019, 50 GBMSM completed qualitative interviews 3 months after receiving an HIV-positive result. Interviews explored barriers to and facilitators of engagement and retention in HIV testing and care. Thematic analysis revealed five major themes: (1) reason for HIV testing (e.g., self-testing), (2) linkage to care (e.g., appointment/logistic issues and social support as encouragement), (3) barriers to engagement in care (e.g., financial burden, competing priorities, and fear/stigma), (4) facilitators of engagement (e.g., financial assistance, patient-provider relationships, auxiliary support services, and health agency), and (5) PrEP as a missed prevention opportunity. Addressing individual-, social-, and policy-level barriers could improve GBMSM's engagement in HIV care. Further, capitalizing on GBMSM's health agency through partnerships with local agencies and fostering better patient-provider relationships could optimize HIV care continuity.

Formative assessment to identify perceived benefits and barriers of HIV oral self-testing among female sex workers, service providers, outreach workers, and peer educators to inform scale-up in Kenya

In Kenya, HIV prevalence estimates among female sex workers (FSWs) are almost five times higher than among women in the general population. However, only 68% of infected FSWs are aware of their HIV-positive status. We aimed to identify perceived benefits, opportunities, and barriers of HIV self-testing (HIVST) in improving testing coverage among FSWs. Twenty focus group discussions were conducted with 77 service providers, 42 peer educators (PEs) and outreach workers, and 37 FSWs attending drop-in centers (DiCEs) in four regions of Kenya. An additional 8 FSWs with HIV-negative or unknown status-completed in-depth interviews. Data were analyzed thematically. Acceptability of HIVST was high, with cited benefits including confidentiality, convenience, and ease of use. Barriers included absence of counseling, potential for inaccurate results, fear of partner reaction, possible misuse, and fear that HIVST could lead to further stigmatization. PEs and DiCEs were the preferred models for distributing HIVST kits. FSWs wanted kits made available free or at a nominal cost (100 Kenya Shillings or ∼USD 1). Linkage to confirmatory testing, the efficiency of distributing HIVST kits using peers and DiCEs, and the types and content of effective HIVST messaging require further research.

Negotiating Use of a Blood-Based, Dual HIV and Syphilis Test with Potential Sexual Partners Among a Sample of Cisgender Men and Transgender Women Who Have Sex with Men in New York City

Cisgender men who have sex with men (cMSM) and transgender women (TGW) are disproportionally burdened by HIV. Among these populations, HIV partner-testing is a highly acceptable harm reduction tool. Particularly, cMSM and TGW report a stronger preference for blood-based tests that include assays for multiple STIs. However, no existing research has explored how these populations negotiate blood-based testing with sexual partners. In the SMARTtest study, 48 sexually active cMSM and TGW took home dual, blood-based HIV/Syphilis kits for self- and partner-testing. After 3 months, they completed a follow-up assessment and in-depth interviews about their experiences initiating testing. Of the 42 responding participants, 27 (64%) reported that it had been "fairly" or "very easy" to raise the idea of testing with partners. Participants predominantly employed partner-conscious communication strategies, including framing the testing proposal as a mandatory, non-personal component of their participation in a research study, gradually incorporating testing mentions into discussions about sexual health, and using the kits to facilitate joint testing. Yet, 21 (44%) participants reported having sex with at least one partner they did not ask to test. Concern regarding partner reactions emerged as a significant barrier to discussing test use; similarly, many partners were averse to taking a blood-based test in the context of a casual sexual encounter. Nonetheless, these findings suggest that dual, blood-based HIV/STI rapid tests may represent acceptable harm reduction tools among similar populations of cMSM and TGW, particularly if future partner-testing research is broadened to consider key couples' dynamics that may impact test usage.

Combating Stigma Through HIV Self-Testing: New York State's HIV Home Test Giveaway Program for Sexual Minorities

CONTEXT

Gay, bisexual, and men who have sex with men (MSM) are disproportionately affected by the HIV/AIDS epidemic more than any other group. In New York State (NYS) outside of New York City (NYC), MSM accounted for 57% of new HIV/AIDS diagnoses in 2017. HIV/AIDS home testing initiatives have been effective at getting priority populations tested for HIV.

OBJECTIVES

The NYS Department of Health (NYSDOH) administered the HIV Home Test Giveaway (HHTG) program through social media and mobile applications popular among the priority populations to (1) promote HIV screening among gay and bisexual men, MSM, transgender (TG), and gender queer/gender nonconforming (GNC) individuals who have sex with men, and (2) identify individuals with undiagnosed HIV infection.

DESIGN/SETTING

The NYSDOH recruited participants from NYS (excluding NYC) through social media campaigns between November 2016 and January 2018. Interested individuals were directed to an online eligibility survey. Eligible participants received a coupon via e-mail for a free HIV self-test (HIVST) kit through the manufacturer's Web site. Eligible participants received a $20 to $25 Amazon online gift card if they completed a voluntary online follow-up survey regarding their test results, experiences with the HHTG, and HIV/AIDS risk behaviors. Participants were also able to request assistance from the NYSDOH with further testing and various prevention and supportive services.

PARTICIPANTS

In total, 6190 individuals participated and 3197 (52%) were eligible and received a coupon. Of the eligible, 2022 (63%) redeemed coupons for HIVST.

RESULTS

Among eligible participants, 976 (31%) reported having never been tested for HIV. On the follow-up survey, 922 (29%) participants reported having used the HIVST kit for themselves; 203 (22%) were first-time testers; and 7 (0.8%) tested HIV reactive. Of the follow-up survey participants, 761 (59%) requested assistance with various services.

CONCLUSIONS

Media campaigns were effective in promoting HIV testing among priority populations and reaching individuals who have never been tested for HIV.

Attitudes and Perceptions About Disclosing HIV and Syphilis Results Using Smarttest, a Smartphone App Dedicated to Self- and Partner Testing

We explored interest in disclosing test results through a smartphone app dedicated to self- and partner testing for HIV/syphilis. Fifty-nine cisgender men and transgender women each participated in an in-person survey and interview. We examined their interests in sharing test results by audience (e.g., partners, physicians) and by positive versus negative test result. Participants wanted the ability to share results, with notable interest in disclosing negative results to sexual partners and on social media and forwarding positive results to physicians. Participants envisioned smartphone sharing as a means to normalize testing, to notify partners of results, and to expedite linkage to care. Some questioned the authenticity of results shared by smartphone, while others voiced optimism that a personalized, authenticated app could ensure the security and veracity of results. Smartphone testing apps for HIV/syphilis may facilitate disclosure, partner notification, and linkage to care, but need to address concerns about the security and veracity of results.

