Acceptability of a HIV self-testing program among people who use illicit drugs

Decentralized HIV testing: comparing peer and mail-based distribution strategies to improve the reach of HIV self-testing among people who use drugs in Florida

INTRODUCTION

People who use drugs (PWUD) are at increased risk for HIV infection. HIV self-testing (HIVST) is a promising method for identifying new infections, but optimal distribution strategies remain understudied.

METHODS

To characterize PWUD by HIVST distribution strategy (peers vs. mail), we examined data from July 2022 to June 2023 collected from a real-world HIVST program led by the non-profit, Florida Harm Reduction Collective. We used descriptive statistics and Poisson regressions with robust error variance to compare those who received HIVST through peers or via mail by socio-demographics, Ending the HIV Epidemic (EHE) county designation, and HIV testing experience.

RESULTS

Among 728 participants, 78% received HIVST from peers, 47% identified as cisgender female, 48% as heterosexual, and 45% as non-White; 66% resided in an EHE county, and 55% had no HIV testing experience. Compared to those who received an HIV self-test from peers, those who received tests via mail were less likely to be cisgender male (vs. cisgender female; prevalence ratio [PR] = 0.59, 95% confidence interval [CI]: 0.43, 0.81), non-Hispanic Black (vs. non-Hispanic White; PR = 0.57, 95% CI: 0.36, 0.89) or from EHE counties (vs. non-EHE counties; PR = 0.33, 95% CI: 0.25, 0.44). Those who received tests via mail were also more likely to identify their sexual orientation as "Other/Undisclosed" (vs. straight/heterosexual; PR = 2.00, 95% CI: 1.51, 2.66).

CONCLUSION

Our findings support the role of community-based HIVST distribution strategies in increasing HIV testing coverage among PWUD. Additional research could help inform the equitable reach of HIVST.

Community-based HIV Self-testing for Persons Who Use Drugs Can Contribute to Reaching Ending the HIV Epidemic in the US (EHE) Goals

In a pilot study providing HIV self-testing to persons who use drugs (N = 40), we identified 3 new HIV cases when partnering with a community-based organization. Most (82%) participants were interested in preexposure prophylaxis. HIV self-testing could contribute to efforts to Ending the HIV Epidemic in the United States. ClinicalTrials.gov registration: NCT05528562.

Health, harm reduction, and social service providers' perspectives on the appropriateness and feasibility of peer distribution of HIV self-test kits among people who use drugs

BACKGROUND

People who use drugs (PWUD) experience elevated HIV risk and numerous barriers to facility-based HIV testing. HIV self-testing (HIVST) could circumvent many of those barriers and is acceptable among PWUD, yet HIVST implementation for PWUD is limited. Service providers' perspectives on specific HIVST delivery strategies could help increase availability for PWUD.

METHODS

From April-November 2021, we interviewed 16 health, harm reduction, and social service providers working with PWUD in San Diego, CA. Interviews and rapid thematic analysis explored perspectives on HIVST's utility and appropriateness, as well as the feasibility of and anticipated challenges with specific HIVST delivery strategies, including peer or secondary distribution.

RESULTS

Participants viewed HIV as a significant threat to PWUD health and confirmed the presence of numerous barriers to local facility-based HIV testing. Participants viewed HIVST as a promising and potentially empowering solution. Based on community familiarity with secondary distribution of harm reduction supplies (i.e., naloxone) and information, participants viewed secondary distribution of HIVST kits as an appropriate and feasible strategy for increasing the reach of HIVST, but also described potential barriers (e.g., engaging socially disconnected individuals, ensuring linkages to services following HIVST) and provided suggestions for alternative HIVST kit delivery models (e.g., harm reduction vending machines).

CONCLUSIONS

Service providers viewed secondary distribution of HIVST kits among PWUD as promising, appropriate, and feasible, yet specialized efforts may be needed to reach the most marginalized individuals and ensure consistent provision of educational information and referral supports that maximize the impact of this approach.

Willingness to use and distribute HIV self-testing kits among people who inject drugs in the San Diego-Tijuana border region

BACKGROUND

HIV self-testing (HIVST) could increase HIV testing access among people who inject drugs (PWID), and secondary distribution (i.e., peer-delivery) of HIVST kits in PWID social networks could further expand coverage. We assessed willingness to use and distribute HIVST kits among PWID in the San Diego-Tijuana border region.

