Barriers to HIV Testing: Patient and Provider Perspectives in the Deep South

Spatial distribution and factors associated with HIV testing among adolescent girls and young women in Sierra Leone

BACKGROUND

Sierra Leone faces a significant challenge in addressing HIV/AIDS, particularly among adolescent girls and young women. This age group is considered highly vulnerable due to biological factors and social inequalities. Understanding the prevalence of HIV testing in this demographic is crucial for designing effective prevention and treatment strategies. This study investigated the spatial distribution of HIV testing and its associated factors among adolescent girls and young women in Sierra Leone.

METHODS

Data from the 2019 Sierra Leone Demographic and Health Survey was used for the study. The sample comprised 6,062 adolescent girls and young women between the ages of 15 and 24. Spatial autocorrelation and Moran's I statistic were employed to analyze the spatial distribution of HIV testing. An analysis utilising mixed-effect multilevel binary logistic regression was performed to determine the factors associated with HIV testing. The findings were presented as adjusted odds ratios (aOR) and a 95% confidence interval (CI).

RESULTS

The national prevalence of HIV testing among adolescents and young women in Sierra Leone was 42.1% [40.3,43.9]. Kailahun, Kambia, Tonkolil, some parts of the Western rural area, and Bonthe districts were found to be statistically significant hotspot for HIV testing. Whereas, Karene, Falaba, Bo, kenema, and some parts of Pujuhun were statistically cold spot districts. Adolescent girls and young women aged 20-24 [aOR = 1.63, 95% CI = 1.29, 2.07] had higher odds of HIV testing than those aged 15-19. Those with secondary/higher education [aOR = 1.87, 95% CI = 1.40, 2.51] had higher odds of HIV testing than those with no education. The odds of HIV testing was higher among adolescent girls and young women who use the Internet [aOR = 1.75, 95% CI = 1.32, 2.33] than those who did not use internet. Adolescent girls and young women with one [aOR = 16.56, 95% CI = 12.31, 22.29] and two or more parity [aOR = 16.37, 95% CI = 10.86, 24.68] had higher odds of HIV testing than those with no parity. The likelihood of HIV testing was higher among adolescent girls and young women who had sex below 18 [aOR = 4.54, 95% CI = 3.25, 6.34] and those who had sex at 18+ [aOR = 5.70, 95% CI = 3.84, 8.45] compared to those who had never had sex. Adolescent girls and young women who visited health facilities in the past 12 months [aOR = 1.82, 95% CI = 1.46, 2.26] had higher odds of HIV testing than those who did not.

CONCLUSION

Despite some positive trends, HIV testing rates among adolescent girls and young women in Sierra Leone remain moderate. Spatial autocorrelation analysis consistently revealed hotspots and cold spots for HIV testing, with Kailahun, Kambia, Tonkolil, some parts of the Western rural area, and Bonthe districts remaining persistent hotspots. Age, education, internet use, sexual history, parity, and healthcare access are significant factors influencing testing behaviour. To improve testing rates, the government and policymakers should prioritize educational campaigns, expand internet access, integrate HIV testing into routine healthcare, and address stigma associated with HIV.

Innovation and implementation determinants of HIV testing and linkage-to-care in the U.S.: a systematic review

OBJECTIVE

To identify innovation and implementation determinants of HIV testing, diagnosis, and linkage-to-care in the U.S.

DATA SOURCES AND STUDY SETTING

Between November 2020 and January 2022, a broad search strategy was employed in three literature databases: Ovid MEDLINE, PsycINFO, and Web of Science.

STUDY DESIGN

A systematic review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement.

DATA COLLECTION/EXTRACTION METHODS

A team of master's and Ph.D.-level researchers screened eligible studies against the inclusion criteria and extracted the data using COVIDENCE software in pairs with consensus performed by a senior member of the team. Barriers and facilitators were extracted and analyzed according to the Consolidated Framework for Implementation Research (CFIR). Frequency of determinants across studies was mapped according to CFIR, valence, study design, delivery setting, unit of analysis, population of interest, region of the U.S., and year.

RESULTS

We identified 1,739 implementation and innovation determinants from 186 articles. Most determinants were for HIV testing rather than linkage-to-care. Most determinants were identified in the inner setting and individuals domains of CFIR, with the fewest identified in the process and innovations domains. Determinants of providers were only slightly more frequently identified than determinants of recipients. However, determinants of organizations and systems were rarely identified.

CONCLUSION

This review provides a synthesis of innovation and implementation determinants of HIV testing and linkage-to-care using the most-cited implementation science (IS) framework, CFIR. This synthesis enables the larger field of HIV science to utilize IS in efforts to end the HIV epidemic and positions IS to consider the application of IS frameworks to fields like HIV.

Community recommendations for promoting HIV testing to Black young men who have sex with men in the southern United States

BACKGROUND

Considering the need to increase HIV testing among racial minority youth in the southern United States, we conducted an exploratory study in Alabama to elucidate recommendations on improving testing rates among Black young men who have sex with men (BYMSM).

METHODS

We conducted in-depth interviews and focus groups with BYMSM and prevention and outreach workers. Data collection occurred online and in person between 2020-2022.

RESULTS

Our sample included data from n = 56 BYMSM and n = 12 prevention and outreach workers. BYMSMs' mean age = 24 years. Among prevention and outreach workers, 58% identified as male with mean age = 39 years; 83% identified as Black. Transcripts were coded thematically; five concurrent themes emerged from both BYMSM and prevention and outreach workers: promoting testing at younger ages, need for visibility and outreach, connecting through shared experiences, value of nonjudgmental approaches, and need to increase HIV knowledge in BYMSM.