Behavioral Intentions to Use Patient Portals to Disclose HIV and Other Sexually Transmitted Infection Testing Histories with Sexual Partners Among U.S. Sexual Minority Men

Disclosure of HIV and other sexually transmitted infection (HIV/STI) testing history to sexual partners is low among gay, bisexual, and other U.S. sexual minority men (SMM). Patient portals (PP) could increase HIV/STI testing history disclosure. This study estimated the predictive validity of the Enhancing Dyadic Communication (EDC) latent construct for perceived behavioral intentions to use PP for HIV/STI test disclosures. A randomized subset of SMM completed the Patient Portal Sexual Health Instrument as part of the 2018 American Men's Internet Survey. Multivariable logistic regression models estimated associations between EDC and intentions to use PP for test disclosures. Among a sample of 1,509 SMM aged 15 to 77 years, EDC was associated with intentions to use PP to disclose test history with main partners (aOR 2.17; 95% CI 1.90 to 2.47) and non-main partners (aOR 2.39; 95%CI 2.07 to 2.76). Assessing EDC could be useful in clinical settings for interventions encouraging patients to communicate with partners about testing.

Comparing the effects of HIV self-testing to standard HIV testing for key populations: a systematic review and meta-analysis

BACKGROUND

We update a previous systematic review to inform new World Health Organization HIV self-testing (HIVST) recommendations. We compared the effects of HIVST to standard HIV testing services to understand which service delivery models are effective for key populations.

METHODS

We did a systematic review of randomised controlled trials (RCTs) which compared HIVST to standard HIV testing in key populations, published from 1 January 2006 to 4 June 2019 in PubMed, Embase, Global Index Medicus, Social Policy and Practice, PsycINFO, Health Management Information Consortium, EBSCO CINAHL Plus, Cochrane Library and Web of Science. We extracted study characteristic and outcome data and conducted risk of bias assessments using the Cochrane ROB tool version 1. Random effects meta-analyses were conducted, and pooled effect estimates were assessed along with other evidence characteristics to determine the overall strength of the evidence using GRADE methodology.

RESULTS

After screening 5909 titles and abstracts, we identified 10 RCTs which reported on testing outcomes. These included 9679 participants, of whom 5486 were men who have sex with men (MSM), 72 were trans people and 4121 were female sex workers. Service delivery models included facility-based, online/mail and peer distribution. Support components were highly diverse and ranged from helplines to training and supervision. HIVST increased testing uptake by 1.45 times (RR=1.45 95% CI 1.20, 1.75). For MSM and small numbers of trans people, HIVST increased the mean number of HIV tests by 2.56 over follow-up (mean difference = 2.56; 95% CI 1.24, 3.88). There was no difference between HIVST and SoC in regard to positivity among tested overall (RR = 0.91; 95% CI 0.73, 1.15); in sensitivity analysis of positivity among randomised HIVST identified significantly more HIV infections among MSM and trans people (RR = 2.21; 95% CI 1.20, 4.08) and in online/mail distribution systems (RR = 2.21; 95% CI 1.14, 4.32). Yield of positive results in FSW was not significantly different between HIVST and SoC. HIVST reduced linkage to care by 17% compared to SoC overall (RR = 0.83; 95% CI 0.74, 0.92). Impacts on STI testing were mixed; two RCTs showed no decreases in STI testing while one showed significantly lower STI testing in the intervention arm. There were no negative impacts on condom use (RR = 0.95; 95% CI 0.83, 1.08), and social harm was very rare.

CONCLUSIONS

HIVST is safe and increases testing uptake and frequency as well as yield of positive results for MSM and trans people without negative effects on linkage to HIV care, STI testing, condom use or social harm. Testing uptake was increased for FSW, yield of positive results were not and linkage to HIV care was worse. Strategies to improve linkage to care outcomes for both groups are crucial for effective roll-out.

[Pharmacists’ and key populations’ points of view on HIV self-test dispensation in pharmacies in France]

OBJECTIVE

The HIV self-test has been on sale in France since September 2015. What is the point of view of pharmacists and key populations with regard to accessing self-tests in community pharmacies ?

METHOD

One year after the HIV self-test came onto the market, the points of view of pharmacists and key populations with regard to HIV were collected during six focus groups: the pharmacists themselves; people who had already used HIV self-tests; potential users from two key populations with regard to HIV: migrants from sub-Saharan Africa and men who have sex with men; potential users from populations with active sex lives but not particularly vulnerable with regard to HIV: young adults (<25 years of age), multi-partner heterosexual adults.

RESULTS

The HIV self-test in community pharmacies is perceived by all participants as a significant step forward for accessing screening for HIV. However, issues around discretion and anonymity were seen to create significant tensions with regard to accessing the test itself, but also the information necessary to use it correctly both at a technical level and above all concerning how to interpret test results.

CONCLUSION

Although the present study underlines the role of the pharmacist as a significant public health actor in the dispensation of the self-test, the sales price and questions of anonymity are seen as major obstacles. Priority actions include renewing communication campaigns concerning the existence and the use of the product for the upcoming generations of young people but also specific campaigns targeting more vulnerable populations.

Increases in HIV status disclosure and sexual communication between South African men who have sex with men and their partners following use of HIV self-testing kits

Availability of HIV self-testing may increase HIV testing frequency among men who have sex with men (MSM). It is unclear, however, if self-testing may impact HIV-related sexual behaviors among MSM, including HIV status disclosure and condom use. We conducted a mixed methods analysis of changes in HIV-related behaviors after HIV self-testing introduction, using data from 110 MSM participating in a feasibility and acceptability study of HIV self-testing in Mpumalanga Province, South Africa. We found increased HIV status disclosure from study participants to sexual partners after HIV self-testing introduction, from 61.8% at baseline to 75.5% at 6-month follow-up (p = 0.04), but decreased condom use with female partners (p = 0.03). Qualitative interviews reveal that some participants used test results to inform condom use. Distribution of self-testing kits can improve mutual disclosure, but should be accompanied by information stressing that the tests may not detect early HIV infections or other sexually transmitted infections.