METHODS

From 2020 to 2021, HIV-negative PWID in San Diego, USA, and Tijuana, Mexico, completed surveys and provided data on individual (N = 539) and social network (N = 366) characteristics. We used modified Poisson regression to examine the effects of individual and social network characteristics on willingness to use and distribute HIVST kits.

RESULTS

Most participants were willing to use (81%) and distribute (81%) HIVST kits. At the individual level, prior HIV testing was positively associated with willingness to use (adjusted prevalence ratio [aPR] = 1.24, 95% confidence interval [CI] 1.10-1.40) and distribute (aPR = 1.27, 95% CI 1.12-1.43) HIVST kits, while perceiving oneself to be at higher HIV risk than others was negatively associated with willingness to use HIVST kits (aPR = 0.83, 95% CI 0.74-0.93). At the network level, willingness to distribute HIVST kits was positively associated with network size (aPR = 1.04 per member, 95% CI 1.01-1.08) and greater proportions of one's network encouraging them to use drugs (aPR = 1.29, 95% CI 1.16-1.44) and having a history of homelessness (aPR = 1.51, 95% CI 1.31-1.74) or detention/arrest (aPR = 1.57, 95% CI 1.36-1.82), and negatively associated with a greater proportion of one's network including "very close" persons (aPR = 0.80, 95% CI 0.69-0.94).

CONCLUSIONS

We found high potential for HIVST kits and their secondary distribution to increase HIV testing among PWID who face the greatest barriers to facility-based testing.

Acceptability and usability of oral fluid HCV self-testing for hepatitis C diagnosis: A systematic review and meta-analysis

Data on the acceptability and usability of hepatitis C virus self-testing (HCVST) remain scarce. We estimated the pooled rates of acceptability/feasibility and re-reading/re-testing agreement of HCVST using oral fluid tests (PROSPERO-CRD42022349874). We searched online databases for studies that evaluated acceptability, usability and inter-reader/operator variability for HCVST using oral fluid tests. Pooled estimates of feasibility, agreement and post-testing perspectives were analysed. Sensitivity analyses were performed in men who have sex with men (MSM) and people who inject drugs (PWID). Heterogeneity was assessed using the I2 statistics. A total of six studies comprising 870 participants were identified: USA (n = 95 with liver disease), Kenya (n = 150 PWID), Egypt (n = 116 from the general population), Vietnam (n = 104 MSM and n = 105 PWID), China (n = 100 MSM) and Georgia (n = 100 MSM and n = 100 PWID)]. All studies used OraQuick® HCV Rapid Antibody Test. The pooled overall estimates for correct sample collection and for people who performed HCVST without needing assistance in any step (95% confidence interval [CI]) were 87.2% [76.0-95.3] (n = 755; I2  = 93.7%) and 62.6% [37.2-84.8] (n = 755; I2  = 98.0%), respectively. The pooled estimate of agreement for re-reading was 95.0% [95% CI 91.5-97.6] (n = 831; I2  = 74.0%) and for re-testing was 94.4% [90.3-97.5] (n = 726; I2  = 77.1%). The pooled estimate of those who would recommend HCVST was 94.4% [84.7-99.6] (n = 625; I2  = 93.7%). Pooled estimates (95% CI) of correct sample collection (72.8% [63.3-81.5] vs. 90.8% [85.9-94.8]) and performance of HCVST without needing assistance (44.1% [14.1-76.7] vs. 78.1% [53.4-95.3]) was lower in PWID compared to MSM. In summary, HCV testing with oral fluid HCVST was feasible and well-accepted. Oral fluid HCVST should be considered in key populations for uptake HCV testing.

Awareness and willingness to use HIV self-testing among people who inject drugs in Iran

BACKGROUND

Most people who inject drugs (PWID) in Iran have not undergone recent HIV testing. While PWID face barriers when seeking HIV testing at health facilities, HIV self-testing (HIVST) could be a promising approach to improve HIV testing uptake. We examined the awareness and willingness to use HIVST among PWID in Iran. We also identified participants' characteristics associated with a higher willingness to use HIVST.

METHODS

PWID were recruited in 11 cities using a respondent-driven sampling method. Willingness to use HIVST was defined as a binary variable (very low/low willingness vs. high/very high willingness). We performed multivariable modified Poisson regression to examine associated factors and report adjusted prevalence ratios (aPR) and 95% confidence intervals (CI).