CONCLUSIONS

Findings suggest that cultivating trust is salient to promoting HIV testing in BYMSM. To end the epidemic in the southern United States, a region that is heavily rural with high rates of HIV, it may be necessary to begin prevention conversations at younger ages and equip prevention and outreach workers with communication skills that leverage de-stigmatizing approaches.

A. Prevalence of HIV Self-Testing Among Men Who Have Sex With Men: Evidence Synthesis by Systematic Review and Meta-Analysis

HIV self-testing (HIVST) plays a significant role in addressing the health care needs of high-risk populations, particularly men who have sex with men (MSM). The present systematic review and meta-analysis provide an assessment of the prevalence of HIVST among MSM within the last 5 years. Seven databases (PubMed, Web of Science, Cochrane, Scopus, EMBASE, ProQuest, and EBSCOhost) were searched systematically from January 1, 2018 to March 10, 2023. After an independent search and quality assessment, the pooled prevalence was calculated using a random-effects model. Eight relevant studies were finally included in our study from an initial pool of 288 articles identified through a systematic search. Our meta-analysis revealed that the pooled prevalence of HIVST among MSM is 8% (95% CI: 5%-14%). Significant heterogeneity was noticed among the studies, with an I2 value of 99% and a 95% prediction interval of 3% to 11%. Geography emerged as a significant moderator of this heterogeneity (p < .001). Specifically, studies from China reported a notably higher prevalence of 20% (15%-26%), while other countries reported a lower prevalence of 5% (3%-6%). A symmetrical Doi plot with a Luis-Furuya-Kanamori (LFK) index of -0.57 indicated no publication bias. HIVST has a low take-up among MSM globally. Factors leading to variation in HIVST need to be studied. The coordinated efforts of policymakers, health care providers, and affected communities are required in HIVST promotion.

The health equity implications of the Health Resources and Services Administration's Ryan White HIV/AIDS Program

OBJECTIVE

Investigate the role of the Ryan White HIV/AIDS Program (RWHAP) - which funds services for vulnerable and historically disadvantaged populations with HIV - in reducing health inequities among people with HIV over a 10-year horizon.

DESIGN

We use an agent-based microsimulation model to incorporate the complexity of the program and long-time horizon.

METHODS

We use a composite measure (the Theil index) to evaluate the health equity implications of the RWHAP for each of four subgroups (based on race and ethnicity, age, gender, and HIV transmission category) and two outcomes (probability of being in care and treatment and probability of being virally suppressed). We compare results with the RWHAP fully funded versus a counterfactual scenario, in which the medical and support services funded by the RWHAP are not available.

RESULTS

The model indicates the RWHAP will improve health equity across all demographic subgroups and outcomes over a 10-year horizon. In Year 10, the Theil index for race and ethnicity is 99% lower for both outcomes under the RWHAP compared to the non-RWHAP scenario; 71-93% lower across HIV transmission categories; 31-44% lower for age; and 73-75% lower for gender.

CONCLUSION

Given the large number of people served by the RWHAP and our findings on its impact on equity, the RWHAP represents an important vehicle for achieving the health equity goals of the National HIV/AIDS Strategy (2022-2025) and the Ending the HIV Epidemic Initiative goal of reducing new infections by 90% by 2030.

Measuring Spatial Access of Vulnerable Population to HIV Testing Facilities in the Baton Rouge Metropolitan Statistical Area, Louisiana

Ensuring adequate and equitable access to affordable HIV testing is a crucial step toward ending the HIV epidemic (EHE). Using the high-burden Baton Rouge Metropolitan Statistical Area (MSA) as an example, we measure spatial access to HIV testing facilities for vulnerable populations and assess whether their access would improve if eliminating a considerable barrier-costs. Locations and status (free, low-cost, and full cost) of HIV testing facilities are searched on the Internet and confirmed through a field survey. Vulnerable populations include the uninsured and people living with HIV (PLWH), disaggregated from county-level HIV prevalence data. Spatial access is computed by a normalized urban-rural two-step floating catchment area (NUR2SFCA) method. Our survey confirms that only 11% and 37% of the 103 Internet-searched HIV testing facilities are indeed free and low-cost. Making more facilities cheaper or free increases the average access of PLWH, the uninsured, and the entire population but their geographic patterns vary. Free testing facilities, clustered in Baton Rouge city, are highly accessible to 82.6%, 69.4%, and 70.2% of three population groups living in East and West Baton Rouge Parish. In comparison, making all low-cost facilities free increases access in most outlying parishes but at the cost of reducing access in East Baton Rouge Parish, leaving west Livingston, north Iberville, and east Pointe Coupee Parish with the poorest access. Making all full-cost facilities cheaper or free exhibits a similar pattern. The study has important policy implications for where and how to improve access to HIV testing for vulnerable populations.