Substance Use and Testing Sexual Partners Using HIV Self-tests

HIV self-tests (HIVST) provide the possibility of testing partners prior to sexual activity. This study examines the role of substance use among men who have sex with men (n = 123) and transgender women (n = 13) who were provided HIVST to use with potential sex partners. Several reported avoiding/delaying alcohol (44%) or drug use (27%) because they intended to use HIVST. Those who used HIVST with alcohol (37%) or drugs (24%) did not differ from those who did not on number of partners asked, proportion who agreed, or intentions to use HIVST. A minority reported problems caused by substances. Ten did not ask someone to test because they were too drunk/high. Fourteen said it was fairly or very hard to use HIVST when under the influence. Eleven reported substances caused problems when discussing or administering HIVST, but only two of those felt the problems were major.

Low sexually transmissible infection knowledge, risk perception and concern about infection among men who have sex with men and transgender women at high risk of infection

Background Amidst an increase in STI rates among men who have sex with men (MSM) and transgender women (TGW), there is little research on STI knowledge, risk perception and concern about infection in these populations.

METHODS

This mixed-methods study explored these constructs among 60 racially and ethnically diverse MSM and TGW who regularly engage in condomless anal intercourse with multiple partners.

RESULTS

Participants had a mean age of 40.63 years. Most (95%) identified as a man and as gay or homosexual (73%); 55% were college graduates. Almost half the respondents reported a prior STI. Participants correctly answered a mean of 55.36% and 76.90% STI and HIV knowledge items respectively. STI knowledge was positively correlated with education and prior HIV tests, and was higher among those with a prior STI. During in-depth interviews, some participants expressed concerns about limited knowledge of STIs and syphilis. Half reported low concern about syphilis infection, due to prior treatment that was perceived as relatively simple, lack of STI infection in the past, erroneous information about transmission routes or simply not thinking about it.

CONCLUSIONS

Among this high-risk sample who perceived themselves to be at low risk of infection, knowledge was primarily gained through being diagnosed and treated for an STI rather than from acquiring knowledge to prevent STI infection. Participants expressed interest in increasing their STI knowledge and recognised the importance of regular STI testing. Dissemination of targeted information about STI prevention, routinising of STI testing and STI self-testing might contribute to decreasing STI infection rates among this population.

HIV and other STIs self-testing to reduce risk compensation among men who have sex with men who use oral pre-exposure prophylaxis in China: protocol for a randomised waitlist-controlled trial

INTRODUCTION

Pre-exposure prophylaxis (PrEP) reduces the risk of HIV infection among men who have sex with men by up to 99%. However, in real-world settings, PrEP users may exhibit risk compensation after uptake of PrEP, including more condomless anal intercourse (CAI) and increased sexually transmitted infection (STI) acquisition. HIV self-testing (HIVST) decreases CAI among men who have sex with men (MSM) by providing awareness of the HIV status of oneself and one's sexual partners. Here, we describe the rationale and design of a randomised waitlist-controlled trial to examine the impact of HIVST on risk compensation among PrEP users.

METHODS AND ANALYSIS

The study is a two-arm randomised waitlist-controlled trial with 1000 HIV-negative MSM in four major cities in China who will be taking oral PrEP (involving tenofovir disoproxil fumarate/emtricitabine) either daily (n=500) or in an event-driven regimen (n=500). The participants will be randomised (1:1) to either the immediate HIVST intervention arm (HIVST plus standard facility-based counselling and testing from 0 to 12 months) or the waitlist arm (standard facility-based counselling and testing from 0 to 6 months, then crossover to receive the HIVST intervention in months 7-12). Participants will provide blood samples to assess the incidence of syphilis and herpes simplex virus type 2 (HSV-2) during a follow-up. The primary outcomes will be the occurrence of CAI, number of sexual partners and incidence of syphilis and HSV-2 during a follow-up. The secondary outcomes will be the HIV and STI testing frequency and STI treatment adherence during a follow-up. The planned start and end dates for the study is 26 December 2018 and 31 December 2020.

ETHICS AND DISSEMINATION

The Medical Science Research Ethics Committee of The First Affiliated Hospital of China Medical University has approved the study (IRB(2018)273).

TRIAL REGISTRATION NUMBER

ChiCTR1800020374.

Use of Rapid HIV Self-Test to Screen Potential Sexual Partners: Results of the ISUM Study

ISUM ("I'll show you mine") was a randomized controlled trial in which 272 transgender women and men who have sex with men in New York, NY (NYC) and San Juan, Puerto Rico (SJU) were assigned to an intervention group (n = 136), in which they had access to free HIV self-testing (ST) kits, or to a control group (n = 136). The trial aimed to determine whether the intervention group would use ST to screen sexual partners and have fewer condomless anal intercourse (CAI) occasions with serodiscordant or unknown status partners than the control group. The intervention group had on average 10 (32%) fewer CAI occasions; though clinically relevant, this difference fell short of statistical significance (p = .08). In NYC (n = 166) intervention participants had significantly fewer CAI occasions, whereas in SJU (n = 106) they reported non-significantly more CAI occasions. Two devastating hurricanes hit SJU during the study and may have impacted results in unmeasured ways.

SMARTtest: A Smartphone App to Facilitate HIV and Syphilis Self- and Partner-Testing, Interpretation of Results, and Linkage to Care

Acceptability of rapid HIV self-testing is high but potential users remain concerned about correct use, interpretation of test results, and linkage to care. This article describes user preferences for a smartphone app to mitigate these challenges and how these were integrated into the SMARTtest app to support self- and partner-testing using the INSTI Multiplex^®. Sixty men and transgender women who have sex with men self-tested for HIV and syphilis while guided by a prototype app that provided a video, pictorial step-by-step instructions, and sample test results presented textually ("positive," "negative"). Subsequently, participants provided feedback on revisions and additional app content. Participants recommended offering different user modes (self, partner, both), and retaining the video, step-by-step instructions, and textual test results. They strongly favored the ability to save and send test results to sexual partners or providers. These features were integrated into the SMARTtest app to facilitate HIV/syphilis self- and partner-testing, HIV/syphilis status awareness and disclosure, and linkage to care.

