Free HIV self-test for identification and linkage to care of previously undetected HIV infection in men who have sex with men in England and Wales (SELPHI): an open-label, internet-based, randomised controlled trial

Targeted HIV Self-Testing Identifies Persons with Undiagnosed HIV and Active Engagement Links them to Care: The GetaKit Study

Current international HIV testing guidelines recommend that HIV negative persons from HIV priority groups complete repeat screening every 3-6 months; local guidelines in our jurisdiction recommend that such retesting should occur every 3 months. Such an approach allows for timely HIV diagnosis and linkage to care - and aligns with the UNAIDS 95-95-95 targets to have 95% of undiagnosed persons be aware of their HIV status. To meet these aims, new approaches to HIV testing have been developed, including our HIV self-testing initiative, GetaKit.ca, which uses an online screening algorithm to determine eligibility and has built in pathways for re-test reminders, linkage HIV prevention care, and rapid follow-up for positive test results. To understand self-testing frequency in relation to our local recommendations for resting every 3 months, we evaluated data from participants who ordered repeat HIV self-tests through GetaKit.ca. Descriptive analyses were performed on participant characteristics and chi-square tests were performed on aggregated participant risk data. During the study period, 5235 HIV self-tests were distributed to 3627 participants, of whom, 26% ordered more than once and 27% belonged to an HIV priority population. Participants who retested were more likely to have been white, male, and part of an HIV priority population; they were also more likely to have completed prior STI or HIV testing or had a prior STI diagnosis, compared to those who did not. We identified 16 new HIV diagnoses, 2 of which were among repeat testers. Our results suggest that HIV self-testing can be useful to help meet UNAIDS targets to identify undiagnosed infections; however, such efforts are less likely to be successful without adequate linkage to follow-up services, including HIV treatment and prevention care.

Estimating the Cost-Effectiveness of HIV Self-Testing in the United States Using Net Benefit Regression

BACKGROUND

Cost-effectiveness analysis of HIV self-testing using patient-level data from a randomized clinical trial can inform HIV prevention funding decisions. Cost-effectiveness analysis using net-benefit regression addresses the sampling uncertainty in the trial data and the variability of policymakers' willingness to pay (WTP).

METHODS

We used published data from a 12-month longitudinal randomized clinical trial that enrolled 2665 men who had sex with men randomly assigned to the self-testing arm (participants receiving self-test kits) and control arm (participants receiving standard-of-care), and the self-testing arm identified 48 additional new HIV cases. We used net-benefit regression to investigate the cost-effectiveness of an HIV self-testing intervention, which compared the incremental cost per new HIV diagnosis with policymakers' WTP thresholds. We addressed the uncertainties in estimating the incremental cost and the policymakers' WTP per new diagnosis through the incremental net-benefit (INB) regression and cost-effectiveness acceptability curve (CEAC) analyses.

RESULTS

From the health care provider's perspective, the INB analysis showed a positive net benefit of HIV self-testing compared with standard-of-care when policymakers' WTP per new HIV diagnosis was $9365 (95% confidence interval: $5700 to $25,500) or higher. The CEAC showed that the probability of HIV self-testing being cost-effective compared with standard-of-care was 58% and >99% at a WTP of $10 000 and $50 000 per new HIV diagnosis, respectively.

CONCLUSION

The INB and CEAC analyses suggest that HIV self-testing has the potential to be cost-effective for relatively low values of policymakers' WTP.

Factors Associated with the First-time HIV Testing Among Chinese men who have sex with men Who Received HIV Self-tests from Partners or Friends

Secondary distribution of HIV self-testing (HIVST) among individual social networks was an effective approach to expanding HIV testing among men who have sex with men (MSM). However, understanding the factors associated with first-time HIV testing behaviors in the secondary distribution of HIVST programs is limited. Hence, this study aims to identify factors related to first-time testers in the secondary distribution of HIVST. Participants were recruited from five provinces in southern China through Blued, a geo-social gay networking app in China from January 2021 to December 2021. Eligible consented participants (referred to as "seeds") finished a baseline survey and then applied for up to five HIVST kits. They were encouraged to distribute HIVST kits to other MSM (referred to as "alters") and alters were encouraged to scan a QR code to return their photographed testing results. All alters were invited to finish an online survey. In total, 229 seeds reached 292 alters, among whom 126 (43.2%) were first-time testers whereas 166 (56.8%) were non-first-time testers. Importantly, our results demonstrated that the first-time HIV testers were more likely to self-report as heterosexual (aOR = 4.88, 95% CI 1.01-23.61), disclose sexual orientation and/or SSB (aOR = 1.73, 95% CI 1.01-2.96), and receive HIVST knowledge from the seeds (aOR = 3.25, 95% CI 1.02-10.34). However, those who had sex with male partners in the last three months were less likely to be first-time testers (aOR = 0.43, 95% CI 0.23-0.82). Practical implications and limitations were also discussed to improve future HIV prevention programs.