Predictors of never testing for HIV among sexually active individuals aged 15-56 years in Rwanda

Human Immunodeficiency Virus (HIV) testing services are known as the primary step in preventing the spread of HIV. However, access to these crucial services varies across regions within continents due to disparities in healthcare infrastructure, resources, and awareness. Approximately one in every five people living with HIV (PLWH) encounters obstacles in accessing HIV testing, notably in Eastern and Southern Africa, where geographical, resource, awareness, and infrastructure limitations prevail. Consequently, HIV remains a significant public health concern in these regions, necessitating expanded testing efforts to combat the HIV/AIDS disaster. Despite these challenges, there is a lack of scientific evidence on the prevalence of HIV testing and its determining factors in Rwanda. This study determined the prevalence of never being tested for HIV and its associated factors among sexually active individuals aged 15-56 who participated in the Rwanda AIDS Indicators and HIV Incidence Survey (RAIHIS). This cross-sectional study enrolled 1846 participants. The variables were extracted from the RAIHIS dataset and statistically analyzed using STATA software version 13. Bivariate and multivariate logistic regression models were employed to identify predictors of never having undergone HIV testing, with a 95% confidence interval and a 5% statistical significance level applied. The prevalence of non-testing for HIV was 17.37%. Being aged 15-30 years (aOR 2.57, 95%CI 1.49-4.43, p < 0.001) and male (aOR 2.44, 95%CI 1.77-3.36, p < 0.001) was associated with an increase in the odds of never testing for HIV. Further, those from urban area were less likely than those living in rural areas to have never tested for HIV (aOR 0.31; 95% CI 0.38-0.67; p < 0.001). Participants who were not aware of HIV test facilitates were more likely to have never undergone HIV testing (aOR 1.75; 95% CI 1.25-2.47; p = 0.031) than their counterparts. While the prevalence of HIV non-testing remains modest, the significance of youth, male gender, lack of awareness, and rural residence as influential factors prompts a call for inventive strategies to tackle the reasons behind never having undergone HIV testing. Further exploration using mixed methodologies is advocated to better comprehend socio-cultural impacts and causation relating to these identified factors.

HIV Knowledge, Risk Factors, and Utilization of Services in the US Rural Deep South

BACKGROUND

HIV prevalence in the rural South remains high among Black Americans due to limited access to prevention and treatment services and poverty. HIV care inequities for Black Americans living in the rural South are further intensified by high mortality rates, low HIV health literacy, stigma, and discrimination. Few studies have focused on HIV knowledge and risk factors within Black Americans in the rural South.

METHODS

This cross-sectional study examined the association between HIV risk factors, HIV knowledge, and utilization of HIV and/or sexually transmitted infection (STI) testing services among Black Americans (N = 200) living in the rural South. HIV knowledge, risk factors, and utilization of testing services were assessed via The HIV Knowledge Questionnaire, The HIV Risk Factor Questionnaire, and three investigator-generated questions, respectively. Linear regression was used to examine the relationship between demographic characteristics, HIV knowledge, utilization of testing services, and HIV risk factors.

RESULTS

Among 200 participants, a smaller percentage (37.7%, n = 75) reported using HIV/STI testing services compared to non-users. Controlling for demographic covariates in the model, HIV knowledge (p < .0001) and marital status (p = .010) were significantly associated with HIV risk factors. HIV risk factors decreased as HIV knowledge increased. Individuals who reported being single also reported having fewer risk factors.

CONCLUSION

Future research should examine the impact of HIV education tailored for individuals with greater HIV risk factors within rural Black Americans. Studies exploring barriers to the utilization of HIV/STI testing services within Black American rural communities are warranted.

Stakeholder-led design of a mobile HIV clinic model to enhance engagement and retention in HIV care in the Southern United States

To foster retention of people living with HIV (PLWH) in HIV care in the Southern United States, we aimed to develop a stakeholder-driven mobile HIV clinic (MHC) model. From June 2019 to May 2021 we conducted a mixed-methods study: 50 surveys with out-of-care PLWH and 41 in-depth interviews with PLWH, HIV clinic staff, city officials, AIDS service organizations, and mobile clinics to examine preferences for MHC implementation. Survey data was analyzed descriptively, and interview transcripts were coded thematically. Participants recommended the MHC: (1) have nondescript exterior and HIV services nested in non-HIV care to foster confidentiality, (2) be located along public transportation and have extended hours to promote accessibility, (3) have established protocols addressing security, biosafety, and data safety; (4) provide comprehensive clinical and support services to address retention barriers; and (5) be integrated within the health system, use low-cost, diverse staffing, and establish appointment notification systems. By informing MHC design, these findings add to the toolbox of strategies that can render HIV care more accessible.

The moderating effects of alcohol use on the association between sexual orientation and HIV testing: results from the 2013-2018 National Health Interview Study

Routine screening and testing for HIV are recommended for all adolescents and adults. However, only one-third of the U.S. population has been tested for HIV. Women, sexual minorities, and people who use alcohol are more likely to be tested for HIV, but less is known about how alcohol use and sexual orientation impact the likelihood of HIV testing synergistically. Examining both alcohol use and sexual orientation is especially relevant, because sexual minorities are at increased risk for alcohol use, including heavy drinking. This study tested an alcohol x sexual orientation interaction effect on HIV testing through logistic regression modeling with a nationally representative sample. Results of the significant interaction identify demographic groups that are particularly at-risk for not being tested for HIV. These groups include lesbian women who currently use alcohol or previously used alcohol; bisexual men who have not used or previously used alcohol; and gay men who previously used alcohol. Although efforts to test all adolescents and adults are warranted, these findings highlight the importance of assessing alcohol and sexual orientation and augmenting testing efforts for highrisk groups.