Anticipated HIV stigma among HIV negative men who have sex with men in China: a cross-sectional study

BACKGROUND

Anticipated HIV stigma, i.e., the expectation of adverse experiences from one's seroconversion, is associated with both negative psychological and behavioral outcomes. We know little about anticipated HIV stigma's relationship with emerging technologies, such as HIV self-testing (HIVST) and online sex-seeking platforms, that have become popular among populations that are disproportionately affected by HIV/AIDS. This study examined correlates of anticipated HIV stigma among Chinese men who have sex with men (MSM).

METHODS

In July 2016, MSM, who were ≥ 16 years old and self-reported as HIV negative or unknown, were recruited from a gay mobile phone application in China. Information regarding socio-demographics, sexual behaviors, sexual health service utilization, and anticipated HIV stigma were collected. Anticipated HIV stigma (i.e., negative attitude toward future stigmatization of HIV seroconversion by others) was measured as the mean score from a 7-item Likert-scale ranging from 1 (low) to 4 (high). Generalized linear models were conducted to examine the factors associated with the anticipated HIV stigma scores.

RESULTS

Overall, 2006 men completed the survey. Most men completed high school (1308/2006, 65.2%) and had an annual personal income of ≤9200 USD (1431/2006, 71.3%). The mean anticipated HIV stigma score for the participants was 2.98 ± 0.64. Using social media to seek sexual partners was associated with higher anticipated HIV stigma (Adjusted β = 0.11, 95% confidence interval (CI): 0.05 to 0.17, p = 0.001). HIV self-testing (Adjusted β = - 0.07, 95%CI: - 0.13 to - 0.01, p = 0.02) and having disclosed one's sexual orientation to a healthcare provider (Adjusted β = - 0.16, 95%CI: - 0.22 to - 0.96, p < 0.001) were associated with lower anticipated HIV stigma.

CONCLUSION

Our data suggested that anticipated HIV stigma is still common among Chinese MSM not living with HIV. Tailored anti-HIV stigma campaigns on social media are especially needed, and the promotion of HIVST may be a promising approach.

HIV Self-Testing Increases HIV Testing Frequency in High-Risk Men Who Have Sex With Men: A Randomized Controlled Trial

BACKGROUND

Self-testing may increase HIV testing and decrease the time people with HIV are unaware of their status, but there is concern that absence of counseling may result in increased HIV risk.

SETTING

Seattle, Washington.

METHODS

We randomly assigned 230 high-risk HIV-negative men who have sex with men to have access to oral fluid HIV self-tests at no cost versus testing as usual for 15 months. The primary outcome was self-reported number of HIV tests during follow-up. To evaluate self-testing's impact on sexual behavior, we compared the following between arms: non-HIV-concordant condomless anal intercourse and number of male condomless anal intercourse partners in the last 3 months (measured at 9 and 15 months) and diagnosis with a bacterial sexually transmitted infection (STI: early syphilis, gonorrhea, and chlamydial infection) at the final study visit (15 months). A post hoc analysis compared the number of STI tests reported during follow-up.

RESULTS

Men randomized to self-testing reported significantly more HIV tests during follow-up (mean = 5.3, 95% confidence interval = 4.7 to 6.0) than those randomized to testing as usual (3.6, 3.2 to 4.0; P < 0.0001), representing an average increase of 1.7 tests per participant over 15 months. Men randomized to self-testing reported using an average of 3.9 self-tests. Self-testing was noninferior with respect to all markers of HIV risk. Men in the self-testing arm reported significantly fewer STI tests during follow-up (mean = 2.3, 95% confidence interval = 1.9 to 2.7) than men in the control arm (3.2, 2.8 to 3.6; P = 0.0038).

CONCLUSIONS

Access to free HIV self-testing increased testing frequency among high-risk men who have sex with men and did not impact sexual behavior or STI acquisition.

Integrating user behavior with engineering design of point-of-care diagnostic devices: theoretical framework and empirical findings

With point-of-care (POC) diagnostic devices becoming increasingly available to untrained users, it will be critical to understand how real-world user behavior can best inform and guide the engineering design process. Social sciences present frameworks for analyzing user behavior, but they have not yet been applied to POC diagnostics in a methodical manner. Here, we develop a framework that synthesizes two models that can collectively account for user behavior and experience with POC diagnostic devices: a social psychological information-motivation-behavior (IMB) model (first described by Fisher and Fisher) for identifying determinants for health-related behavior, and user experience (UX) elements for studying interactions between users and products. Based on studies of 40 naïve users of our smartphone-enabled microfluidics device that can be used for HIV home-testing, we found that untrained participants could perform 90% of steps correctly, with engineering design elements that provided feedback that was either direct (e.g., a light or click) or binary (e.g., a switch) enhancing usability. Interestingly, of the steps performed incorrectly, over 70% were due not to errors in the device or user operation, but user-to-user variability (e.g. time in collecting fingerstick and force applied to initiate vacuum), which could be addressed by further modifications to the device. Overall, this study suggests that microfluidic POC HIV home-testing is likely to benefit from smartphone integration, and that engineering design of POC diagnostic devices can benefit from a structured evaluation of user behavior and experience, as guided by a social-psychological framework, which emphasizes user credibility, accessibility, acceptability, usability, and value.

Investigating the addition of oral HIV self-tests among populations with high testing coverage - Do they add value? Lessons from a study in Khayelitsha, South Africa

INTRODUCTION

HIV self-testing (HIVST) offers a useful addition to HIV testing services and enables individuals to test privately. Despite recommendations to the contrary, repeat HIV testing is frequent among people already on anti-retroviral treatment (ART) and there are concerns that oral self-testing might lead to false negative results. A study was conducted in Khayelitsha, South Africa, to assess feasibility and uptake of HIVST and linkage-to-care following HIVST.