RESULTS

Of 2,252 PWID, 362 (16.2%; 95% CI 14.7, 17.8) had ever heard of HIVST; however, 1,658 (73.6%; 95% CI 71.7, 75.4) reported high/very high willingness to use HIVST. Willingness to use HIVST was higher among PWID who reported having a high/moderate HIV risk perception (aPR 1.22; 95% CI 1.09, 1.37), ever experiencing homelessness (aPR 1.15; 95% CI 1.03, 1.28), > 10 years of injecting history (aPR 1.16; 95% CI 1.00, 1.34), and high injection frequency in the last three months (aPR 1.18; 95% CI 1.05, 1.32).

CONCLUSION

Most PWID in Iran, particularly those experiencing homelessness, have a longer injecting history, engage in more frequent injection practices, and possess a heightened perception of HIV risk would be willing to adopt HIVST. Enhancing HIVST awareness through increased access to HIVST and health education programs are needed. Additionally, conducting implementation science studies to effectively design and run HIVST programs in Iran can also increase PWID's access to HIV testing.

Acceptability and feasibility of HIV self-testing in Southeast Asia: A scoping review

BACKGROUND

HIV self-testing (HIVST) policies in Southeast Asia are under development. This scoping review aimed to systematically synthesize the available literature on the acceptability and feasibility of HIVST in Southeast Asia.

METHODS

Systematic search was conducted on January 20, 2022, in eight databases: PubMed/MEDLINE, CINAHL, Web of Science, Academic Search Complete, SocINDEX, PsycINFO, PsycArticles, and CENTRAL. Acceptability (HIV testing frequency, willingness to pay, use, and recommend the test, ease of use, preference over standard tests, and partner testing) and feasibility (error rate, readability, and diagnostic performance) parameters were followed for the inclusion of articles. A narrative synthesis was done to present findings from included studies on the acceptability and feasibility of HIVST.

RESULTS

A total of 5091 records were identified through database search, and 362 were deleted after deduplication. The screening process resulted in 18 studies that met the inclusion criteria. Results indicated a high acceptability rate due to convenience, increasing awareness about HIVST, availability, and affordability of test kits, and confidentiality of test results. A high feasibility rate was reported due to a low occurrence of errors in self-testing, interpretability of results, and a low percentage of invalid and false-reactive results. Issues identified include costs of HIVST for individual use, distribution mode, type of supervision, counseling, geographic location, and socioeconomic status.

CONCLUSIONS

Evidence supports the acceptability and feasibility of HIVST in Southeast Asia. There is a need to regulate and license HIVST in Southeast Asia to have better recognition as a supplement to HTS.

Acceptability and strategies for enhancing uptake of human immunodeficiency virus self-testing in Nigeria

BACKGROUND

In 2019, the Nigerian Ministry of Health published the first operational guidelines for human immunodeficiency virus self-testing (HIVST) to improve access to human immunodeficiency virus (HIV) testing services among undertested populations in the country. Also, as part of the campaign to increase HIV testing services in Nigeria, the Nigerian Ministry of Health developed standard operating procedures for using HIVST kits.

AIM

To systematically review the acceptability and strategies for enhancing the uptake of HIVST in Nigeria.

METHODS

The systematic review was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Different databases were searched to get the necessary materials needed for this review. Standardized forms developed by the authors were used for data extraction to minimize the risk of bias and ensure that the articles used for the study were properly screened. Identified articles were first screened using the titles and their abstracts. The full papers were screened, and the similarities of the documents were determined. Qualitative, quantitative, and mixed-method studies were evaluated using the Critical Appraisal Skills Programme and Critical Appraisal Framework criteria.

RESULTS

All the publications reviewed were published between 2015 and 2022, with 33.3% published in 2021. Most (77.8%) of the studies were cross-sectional, 43.3% were conducted in Lagos State, and 26.3% were conducted among young people. The study revealed a high level of acceptability of HIVST. Certain factors, such as gender, sexual activity, and previous testing experience, influence the acceptability of HIV self-testing, with some individuals more likely to opt-out. The cost of the kit was reported as the strongest factor for choosing HIVST services, and this ranged from 200 to 4000 Naira (approximately United States Dollar 0.55-11.07), with the majority willing to pay 500 Naira (approximately United States Dollar 1.38). Privately-owned, registered pharmacies, youth-friendly centres, supermarkets, and online stores were the most cited access locations for HIVST. The least influential attribute was the type of specimen needed for HIVST. Strategies addressing cost and preferred access points and diverse needs for social media promotion, local translation of product use instructions, and HIVST distribution led by key opinion leaders for key populations were found to significantly enhance HIVST uptake and linkage to care.