HIV testing and risk behaviors associated with depression in the United States

Given the high correlation between depression and HIV infection rates, our objective was to assess national rates for HIV testing and HIV risk behaviors among U.S. adults stratified by self-reports of depression. We conducted a cross-sectional study using data from the 2018-2020 Behavioral Risk Factor Surveillance System (BRFSS). We included respondents aged 18 years old and above with self-reported depression status (Sample size = 1,228,405). The primary outcomes included HIV testing and HIV-related risk behaviors. For respondents with prior HIV testing experience, we estimated the duration since the last HIV test. We applied a multivariable logistic regression model to analyze the correlation between depression and HIV testing or risk behaviors. The results showed people with depression had 51% higher odds of receiving HIV testing [adjusted odds ratio (AOR) = 1.51, 95% CI = 1.48, 1.55] and 51% higher odds of involvement in HIV risk behaviors [AOR = 1.51, 95% CI = 1.44, 1.58] after adjusting for covariates. Various socio-demographics and healthcare access variables were significantly associated with HIV testing and HIV risk behaviors. When comparing the average time from the last HIV test, people with depression had a shorter period compared to those without depression [Median time in months: 27.1 ± 0.45 vs. 29.3 ± 0.34]. Even though people with depression had higher rates of HIV testing, they still experienced long time periods (median = 2 + years) between HIV testing, which exceeded the recommended annual HIV testing for people at high risk from the Centers for Disease Control and Prevention.

Preferences for oral- vs blood-based human immunodeficiency virus self-testing: A scoping review of the literature

BACKGROUND

The evidence on preferences for oral- vs blood-based human immunodeficiency virus self-testing (HIVST) has been heterogenous and inconclusive. In addition, most evaluations have relied on hypothetical or stated use cases using discreet choice experiments rather than actual preferences among experienced users, which are more objective and critical for the understanding of product uptake. Direct head-to-head comparison of consumer preferences for oral- versus blood-based HIVST is lacking.

AIM

To examine the existing literature on preferences for oral- vs blood-based HIVST, determine the factors that impact these preferences, and assess the potential implications for HIVST programs.

METHODS

Databases such as PubMed, Medline, Google Scholar, and Web of Science were searched for articles published between January 2011 to October 2022. Articles must address preferences for oral- vs blood-based HIVST. The study used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist to ensure the quality of the study.

RESULTS

The initial search revealed 2424 records, of which 8 studies were finally included in the scoping review. Pooled preference for blood-based HIVST was 48.8% (9%-78.6%), whereas pooled preference for oral HIVST was 59.8% (34.2%-91%) across all studies. However, for male-specific studies, the preference for blood-based HIVST (58%-65.6%) was higher than that for oral (34.2%-41%). The four studies that reported a higher preference for blood-based HIVST were in men. Participants considered blood-based HIVST to be more accurate and rapid, while those with a higher preference for oral HIVST did so because these were considered non-invasive and easy to use.

CONCLUSION

Consistently in the literature, men preferred blood-based HIVST over oral HIVST due to higher risk perception and desire for a test that provides higher accuracy coupled with rapidity, autonomy, privacy, and confidentiality, whereas those with a higher preference for oral HIVST did so because these were considered non-invasive and easy to use. Misinformation and distrust need to be addressed through promotional messaging to maximize the diversity of this new biomedical technology.

Intimate partner violence, HIV-risk behaviors, and HIV screening among heterosexually active persons at increased risk for infection

ABSTRACTIntimate partner violence (IPV) can increase a person's risk of HIV and other sexually transmitted infections (STIs), and may affect access to sexual health services. We assessed the prevalence of HIV screening and IPV among heterosexually-active persons using data from the 2016 National HIV Behavioral Surveillance. Participants were eligible if they were 18-60 years old, could complete the interview in English or Spanish, and reported having sex with an opposite sex partner in the previous 12 months. People who reported neither injection drug use within the past 12 months nor prior HIV diagnosis, and persons with valid responses to questions regarding HIV screening and physical/sexual IPV within the past 12 months were included (N = 7,777). Overall, 17% reported IPV in the previous 12 months and 19% had never had HIV screening. Abused persons were more likely to have been screened for HIV and to report high risk behaviors than non-abused persons. There was no difference in the proportion being offered HIV screening by their health care provider in the previous year. Findings suggest an integrated approach to violence prevention and sexual health may help increase awareness about clinical best practices and reduce risk for HIV/STIs among at-risk communities.

Categorising implementation determinants and strategies within the US HIV implementation literature: a systematic review protocol

INTRODUCTION

Despite decreased rates of new infections, HIV/AIDS continues to impact certain US populations. In order to achieve the goals laid out in the Ending the HIV Epidemic (EHE) in the US initiative, implementation science is needed to expand the sustained use of effective prevention and treatment interventions, particularly among priority populations at risk for and living with HIV/AIDS. Over 200 HIV-related implementation studies have been funded by the US National Institutes of Health. Therefore, a comprehensive review of the literature identifying implementation determinants (barriers and facilitators) and categorising implementation strategies across the continuum of HIV prevention and care in the USA is appropriate and needed to enhance current knowledge and help achieve the goals laid out in the EHE national strategic plan.

METHODS AND ANALYSIS

This systematic review protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Between November 2020 and January 2022, a broad database search strategy of Ovid MEDLINE, PsycINFO and Web of Science was conducted to capture implementation-related studies along the HIV prevention and care continuum. Articles were eligible for inclusion if they were: conducted in the USA, published after the year 2000, written in English, related to HIV/AIDS, focused on outcomes related to dissemination and implementation (ie, did not test/evaluate/explore implementation determinants or strategies) and were behavioural studies (ie, not basic science). We plan to conduct three systematic reviews to identify and categorise determinants and strategies associated with three HIV focus areas: pre-exposure prophylaxis, testing/diagnosing and linkage to care, and treatment. Determinants will be coded according to an adapted Consolidated Framework for Implementation Research 2.0. Implementation strategies and outcomes will be categorised in accordance with existing taxonomies and frameworks.