METHODS

Participants were recruited at two health facilities from 1 March 2016 to 31 March 2017. People under 18 years, or with self-reported previously-diagnosed HIV infection, were excluded. Participants received an OraQuick Rapid HIV-1/2 Antibody kit, and reported their HIVST results by pre-paid text message (SMS) or by returning to the facility. Those not reporting within 7 days were contacted by phone. Electronic and paper-based clinical and laboratory records were retrospectively examined for all participants to identify known HIV outcomes, after matching for name, date of birth, and sex. These findings were compared with self-reported HIVST results where available.

RESULTS

Of 639 participants, 401 (62.8%) self-reported a negative HIVST result, 27 (4.2%) a positive result, and 211 (33.0%) did not report. The record search identified that of the 401 participants self-reporting a negative HIVST result, 19 (4.7%) were already known to be HIV positive; of the 27 self-reporting positive, 12 (44%) were known HIV positive. Overall, records showed 57/639 (8.9%) were HIV positive of whom 39/57 (68.4%) had previously-diagnosed infection and 18/57 (31.6%) newly-diagnosed infection. Of the 428 participants who self-reported a result, 366 (85.5%) reported by SMS.

CONCLUSIONS

HIVST can improve HIV testing uptake and linkage to care. SMS is acceptable for reporting HIVST results but negative self-reports by participants may be unreliable. Use of HIVST by individuals on ART is frequent despite recommendations to the contrary and its implications need further consideration.

The Effect of HIV Self-Testing Delivery Models on Female Sex Workers' Sexual Behaviors: A Randomized Controlled Trial in Urban Uganda

HIV self-testing increases recent and frequent HIV testing among female sex workers (FSWs) in urban Uganda. Using results from a randomized controlled trial, we aim to establish the effect of HIV self-testing delivery models on FSWs’ sexual behaviors in this setting. Clusters of one peer educator and eight participants were 1:1:1 randomized to: (1) direct provision of an HIV self-test, (2) provision of a coupon for facility collection of an HIV self-test, or (3) referral to standard-of-care HIV testing services. Sexual behaviors were self-reported at 1 and 4 months. From October to November 2016, 960 participants were enrolled and randomized. At 4 months, there were no statistically significant differences in participants’ sexual behaviors, including inconsistent condom use, across study arms. We do not find any changes in sexual risk-taking among FSWs in response to the delivery of HIV self-tests. Routine policies for HIV self-testing are likely a behaviorally safe component of comprehensive HIV prevention strategies.

Effect of HIV self-testing on the number of sexual partners among female sex workers in Zambia

Objectives:

To assess the effect of two health system approaches to distribute HIV self-tests on the number of female sex workers’ client and nonclient sexual partners.

Design:

Cluster randomized controlled trial.

Methods:

Peer educators recruited 965 participants. Peer educator–participant groups were randomized 1 : 1 : 1 to one of three arms: delivery of HIV self-tests directly from a peer educator, free facility-based delivery of HIV self-tests in exchange for coupons, or referral to standard-of-care HIV testing. Participants in all three arms completed four peer educator intervention sessions, which included counseling and condom distribution. Participants were asked the average number of client partners they had per night at baseline, 1 and 4 months, and the number of nonclient partners they had in the past 12 months (at baseline) and in the past month (at 1 month and 4 months).

Results:

At 4 months, participants reported significantly fewer clients per night in the direct delivery arm (mean difference −0.78 clients, 95% CI −1.28 to −0.28, P = 0.002) and the coupon arm (−0.71, 95% CI −1.21 to −0.21, P = 0.005) compared with standard of care. Similarly, they reported fewer nonclient partners in the direct delivery arm (−3.19, 95% CI −5.18 to −1.21, P = 0.002) and in the coupon arm (−1.84, 95% CI −3.81 to 0.14, P = 0.07) arm compared with standard of care.

Conclusion:

Expansion of HIV self-testing may have positive behavioral effects enhancing other HIV prevention efforts among female sex workers in Zambia.

Trial Registration:

ClinicalTrials.gov NCT02827240.

HIV Testing in Men who have Sex with Men: A Follow-up Review of the Qualitative Literature since 2010

The landscape of HIV testing has changed significantly in recent years following the rise in importance of the 'treatment as prevention' strategy and advancements in new HIV testing and prevention technologies. This review provides a synthesis of qualitative research findings published since 2010 on preferences and practices of men who have sex with men (MSM) surrounding HIV testing in high-income settings. MSM are one of the hardest groups to reach with standard or conventional HIV testing approaches. To develop innovative testing strategies for this particular group, a good understanding of their concerns, barriers and facilitators of accessing HIV testing is needed. This updated review provides valuable information for improving existing programs and designing new testing services for MSM.

A Global Review of HIV Self-testing: Themes and Implications

HIV self-test kits may have the potential to increase testing rates around the globe, and thereby lead to reductions in HIV-related incidence and mortality. However, the effectiveness of these self-test kits and the issues surrounding self-testing have been greatly debated in recent years. We conducted a literature review on the acceptability, feasibility, and effectiveness of HIV self-testing (HST) around the world. Of the 28 articles abstracted, several themes of HST were explored, including behavioral risk compensation, presence of counseling, uses of HST, ability to perform the self-test, sensitivity and specificity, concordance with confirmatory testing, perceptions surrounding HST, instruction and supervision, and cost. Overall, this literature review found that this diverse group of participants generally performed HST correctly with a few exceptions, were accepting of the test if available at a relatively low cost, and preferred the oral-based HST over the blood-based test.

Experiences using and organizing HIV self-testing

OBJECTIVE

HIV self-testing (HIVST) is now officially recommended by the WHO, yet much of HIVST evidence to date has focused on quantitative data and hypothetical concerns. Effective scale-up of HIVST in diverse local contexts requires qualitative data from experiences using and organizing HIVST. This qualitative systematic review aims to appraise and synthesize research evidence on experiences using and organizing HIVST.

METHODS

We conducted a systematic search of seven primary literature databases, four gray literature sources, and reference lists reporting qualitative evidence on HIVST. Data extraction and thematic analysis were used to synthesize findings. Quality of studies was assessed using the Critical Appraisal Skills Programme tool. Confidence in review findings was evaluated using the Confidence in the Evidence from Reviews of Qualitative Research approach. The review protocol was registered (CRD42015027607).