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.

Sustained high HIV incidence among men who have sex with men in Jiangsu province, China: based on the limiting-antigen avidity EIA method and six consecutive surveys, 2016-2021

Background

The epidemic of HIV infection among men who have sex with men (MSM) is a major public health concern in some parts of China, but data on trends in HIV incidence are limited. This study aimed to examine the trends in HIV incidence and factors associated with recent HIV infection among MSM in Jiangsu province, China, based on the limiting-antigen avidity enzyme immunoassay (LAg-Avidity-EIA) method.

Methods

Six consecutive surveys were implemented among MSM throughout Jiangsu province from 2016 to 2021. Participants were recruited in three ways. Socio-demographic and behavioral information were collected through face-to-face interviews. Venous blood samples were taken to test for HIV and syphilis. HIV incidence was estimated using the LAg-Avidity-EIA method. Chi-square trend tests were used to observe trends over the years. Multivariate regression analyses were used to identify factors associated with recent HIV infection.

Results

A total of 15,401 participants were enrolled in the study. The prevalence of HIV infection ranged from 8.0 to 9.8%, with no consistent rise or fall over the years (P = 0.189). HIV incidence ranged from 5.0 to 9.0%, and no uptrend or downtrend was shown (P = 0.418). MSM who lived locally for more than 2 years (aOR = 1.366, P = 0.019), had a lack of comprehensive HIV knowledge (aOR = 1.643, P = 0.031), had engaged in unprotected anal intercourse (UAI) in the past 6 months (aOR = 7.373, P < 0.001), had been tested for HIV within 12 months (aOR = 1.292, P = 0.035), and tested positive for syphilis (aOR = 2.840, P < 0.001) were likely to be recently infected with HIV.

Conclusions

HIV incidence among MSM has remained at a high level in Jiangsu province. In China, health education, condom use, and HIV/syphilis testing should continue to be top priorities for HIV prevention among MSM to reduce HIV transmission.

The effect of combination prevention strategies on HIV incidence among gay and bisexual men who have sex with men in the UK: a model-based analysis

BACKGROUND

In the UK, the number of new HIV diagnoses among gay and bisexual men who have sex with men (GBMSM) has decreased substantially. We aimed to understand the contribution of different interventions in reducing HIV incidence so far; to estimate future HIV incidence with continuation of current policies and with further scaling up of current interventions; and to estimate the maximum additional annual cost that should be spent towards these interventions for them to offer value for money.

METHODS

We calibrated a dynamic, individual-based, stochastic simulation model, the HIV Synthesis Model, to multiple sources of data on HIV among GBMSM aged 15 years or older in the UK. Primarily these were routine HIV surveillance data collected by the UK Health Security Agency. We compared HIV incidence in 2022 with the counterfactual incidence: if HIV testing rates stopped increasing in 2012 and the policy of antiretroviral therapy (ART) at diagnosis was not introduced in mid-2015; if pre-exposure prophylaxis (PrEP) was not introduced; if condom use was low from 2012 in all GBMSM, at levels similar to those observed in 1980; and in the first and second scenario combined. We also projected future outcomes under the assumption of continuation of current policies and considering increases in PrEP and HIV testing uptake and a decrease in condomless sex.

FINDINGS

Our model estimated a 77% (90% uncertainty interval [UI] 61-88) decline in HIV incidence since around 2014, with an estimated 597 infections ([90% UI 312-956]; 1·1 per 1000 person-years [90% UI 0·6-1·8]) in men aged 15-64 years in 2022. Both PrEP introduction and increased HIV testing with ART initiation at diagnosis each had a substantial effect on HIV incidence. Without PrEP introduction, we estimate there would have been 2·16 times the number of infections that actually occurred (90% UI 1·06-3·75) between 2012 and 2022; without increased HIV testing and ART initiation at diagnosis there would have been 2·18 times the number of infections that actually occurred (1·18-3·60), and if condomless sex was at the levels before the HIV epidemic, there would have been 2·27 times the number of infections that actually occurred (0·9-5·4). If rates of testing, ART use, and PrEP use remain as they are currently, there is a predicted decline in incidence to 388 HIV infections in 2025 (90% UI 226-650) and to 263 (137-433) in 2030. Increases in HIV testing and PrEP use were predicted to accelerate the decline in HIV incidence. Given the quality-adjusted life-year (QALY) benefit and a cost-effectiveness threshold of £30 000 per QALY gained, in order to be cost-effective an additional £1·62 million could be spent per year to increase testing levels by 34% (90% UI 25-46) and PrEP use by 55% (10-107). To achieve that, a 16% reduction in the cost of delivery of testing and PrEP would be required.

INTERPRETATION

Combination prevention, including a PrEP strategy, played a major role in the reduction in HIV incidence observed so far in the UK among GBMSM. Continuation of current activities should lead to a continued decline; however, it is unlikely to lead to reaching the target of fewer than 50 HIV infections per year among GBMSM by 2030. It will be important to reduce costs for testing and PrEP for their continued expansion to be cost-effective.