ETHICS AND DISSEMINATION

Ethics approval is not applicable. No original data will be collected. Results will be disseminated through peer-reviewed publications, conference presentations and via online tools.

PROSPERO REGISTRATION NUMBER

CRD42021233089.

Rapid qualitative analysis approach to stakeholder and client interviews to inform mobile-based HIV testing in the U.S. Deep South

BACKGROUND

The severity of the HIV epidemic in the United States' rural South highlights geographic, socioeconomic, and racial disparities that disproportionately affect poor Black Americans. Approximately 16% of Alabamians living with HIV remain undiagnosed and just 37% of rural Alabamians have ever been tested for HIV.

METHODS

We conducted in-depth interviews with 22 key stakeholders involved in HIV prevention, testing, treatment, or community health initiatives, and 10 adults living in rural communities across Alabama to explore HIV testing challenges and opportunities. We utilized a rapid qualitative analysis approach and engaged community partners for feedback and discussion. This analysis will inform the implementation of a mobile HIV testing service in rural Alabama.

RESULTS

The following themes were identified: (1) Cultural norms, racism, poverty, and rurality impair access to healthcare. (2) Lack of sex education, low knowledge of HIV and perception of risk reinforce stigmas. (3) Messaging about "Undetectable = Untransmissible" (U = U) is not well understood in communities. (4) Community involvement may promote communication and trust between communities and testing advocates. (5) Novel testing strategies are acceptable and may diminish barriers.

CONCLUSIONS

Working with community "gatekeepers" may be a key strategy to understand and promote acceptability of interventions new to rural Alabama and ameliorate stigma within communities. The implementation of new HIV testing strategies requires building and maintaining relationships with advocates, especially faith-based leaders, who engage people across many demographics.

Knowledge about, acceptance of and willingness to use over-the-counter COVID-19 self-testing kits

Objectives

Early investments in new diagnostic technologies that allow for rapid and decentralized testing were critical in reducing SARS-CoV-2’s detrimental health and economic effects. This study evaluates public knowledge about, acceptance of and willingness to use COVID-19 self-testing kits.

Methods

An online descriptive cross-sectional questionnaire was used in this study. The final study population included all contacted national and resident adults, age 18 and over, who were willing to engage in the study. The survey was divided according to participants’ demographic information and 11 questions assessed the respondents’ understanding of and willingness to use COVID-19 self-testing kits. The statistical analysis was carried out using SPSS version 24. Multivariate linear regression models were used to identify the factors influencing respondents’ knowledge of and attitudes toward the acceptability of self-testing kits for COVID-19 and their willingness to use these kits.

Key findings

A total of 876 respondents participated in the study and completed the whole questionnaire. The average knowledge score on the acceptability of and willingness to use self-testing kits for COVID-19 was 70.2%, with a 95% confidence interval (CI) [69.1%, 71.4%]. Participants who were postgraduate, female and vaccinated against COVID-19, as well as employees and older participants, were jointly highly associated with higher levels of knowledge about, acceptance of and willingness to use self-testing kits for COVID-19. Moreover, participants who had been infected with COVID-19, were vaccinated against COVID-19 or were female, employees, older, Western or Arabic were jointly highly associated with positive attitudes about the acceptability of and willingness to use self-testing kits for COVID-19.

Conclusions

The majority of the respondents have acceptable levels of knowledge about, acceptance of and willingness to use self-testing kits for COVID-19. Nonetheless, future studies should consider the issues of pre- and post-test counselling, false negative results and the sale of unregulated testing kits. Additional information should be communicated so that people can make informed decisions and be protected from possible abuse of COVID-19 self-testing kits when they become available in pharmacies.

Motivations and Barriers to Routine HIV Testing Among Men Who Have Sex with Men in New York City

In-depth qualitative interviews explored the experiences and understandings of men 18-39 years old who have sex with men that could facilitate or prevent HIV testing and routine HIV testing. For many men who tested frequently, testing and routine testing were motivated by awareness of the benefit of prompt treatment; public health and provider encouragement to test periodically; responsibility towards sexual partners; and wanting to share a recent HIV-negative test result when seeking sex online. For some men, any testing was impeded by anxiety around possible HIV diagnosis that made testing a stressful occasion that required time and energy to prepare for. This anxiety was often compounded by stigma related to sex between men, having condomless sex, or having HIV. Routine testing could be further stigmatized as some men felt judged by testing providers or partners if they asked for a test or said they tested frequently. We describe efforts to promote testing and routine testing by countering fear and stigma associated with HIV and testing.

Informed consent for HIV screening in the emergency departments and human rights in patient care: seeking the right balance

HIV exceptionalism refers to the fact that the illness is so different from other diseases that testing needs a special approach to informed consent. HIV infected people often visit health clinics, especially emergency departments, years before receiving a diagnosis without being tested for HIV. There is considerable public interest in increasing HIV testing in emergency departments. However, because these departments are sensitive environments that primarily provide urgent and emergency care, a number of ethical questions have been raised about the appropriateness of these settings for the implementation of universal screening programs. Human rights in patient care therefore constitutes an essential theoretical framework for analyzing ethical and legal dilemmas that arise in clinical encounters, thus strengthening the application of human rights principles to the context of patient care.