RESULTS

From 1266 potential articles, we included 18. Four studies were conducted in low-income countries, three in middle-income countries, 10 in high-income countries, and one in multiple countries. Generally, HIVST increased capacity to reach priority populations and expanded opportunities for service delivery. Self-testing was preferred to facility-based testing due to increased convenience and confidentiality, especially among stigmatized populations. HIVST decreased test-associated stigma compared with facility-based testing. HIVST generally empowered people because it provided greater control over individual testing needs. At the same time, HIVST rarely allowed husbands to coerce their wives to test.

CONCLUSIONS

This review suggests that HIVST should be offered as an additional HIV testing option to expand testing and empower testers. Adapting national policies to incorporate HIVST will be necessary to guide scale-up.

Usage of purchased self-tests for HIV and sexually transmitted infections in Amsterdam, the Netherlands: results of population-based and serial cross-sectional studies among the general population and sexual risk groups

OBJECTIVES

There are limited data on the usage of commercially bought self-tests for HIV and other sexually transmitted infections (STIs). Therefore, we studied HIV/STI self-test usage and its determinants among the general population and sexual risk groups between 2007 and 2015 in Amsterdam, the Netherlands.

SETTING

Data were collected in four different studies among the general population (S1-2) and sexual risk groups (S3-4).

PARTICIPANTS

S1-Amsterdam residents participating in representative population-based surveys (2008 and 2012; n=6044) drawn from the municipality register; S2-Participants of a population-based study stratified by ethnicity drawn from the municipality register of Amsterdam (2011-2015; n=17 603); S3-Men having sex with men (MSM) participating in an HIV observational cohort study (2008 and 2013; n=597) and S4-STI clinic clients participating in a cross-sectional survey (2007-2012; n=5655).

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence of HIV/STI self-test usage and its determinants.

RESULTS

The prevalence of HIV/STI self-test usage in the preceding 6-12 months varied between 1% and 2% across studies. Chlamydia self-tests were most commonly used, except among MSM in S3. Chlamydia and syphilis self-test usage increased over time among the representative sample of Amsterdam residents (S1) and chlamydia self-test usage increased over time among STI clinic clients (S4). Self-test usage was associated with African Surinamese or Ghanaian ethnic origin (S2), being woman or MSM (S1 and 4) and having had a higher number of sexual partners (S1-2). Among those in the general population who tested for HIV/STI in the preceding 12 months, 5-9% used a self-test.

CONCLUSIONS

Despite low HIV/STI self-test usage, we observed increases over time in chlamydia and syphilis self-test usage. Furthermore, self-test usage was higher among high-risk individuals in the general population. It is important to continue monitoring self-test usage and informing the public about the unknown quality of available self-tests in the Netherlands and about the pros and cons of self-testing.

A qualitative study of secondary distribution of HIV self-test kits by female sex workers in Kenya

Promoting awareness of serostatus and frequent HIV testing is especially important among high risk populations such as female sex workers (FSW) and their sexual partners. HIV self-testing is an approach that is gaining ground in sub-Saharan Africa as a strategy to increase knowledge of HIV status and promote safer sexual decisions. However, little is known about self-test distribution strategies that are optimal for increasing testing access among hard-to-reach and high risk individuals. We conducted a qualitative study with 18 FSW who participated in a larger study that provided them with five oral fluid-based self-tests, training on how to use the tests, and encouragement to offer the self-tests to their sexual partners using their discretion. Women demonstrated agency in the strategies they used to introduce self-tests to their partners and to avoid conflict with partners. They carefully considered with whom to share self-tests, often assessing the possibility for negative reactions from partners as part of their decision making process. When women faced negative reactions from partners, they drew on strategies they had used before to avoid conflict and physical harm from partners, such as not responding to angry partners and forgoing payment to leave angry partners quickly. Some women also used self-tests to make more informed sexual decisions with their partners.

Acceptability of Three Novel HIV Prevention Methods Among Young Male and Transgender Female Sex Workers in Puerto Rico

Sex workers need HIV-prevention methods they can control and incorporate easily in their work. We studied the acceptability of three methods: HIV self-test use with clients, oral pre-exposure prophylaxis (PrEP), and rectal microbicide gel. Four male and eight transgender female (TGF) sex workers in Puerto Rico completed a baseline survey with a quantitative measure of likelihood of use. From them, one male and four TGF also completed a 12-week study of rectal microbicide placebo gel use prior to receptive anal intercourse with male clients and evaluated via qualitative in-depth interviews and follow-up quantitative assessments how each method could be incorporated into their work. Most were interested in a rectal microbicide gel and able to use it covertly with clients. Challenges to using the HIV self-test with clients included the potential for both breach of confidentiality and confronting violent situations. Participants also expressed interest in oral PrEP, but raised concerns about side effects.

Human Immunodeficiency Virus Testing Practices and Interest in Self-Testing Options Among Young, Black Men Who Have Sex With Men in North Carolina

BACKGROUND

Young, black men who have sex with men (YBMSM) experience disproportionately high human immunodeficiency virus (HIV) incidence in the United States. Relative to other at-risk populations, less is known about their HIV testing behaviors and preferences regarding self-testing.

METHODS

We used an online survey to investigate testing practices and interest in self-testing among HIV-uninfected, 18- to 30-year-old YBMSM in North Carolina.

RESULTS

From July 2014 to March 2015, 212 completed the survey; median age was 24 years. Among 175 (83%) who had ever been tested, 160 (91%) reported testing in the prior year, 124 (71%) tested at least every 6 months, and 71 (40%) tested at least quarterly. About three quarters (77%; n = 164) were aware of HIV self-testing; 35 (17%) had ever purchased rapid (n = 27) or dried blood spot-based (n = 14) kits. Participants aware of kits had greater intention to test in the next 6 months, were more likely to have income for basic necessities and to ask sex partners about HIV status, and were less likely to have a main sex partner or to have had transactional sex. Among 142 participants at least somewhat likely to self-test in the future, convenience (35%), privacy (23%), and rapid result delivery (18%) were the principal motivators.

CONCLUSIONS

Eight of every 10 YBMSM have ever been tested for HIV, but intertest intervals remain unacceptably long for many. Awareness of and interest in self-testing is substantial, but few have used this method. Expanded use of self-tests could help increase the frequency of HIV testing in this epidemiologically important population.