CONCLUSION

HIVST acceptability is generally high from an intention-to-use perspective. Targeted strategies are required to improve the acceptability of HIV self-testing, especially among males, sexually active individuals, and first-time testers. Identified and proposed uptake-enhancing strategies need to be investigated in controlled settings and among different populations and distribution models in Nigeria.

Preliminary Efficacy of a Theory-Informed Intervention to Increase COVID-19 Testing Uptake Among People Who Inject Drugs in San Diego County: Findings From a Pilot Randomized Controlled Trial

BACKGROUND

People who inject drugs (PWID) have low rates of COVID-19 testing yet are vulnerable to severe disease. In partnership with a mobile syringe service program (SSP) in San Diego County, CA, we developed the evidence-, community-, and Social Cognitive Theory-informed "LinkUP" intervention (tailored education, motivational interviewing, problem-solving, and planning) to increase COVID-19 testing uptake among PWID.

PURPOSE

To assess preliminary efficacy of LinkUP in increasing PWID COVID-19 testing in a pilot randomized controlled trial (RCT).

METHODS

We referred participants (PWID, ≥18 years old, San Diego County residents who had not recently undergone voluntary COVID-19 testing) to mobile SSP sites that had been randomized (by week) to offer the active LinkUP intervention or didactic attention-control conditions delivered by trained peer counselors. Following either condition, counselors offered on-site rapid COVID-19 antigen testing. Analyses estimated preliminary intervention efficacy and explored potential moderation.

RESULTS

Among 150 participants, median age was 40.5 years, 33.3% identified as Hispanic/Latinx, 64.7% were male, 73.3% were experiencing homelessness, and 44.7% had prior mandatory COVID-19 testing. The LinkUP intervention was significantly associated with higher COVID-19 testing uptake (p < .0001). Homelessness moderated intervention effects; LinkUP increased COVID-19 testing uptake more among participants experiencing homelessness (adjusted risk ratio [aRR]: 1.80; 95% CI: 1.56-2.09; p < .0001) than those not experiencing homelessness (aRR: 1.20; 95% CI: 1.01-1.43; p = .04).

CONCLUSIONS

Findings from this pilot RCT support the preliminary efficacy of the "LinkUP" intervention to increase COVID-19 testing among PWID and underscore the importance of academic-community partnerships and prevention service delivery through SSPs and other community-based organizations serving vulnerable populations.

Awareness With Paralysis Among Critically Ill Emergency Department Patients: A Prospective Cohort Study

OBJECTIVES

In mechanically ventilated patients, awareness with paralysis (AWP) can have devastating consequences, including post-traumatic stress disorder (PTSD), depression, and thoughts of suicide. Single-center data from the emergency department (ED) demonstrate an event rate for AWP factors higher than that reported from the operating room. However, there remains a lack of data on AWP among critically ill, mechanically ventilated patients. The objective was to assess the proportion of ED patients experiencing AWP and investigate modifiable variables associated with its occurrence.

DESIGN

An a priori planned secondary analysis of a multicenter, prospective, before-and-after clinical trial.

SETTING

The ED of three academic medical centers.

PATIENTS

Mechanically ventilated adult patients that received neuromuscular blockers.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

All data related to sedation and analgesia were collected. AWP was the primary outcome, assessed with the modified Brice questionnaire, and was independently adjudicated by three expert reviewers. Perceived threat, in the causal pathway for PTSD, was the secondary outcome. A total of 388 patients were studied. The proportion of patients experiencing AWP was 3.4% ( n = 13), the majority of whom received rocuronium ( n = 12/13; 92.3%). Among patients who received rocuronium, 5.5% ( n = 12/230) experienced AWP, compared with 0.6% ( n = 1/158) among patients who did not receive rocuronium in the ED (odds ratio, 8.64; 95% CI, 1.11-67.15). Patients experiencing AWP had a higher mean ( sd ) threat perception scale score, compared with patients without AWP (15.6 [5.8] vs 7.7 [6.0]; p < 0.01).

CONCLUSIONS

AWP was present in a concerning proportion of mechanically ventilated ED patients, was associated with rocuronium exposure in the ED, and led to increased levels of perceived threat, placing patients at greater risk for PTSD. Studies that aim to further quantify AWP in this vulnerable population and eliminate its occurrence are urgently needed.