Interventions to Increase HIV Testing Uptake in Global Settings

Purpose of Review

HIV testing is the critical first step to direct people living with HIV (PLWH) to treatment. However, progress is still being made towards the UNAIDS benchmark of 95% of PLWH knowing their status by 2030. Here, we discuss recent interventions to improve HIV testing uptake in global settings.

Recent Findings

Successful facility-based HIV testing interventions involve couples and index testing, partner notification, and offering of incentives. Community-based interventions such as home-based self-testing, mobile outreach, and hybrid approaches have improved HIV testing in low-resource settings and among priority populations. Partnerships with trusted community leaders have also increased testing among populations disproportionally impacted by HIV.

Summary

Recent HIV testing interventions span a breadth of facility- and community-based approaches. Continued research is needed to engage men in sub-Saharan Africa, people who inject drugs, and people who avoid biomedical care. Interventions should consider supporting linkage to care for newly diagnosed PLWH.

Facilitators and barriers to implementing provider-initiated HIV counselling and testing at the clinic-level in Ekurhuleni District, South Africa

Background

HIV testing is the entry point into the HIV care continuum and critical for HIV epidemic control. Facility-based HIV testing services (HTS) reach individuals who are already seeking clinical care and engaging with the medical care system. For this reason, individuals diagnosed with HIV during facility-based HIV testing are more likely to continue into HIV care. To increase the number of PLHIV who are diagnosed and initiated on ART, in 2015, the South African Department of Health instituted Provider-Initiated Counselling and Testing (PICT) policy—encouraging healthcare providers to recommend HIV testing, but this strategy remains under-utilized. We aimed to identify key constraints to the normalization of PICT implementation in 10 Ekurhuleni District healthcare facilities in South Africa.

Methods

In-depth interviews were conducted with 40 healthcare workers (28 clinicians and 12 lay counsellors). Health care workers were purposefully selected to participate in the interviews, stratified by health facility and work category. Interviews were audio-recorded, transcribed, and translated for analysis. Thematic analysis was guided by the normalization process theory (NPT). NPT theory explains how practices are routinely embedded within organizational contexts. We used NVivo 10 software for qualitative data management.

Results

Both clinicians and lay counsellors exhibited a clear understanding of the PICT policy— acknowledging its purpose and value. The identified barrier to normalization of PICT among clinicians was offering HIV testing based on suspicion of HIV despite understanding that PICT involves offering testing to all clients. Additionally, clinicians perceived PICT as incongruent with their clinical roles and perceived it to be lay counsellors’ responsibility. The main facilitator was the participation of all healthcare workers, specifically the presence of lay counsellors, although they also faced barriers such as a lack of workspace and under-appreciation.

Conclusions

Use of NPT helped identify barriers that prevent the normalization of PITC and its integration into routine patient care. These barriers can be modified by low-cost interventions that promote congruence of PICT to the roles of clinicians and integrate the role of lay counsellors within the patient flow in the facility.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00269-3.

STI/HIV Testing and Prevalence of Gonorrhea and Chlamydia Among Persons with Their Specified-Type Sex Partner

BACKGROUND

Previous studies have shown that sexually transmitted infections (STI) and human immunodeficiency virus (HIV) testing has varied, but STI prevalence was not estimated among patients during their health care visits in which a high-risk sexual partnership was documented. This study estimated gonorrhea, chlamydia, syphilis, and HIV testing rates and chlamydia and gonorrhea prevalence.

METHODS

From the de-identified commercial claims data of OptumLabs Data Warehouse, we identified men and women aged 15-60 years classified as having high-risk sexual relationships as diagnosis codes: Z72.51 for opposite-sex, Z72.52 for same-sex, and Z72.53 for same-and-opposite-sex relationships, stratified by gender, age group, region, type of health plan, and HIV status. We estimated STI testing rate and prevalence for chlamydia and gonorrhea among patients with high-risk sexual relationships. HIV testing was assessed only in high-risk sexual relationship patients without HIV.

RESULTS

Among 8.2 million females and 7.3 million males aged 15-60 years in the database from 2016 to 2019, 115,884 patients (0.7% of female, 0.8% of male) including 3,535 patients with HIV were diagnosed with high-risk sexual relationships. The testing rates for gonorrhea, chlamydia, syphilis, and HIV were 69.4% (confidence interval [CI]: 69.1-69.7), 68.9% (CI: 68.6-69.2), 43.4% (CI: 43.1-43.7), and 41.7% (CI: 41.4-42.0), respectively. Among patients with valid chlamydia and gonorrhea tests, 7.2% (CI: 7.0-7.5) and 2.6% (CI: 2.4-2.8) had positive chlamydia and gonorrhea test results, respectively, and varied by type of high-risk sexual relationship.

CONCLUSIONS

Our study findings of suboptimal STI screening among patient in high-risk sexual relationships are consistent with previous studies. Administrative records confirmed by lab results indicate a need for STI counseling, testing, and treatment among patients who are diagnosed with high-risk sexual relationships with same-sex, opposite-sex, or same-and-opposite sex partners.

The geographic reach of community-based organizations in addressing HIV-related stigma in the Deep South

Community-based organizations (CBOs) have been instrumental in addressing the needs of people living with HIV, however, little is known about their efforts to address HIV-related stigma through stigma reduction efforts. This study examined practices of CBOs related to mitigating HIV-related stigma in nine Deep South states. CBOs were surveyed as part of a larger study through the Gilead COMPASS Initiative. The CBO survey asked CBO leadership about stigma in their communities and services available to address this stigma. Survey respondents (n = 207) indicated that HIV-related stigma was perceived as a substantial barrier to both HIV care and CBO services. Although just over two-thirds of survey participants reported that there were group-level programs to address HIV-related stigma, 73% reported that there were not enough interventions to meet the need in their community. Further, 68% reported a lack of individual-level stigma reduction interventions. A majority reported a lack of public media campaigns to address stigma and a lack of training available to assist CBOs to address stigma. In addition, services to address stigma were reportedly less available in rural areas compared to their urban counterparts. Study findings indicate a need to identify, implement, and scale-up effective interventions to reduce HIV stigma in the US Deep South.