Information, Motivation, and Behavioral Skills of High-Risk Young Adults to Use the HIV Self-Test

HIV self tests (HIVST) have the potential to increase testing among young adults. However, little is known about high-risk young adults' perception of the HIVST as a risk reduction tool and how they would use the HIVST in their everyday lives. Our study sought to examine these factors. Twenty-one ethnically diverse participants (ages 18-24) used the HIVST at our study site, completed surveys, and underwent an in-depth interview. Descriptive statistics were used to analyze the survey responses, and interview data were coded using constructs from the information-motivation-behavioral skills model. Information deficits included: how to use the HIVST and the "window period" for sero-conversion. Motivations supporting HIVST use included: not needing to visit the clinic, fast results, easy access, and use in non-monogamous relationships. Behavioral skills discussed included: coping with a positive test, handling partner violence after a positive test, and accessing HIV services. These findings can inform the use of the HIVST for improving HIV testing rates and reducing HIV risk behavior.

Promoting male partner HIV testing and safer sexual decision making through secondary distribution of self-tests by HIV-negative female sex workers and women receiving antenatal and post-partum care in Kenya: a cohort study

BACKGROUND

Increased uptake of HIV testing by men in sub-Saharan Africa is essential for the success of combination prevention. Self-testing is an emerging approach with high acceptability, but little evidence exists on the best strategies for test distribution. We assessed an approach of providing multiple self-tests to women at high risk of HIV acquisition to promote partner HIV testing and to facilitate safer sexual decision making.

METHODS

In this cohort study, HIV-negative women aged 18-39 years were recruited at two sites in Kisumu, Kenya: a health facility with antenatal and post-partum clinics and a drop-in centre for female sex workers. Participants gave informed consent and were instructed on use of oral fluid based rapid HIV tests. Participants enrolled at the health facility received three self-tests and those at the drop-in centre received five self-tests. Structured interviews were conducted with participants at enrolment and over 3 months to determine how self-tests were used. Outcomes included the number of self-tests distributed by participants, the proportion of participants whose sexual partners used a self-test, couples testing, and sexual behaviour after self-testing.

FINDINGS

Between Jan 14, 2015, and March 13, 2015, 280 participants were enrolled (61 in antenatal care, 117 in post-partum care, and 102 female sex workers); follow-up interviews were completed for 265 (96%). Most participants with primary sexual partners distributed self-tests to partners: 53 (91%) of 58 participants in antenatal care, 91 (86%) of 106 in post-partum care, and 64 (75%) of 85 female sex workers. 82 (81%) of 101 female sex workers distributed more than one self-test to commercial sex clients. Among self-tests distributed to and used by primary sexual partners of participants, couples testing occurred in 27 (51%) of 53 in antenatal care, 62 (68%) of 91 from post-partum care, and 53 (83%) of 64 female sex workers. Among tests received by primary and non-primary sexual partners, two (4%) of 53 tests from participants in antenatal care, two (2%) of 91 in post-partum care, and 41 (14%) of 298 from female sex workers had positive results. Participants reported sexual intercourse with 235 (62%) of 380 sexual partners who tested HIV-negative, compared with eight (18%) of 45 who tested HIV-positive (p<0·0001); condoms were used in all eight intercourse events after positive results compared with 104 (44%) after of negative results (p<0·0018). Four participants reported intimate partner violence as a result of self-test distribution: two in the post-partum care group and two female sex workers. No other adverse events were reported.

INTERPRETATION

Provision of multiple HIV self-tests to women at high risk of HIV infection was successful in promoting HIV testing among their sexual partners and in facilitating safer sexual decisions. This novel strategy warrants further consideration as countries develop self-testing policies and programmes.

FUNDING

Bill & Melinda Gates Foundation.

Ethical implications of HIV self-testing

In April 2015, the first legally approved HIV self-testing kit went on sale in the UK-except Northern Ireland where they remain illegal. These tests allow individuals to test their HIV status and read the result in the privacy of their own home, much like a home pregnancy test. This paper explores the ethical implications of HIV self-testing. We conclude that there are no strong ethical objections to self-testing being made widely available in the UK. Pretest counselling for an HIV test is not an ethical necessity, and self-testing has the potential to increase early diagnosis of HIV infection and thus improve prognosis and reduce ongoing transmission. Self-testing kits might also empower people and promote autonomy by allowing people to dictate the terms on which they test their HIV status. We accept that there are some potential areas of concern. These include the possibility of user error with the tests, and the concern that individuals may not present to health services following a reactive result. False negatives have the potential to cause harm if the 'window period' is not understood, and false positives might produce psychological distress. There is, however, little evidence to suggest that self-testing kits will cause widespread harm, and we argue that the only way to properly evaluate whether they do cause significant harm is to carefully evaluate their use, now that they are available on the market.

Brief Report: Relationship and Demographic Factors Associated With Willingness to Use an In-Home Rapid HIV Test to Screen Potential Sex Partners Among a US Sample of HIV-Negative and HIV-Discordant Male Couples

With dyadic data from a US Internet sample of 275 HIV-negative and 58 discordant male couples, we assessed HIV-negative partnered men's attitudes toward using an in-home rapid HIV test (HT) to screen potential new sex partners and associated factors by multivariate multilevel modeling. HIV-negative partnered men were "likely" to use an HT for screening purposes. More positive attitudes were associated with being in a mixed/nonwhite relationship; having an open sexual agreement. Less positive attitudes were associated with both partners being well educated. These findings may highlight how to make the most of HTs as risk-reduction screening tool among at-risk male couples.

HIV-negative partnered men's attitudes toward using an in-home rapid HIV test and associated factors among a sample of US HIV-Negative and HIV-discordant male couples

BACKGROUND

Many men who have sex with men acquire HIV while in a same-sex relationship. Studies with gay male couples have demonstrated that relationship characteristics and testing behaviors are important to examine for HIV prevention. Recently, an in-home rapid HIV test (HT) has become available for purchase in the United States. However, HIV-negative partnered men's attitudes toward using an HT and whether characteristics of their relationship affect their use of HTs remain largely unknown. This information is relevant for the development of HIV prevention interventions targeting at-risk HIV-negative and HIV-discordant male couples.