Informed consent for HIV screening in the emergency departments and human rights in patient care: seeking the right balance

Abstract HIV exceptionalism refers to the fact that the illness is so different from other diseases that testing needs a special approach to informed consent. HIV infected people often visit health clinics, especially emergency departments, years before receiving a diagnosis without being tested for HIV. There is considerable public interest in increasing HIV testing in emergency departments. However, because these departments are sensitive environments that primarily provide urgent and emergency care, a number of ethical questions have been raised about the appropriateness of these settings for the implementation of universal screening programs. Human rights in patient care therefore constitutes an essential theoretical framework for analyzing ethical and legal dilemmas that arise in clinical encounters, thus strengthening the application of human rights principles to the context of patient care.

A cross-sectional survey of potential factors, motivations, and barriers influencing research participation and retention among people who use drugs in the rural USA

BACKGROUND

Despite high morbidity and mortality among people who use drugs (PWUD) in rural America, most research is conducted within urban areas. Our objective was to describe influencing factors, motivations, and barriers to research participation and retention among rural PWUD.

METHODS

We recruited 255 eligible participants from community outreach and community-based, epidemiologic research cohorts from April to July 2019 to participate in a cross-sectional survey. Eligible participants reported opioid or injection drug use to get high within 30 days and resided in high-needs rural counties in Oregon, Kentucky, and Ohio. We aggregated response rankings to identify salient influences, motivations, and barriers. We estimated prevalence ratios to assess for gender, preferred drug use, and geographic differences using log-binomial models.

RESULTS

Most participants were male (55%) and preferred methamphetamine (36%) over heroin (35%). Participants reported confidentiality, amount of financial compensation, and time required as primary influential factors for research participation. Primary motivations for participation include financial compensation, free HIV/HCV testing, and contribution to research. Changed or false participant contact information and transportation are principal barriers to retention. Respondents who prefer methamphetamines over heroin reported being influenced by the purpose and use of their information (PR = 1.12; 95% CI: 1.00, 1.26). Females and Oregonians (versus Appalachians) reported knowing and wanting to help the research team as participation motivation (PR = 1.57; 95% CI: 1.09, 2.26 and PR = 2.12; 95% CI: 1.51, 2.99).

CONCLUSIONS

Beyond financial compensation, researchers should emphasize confidentiality, offer testing and linkage with care, use several contact methods, aid transportation, and accommodate demographic differences to improve research participation and retention among rural PWUD.

Rural College Students' Amenability Toward Using At-Home Human Immunodeficiency Virus and Sexually Transmitted Infection Testing Kits

BACKGROUND

College students residing in rural areas of the United States have limited access to human immunodeficiency virus (HIV) and sexually transmitted infection (STI) screening programs; yet, have increased rates of infection.

METHODS

Students (N = 326), attending a state university located within a rural community, completed an online survey containing open-ended questions that gauged their perceptions and experiences with HIV/STI testing, amenability to at-home testing technology, and preferences for obtaining at-home testing kits. Inductive coding was used to create themes for each open-ended question.

RESULTS

Students encounter a number of perceived barriers to accessing clinical HIV/STI testing venues including cost, utilization of parents' medical insurance, and stigma. Students desired screening paradigms that allow for a greater sense of privacy and the ability to be empowered through self-sampling methods. This includes the use of at-home testing kits, which could be accessed via mail, campus, or the local community. Although students were overwhelmingly amenable to using at-home testing, students discussed concerns with potential user error that could impact testing accuracy.

CONCLUSIONS

Study findings suggest the importance of developing less clinically oriented systems of HIV/STI screening, which allow students to choose from an array of screening options. Removing perceived barriers, notably access and privacy concerns, to HIV/STI testing by leveraging at-home testing is one potential method to increase screening uptake among this at-risk population.

Utilizing Alternative Testing Technology for Human Immunodeficiency Virus (HIV) in the COVID era

Purpose of Review

With the onset of the Coronavirus disease 2019 (COVID-19) pandemic, in-person human immunodeficiency virus (HIV) testing is no longer easily accessible. Therefore, alternative testing technologies must be considered and implemented on a large scale to continue prevention efforts. This review seeks to describe the benefits of utilizing at-home HIV testing technologies, traditionally deemed an alternative form of testing.

Recent Findings

Utilizing at-home testing technology during the COVID-19 pandemic overcomes novel and previously identified barriers to HIV testing.

Summary

Ensuring access to HIV testing is imperative to long-term prevention goals. With the Ending the HIV Epidemic (EHE) initiative in the USA targeting achievement by 2030, obstacles to HIV testing must be addressed to ensure its success. Implementing alternative testing technology more broadly allows for continued prevention efforts for HIV in light of COVID era restrictions.

Provider-Initiated HIV Testing in Puerto Rico from Data of the National HIV Behavioral Surveillance-Heterosexual Cycle (NHBS-HET) 2016: National Cross-Sectional Survey (Preprint)

Background

According to the Centers for Disease Control and Prevention and World Health Organization guidelines, all individuals aged 13-64 years should get screened for HIV infection as part of their routine medical examinations. Individuals at high risk should get tested annually.