METHODS

To assess HIV-negative partnered men's attitudes and associated factors toward using an HT, a cross-sectional Internet-based survey was used to collect dyadic data from a national sample of 275 HIV-negative and 58 HIV-discordant gay male couples. Multivariate multilevel modeling was used to identify behavioral and relationship factors associated with 631 HIV-negative partnered men's attitudes toward using an HT.

RESULTS

HIV-negative partnered men were "very likely" to use an HT. More positive attitudes toward using an HT were associated with being in a relationship of mixed or nonwhite race and with one or both men recently having had sex with a casual male partner. Less positive attitudes toward using an HT were associated with both partners being well educated, with greater resources (investment size) in the relationship, and with one or both men having a primary care provider.

CONCLUSIONS

These findings may be used to help improve testing rates via promotion of HTs among gay male couples.

Black men who have sex with men, sexual risk-taking, and willingness to use rapid home HIV tests

The availability of rapid home-based HIV testing (RHT) in the USA has provided us with a valuable, new option in our efforts to identify more people living with HIV and to do so sooner. Furthermore, it is possible that RHT will be or is currently being used as a means of learning one's own and one's partner's HIV status prior to engaging in condomless intercourse. Data regarding knowledge and willingness to use RHT, however, is very limited. In particular, no studies have investigated RHT use among Black men who have sex with men (BMSM). Understanding RHT use among BMSM is critical as we have observed alarming rates of HIV prevalence among this group, and RHT may provide an opportunity to slow HIV transmission among BMSM. In order to better understand RHT, we assessed knowledge, willingness to use and actual use of RHT, HIV testing history, substance use, and sexual risk-taking among 387 HIV-negative BMSM and 157 HIV-positive BMSM attending a community event in the southeastern USA. We used generalized linear modeling to assess factors associated with their willingness to use RHT. Although familiarity with the availability of RHT was somewhat limited among these men, a substantial portion of BMSM did report an interest in using RHT, including with their sex partners. Among HIV-negative BMSM, however, we found a negative relationship between willingness to use RHT and sexual risk-taking, i.e., higher numbers of condomless anal sex acts were associated with a reduction in willingness to use RHT. It appears that men who report the greatest risk-taking for HIV are least interested in RHT. Future research should focus on better understanding concerns regarding RHT among at-risk HIV-negative men and should investigate the usefulness of using RHT as a HIV prevention method.

HIV self-testing among key populations: an implementation science approach to evaluating self-testing

OBJECTIVES

To review methods for measuring HIV self-testing (HIVST) among key populations, including both conventional approaches and implementation science approaches.

METHODS

We reviewed the literature on evaluating HIVST among key populations.

RESULTS

Simple HIV self-tests have already entered markets in several regions, but metrics required to demonstrate the benefits and costs of HIVST remain simplistic. Conventional measurements of sensitivity, specificity, acceptability, and behavioural preferences must be supplemented with richer implementation science measurement tools and innovative research designs in order to capture data on the following components: how self-testing affects subsequent linkage to confirmatory testing, preventive services and onward steps in the HIV continuum of care; how self-testing can be marketed to reach untested subpopulations; and how self-testing can be sustained based on overarching organisational and financial models. We outline an implementation science research agenda that incorporates these components, drawing from evaluation study designs focused on HIVST and testing in general.

CONCLUSION

HIVST holds great promise for key populations, but must be guided by implementation research to inform programmes and scale up.

Arguments for and against HIV self-testing

Approximately 60% of human immunodeficiency virus (HIV)-infected individuals are unaware of their infection, and stigma and discrimination continue to threaten acceptance of HIV testing services worldwide. Self-testing for HIV has garnered controversy for years and the debate reignited with the approval of a point-of-care test for over-the-counter sale in the US in 2012. Here, we present arguments for and against HIV self-testing. The case in support of HIV self-testing contends that: the modality is highly acceptable, especially among the most at-risk individuals; self-testing empowers users, thus helping to normalize testing; and mutual partner testing has the potential to increase awareness of risk and avert condomless sex between discordant partners. Arguments against HIV self-testing include: cost limits access to those who need testing most; false-negative results, especially during the window period, may lead to false reassurance and could promote sex between discordant partners at the time of highest infectivity; opportunities for counseling, linkage to care, and diagnosis of other sexually transmitted infections may be missed; and self-testing leads to potential for coercion between partners. Research is needed to better define the risks of self-testing, especially as performance of the assays improves, and to delineate the benefits of programs designed to improve access to self-test kits, because this testing modality has numerous potential advantages and drawbacks.

After the clinic? Researching sexual health technology in context

There is great interest in what testing, pharmaceutical, information and social media technology can do for sexual health. Much programmatic and research activity is focused on assessing how these technologies can be used to best effect. Less obvious are analyses that place technology into historical, political and real-world settings. Developing an 'in-context' analysis of sexual health technology, this paper draws on interviews with leading community advocates, researchers and clinicians in Australia, Canada and the UK and looks across examples, including social media, rapid HIV testing, pre-Exposure Prophylaxis for HIV and polymerase chain reaction Chlamydia testing. The analysis is framed by studies of techno-society and the dialectics of sex-affirmative advocacy with biomedical authority and attends to: the rationalistic and affective dimensions of the imaginary associated with technology; the role of technology in the re-spatialisation and re-temporalisation of the sexual health clinic; and the re-invention of technology in its real-world contexts. This in-context approach is important for: the effective implementation of new technology; strengthening the social science contribution to the field; and enriching social theory in general on life in techno-societies.

Attitude and behavior changes among gay and bisexual men after use of rapid home HIV tests to screen sexual partners

HIV testing can now be self-administered outside clinical settings through the purchase of home testing (HT) kits. Individuals also can use the kits to perform a test on a potential sexual partner prior to intercourse. We provided a 3-month supply of HT kits to men who reported multiple male partners and little or no condom use for anal intercourse. Participants used the test kits with partners in over 100 occasions. At the end of the study, approximately half of the participants described shifts in their attitudes and/or behaviors related to sexual risk. Reported changes included increased awareness of risk, increased discussion of STI/HIV safety measures, changes in partner choice and heightened consciousness of partner thinking. Easy access to HT kits may be a risk-reduction strategy for men with a high risk profile because their regular use could have an impact beyond the specific sexual encounter.