Objective

This study aimed to identify the sociodemographic, health care, and sexual behavioral characteristics of provider-initiated HIV testing using data from the Puerto Rico National HIV Behavioral Surveillance 2016 cycle, directed toward heterosexual individuals at increased risk of HIV infection.

Methods

A sample of 358 eligible participants were recruited through respondent-driven sampling, where sociodemographic characteristics, health care use, and HIV test referral were used to assess a description of the study sample. Pearson chi-square and Fisher tests were used to evaluate proportional differences. Multivariate logistic regression models were performed to determine the association between independent variables and HIV test referral. Adjusted prevalence ratios by sex and age with their 95% CIs were determined using a statistical significance level of .05.

Results

Despite 67.9% (243/358) of participants showing high-risk sexual behavioral practices and 67.4% (236/350) reporting a low perceived risk of HIV infection among those who visited a health care provider within the last 12 months, 80.7% (289/358) of the study sample did not receive an HIV test referral at a recent medical visit. Multivariate analysis showed that the estimated prevalence of the participants who received an HIV test referral among those who reported being engaged in high-risk sexual behaviors was 41% (adjusted prevalence ratio .59, 95% CI .39-.91; P=.02) lower than the estimated prevalence among those who did not engage in high-risk sexual behavior.

Conclusions

This sample of Puerto Rican adults reported a significantly lower prevalence of receiving an HIV test referral among heterosexual individuals at increased risk of HIV infection who engaged in high-risk behaviors. This study further emphasizes the need for health care providers to follow recommended guidelines for HIV test referrals in health care settings. Promotion practices in the future should include enhancing referral and access to HIV tests and implementing preventive measures to counteract the HIV epidemic in Puerto Rico.

Awareness and Attitudes Toward HIV Self-Testing in Northern Thailand

Human Immunodeficiency Virus self-testing (HIVST) was recently introduced in Thailand, but little is known about receptivity among its residents. Because Human Immunodeficiency Virus (HIV) testing is a critical component of HIV prevention, it is important to understand how HIVST is perceived among potential users. The purpose of this study was to examine awareness and attitudes toward HIVST among adults in Northern Thailand. A convenience sample of 403 adult residents of the Sanpatong district, Chiang Mai Province, was interviewed using a structured questionnaire in 2019. Awareness of HIVST was low (14%), as was the overall HIVST negative attitude score (6.44; possible range of 0–14). The odds of being aware of HIVST were more than twice as high for those with more education compared to those with less (AOR = 2.29, 95% CI: 1.22–4.30), and roughly half as high for those who expressed HIV stigma compared to those who did not (AOR = 0.49, 95% CI: 0.26–0.91). Holding negative attitudes towards HIVST also was associated with lower education and expressing HIV stigma, but these relationships disappeared in multivariate analysis. Findings may be used by local health organizations to tailor HIVST education efforts.

U.S. nurse practitioners' HIV screening behaviors and health center characteristics

ABSTRACT

One of the most effective strategies to end the human immunodeficiency virus (HIV) epidemic is HIV screening technologies. Routine HIV screening reaches the first-time tester, people with undiagnosed HIV, and those persons who are in need of frequent retesting due to their ongoing risk. This secondary analysis examined nurse practitioners' (NPs) rates of offering routine HIV screening and health center HIV screening characteristics. A convenience sample of NPs completed either a paper and pencil or an online survey in February 2016. Nurse practitioners responded to several questions about their behaviors and the health center characteristics where they work related to HIV screening. Many NPs (31%) never offer routine HIV screening to patients. Efforts are needed to implement structural changes to increase HIV screening rates among NPs and the health centers where they work. Nurse practitioners, health centers, and the health center policies must align to address the HIV epidemic and implement national HIV screening recommendations.

A Scoping Review of Patient Preferences for HIV Self-Testing Services in the United States: Implications for Harm Reduction

PURPOSE

Despite marked progress in the ability to test for, treat, and prevent HIV, the epidemic remains a significant public health concern, especially among key populations including prisoners; sex workers; transgender individuals; gay, bisexual, and other men who have sex with men (MSM); and Black and Latinx MSM. This scoping review was conducted to provide an overview of the current research describing patient preferences for HIVST in the United States to understand what key populations value about HIVST and why they are willing to use it. A targeted search for published literature on patient preferences for HIVST was conducted using Ovid Medline, PsychINFO, and an HIVST research database.

RESULTS

We reviewed 700 abstracts and 139 full texts. We found 19 articles published between January 2014 and April 2020 that included findings related to HIVST preferences. Overall, HIVST was preferred to more traditional testing. Six primary factors emerged as important HIVST values including: 1) convenience, 2) type of test; 3) cost, 4) stigma reduction, 5) risk reduction, and 6) self-control. Linkage to care was also identified as a key factor when considering HIVST as an option. Much of what makes HIVST attractive to individuals is their ability to self-determine how HIVST can be best integrated into their lives as a harm reduction tool for stigma and sexual risk mitigation.

CONCLUSION

While there is substantial evidence suggesting HIVST is feasible for use and there are aspects of HIVST that are beneficial and preferred over traditional testing approaches, there is a lack of rigorous implementation studies exploring how best to scale up HIVST in community settings. HIVST has the potential to be a powerful biobehavioral HIV prevention and harm reduction tool to empower individuals to engage with testing on their own terms while providing pathways to prevention and care support.