FUNDING

National Institute for Health Research under its Programme Grants for Applied Research Programme and Medical Research Council-UK Research and Innovation.

HIV self-testing: what GetaKit can tell us about Canada's $8 million one-time investment

At the 16th International AIDS Conference in Montreal, Canada's Federal Health Minister announced that the Government of Canada will invest $17 million to increase access to HIV testing, $8 million of which would be used to purchase and distribute HIV self-tests. While HIV testing, and subsequent diagnoses, is a critical first step to achieving the updated UNAIDS goals of 95-95-95, testing on its own does not guarantee linkage to treatment or prevention services. In other words, it does not alone guarantee progress toward the 95-95-95 goals. GetaKit, Canada's first HIV self-test mail-out project, has demonstrated that a preliminary risk-assessment consistent with US CDC and PHAC screening guidelines ensures targeted uptake among communities most affected by HIV, thus minimizing the risk of false positive results and poor positive predictive values. Furthermore, HIV self-testing must link not only individuals with positive results to treatment, but also persons with negative results to pre-exposure prophylaxis (PrEP) along with re-testing as required. However, both access to treatment and PrEP remain inconsistently available across Canada. Therefore, while this one-time investment of funding to increase HIV testing is encouraging, without clear instructions as to who should be prioritized for testing and definitive next steps to ensure that individuals are successfully linked to care, Canada risks wasting resources, further exacerbating pre-existing inequities.

Predicting Factors of Plasma HIV RNA Undetectability after Switching to Co-Formulated Bictegravir, Emtricitabine, and Tenofovir Alafenamide in Experienced HIV-1 Patients: A Multicenter Study

Switching to bictegravir, emtricitabine, and tenofovir alafenamide (BIC/FTC/TAF) from other antiretroviral regimens is safe and effective for virologically suppressed people living with HIV (PLWH). The term virological suppression includes both low but detectable HIV viremia and undetectable HIV viremia, and the latter is possibly associated with a lower immune activation state. Herein, we describe a 24-month follow-up of experienced PLWH with plasma HIV RNA undetectable or detectable < 50 copies/ml switching to BIC/FTC/TAF. A previous 12-month monitoring was available, and the factors correlated with treatment efficacy. This retrospective multicenter study included PLWH who switched to BIC/FTC/TAF in the period of 2019-2022, and who were HBsAg and HCV RNA negative. The follow-up study times were 6 (T6), 12 (T12), 18 (T18), and 24 (T24) months after the switch (T0). Survival analysis with multiple-failure-per-subject design, Kaplan-Meier survival estimates, multivariate analysis of variance, multilevel linear regression, and a hierarchical ordered logistic model were applied. A total of 329 PLWH had plasma HIV RNA which was either undetectable or detectable at <50 copies/mL at T0, and 197 responded to all inclusion criteria: M/F 140/57; the median CD4+ cell count was 677 cells/mm3; and HIV RNA at T0 was undetectable in 108 patients. Most of the 197 patients (122, 61.9%) were on a previous INSTI-based regimen. HIV RNA undetectability was more frequent at each follow-up point in patients with HIV RNA that was undetectable at T0, and it showed a higher frequency throughout the follow-up period in patients with always-undetectable HIV RNA in the 12 months before the switch. A higher nadir CD4 cell count had a predictive role, and HBcAb positivity had no influence. In conclusion, the switch could be programmed and possibly delayed on a case-by-case basis in order to achieve persistent plasma HIV RNA undetectability. Undiagnosed loss of HBcAb has no detrimental consequences on the response to BIC/FTC/TAF.

Could Home Human Immunodeficiency Virus Self-Testing Ever Become a Game Changer?

Could home human immunodeficiency virus (HIV) self-testing make a major difference in identifying persons with undiagnosed HIV in the United States? We argue that approval of new self-test assays for home use would help but must be combined with extensive investment in community outreach and linkage to care to make an impact.

Highlighting and addressing barriers to widespread adaptation of HIV self-testing in the United States

INTRODUCTION

HIV self-testing (HIVST), whereby an individual performs and interprets their own rapid screening test at home, is another tool to increase the proportion of at-risk individuals who know their status. Globally, HIVST has rapidly been adopted through global partnerships to ensure equitable access to tests in low- and middle-income countries (LMIC).

AREA COVERED

This review discusses the regulatory burdens of HIV self-testing within the United States while examining the use of HIV self-tests on a global scale. While the United States only has one approved HIV self-test, numerous tests have been prequalified by the WHO.

EXPERT OPINION

Despite the US Food and Drug Administration (FDA) clearance of the first and only self-test in 2012, there have been no other tests that have undergone FDA consideration due to regulatory barriers. This, in turn, has stifled market competition. Despite existing evidence that such programs are an innovative approach to testing hesitant or hard-to-reach populations, high individual test cost and bulky packaging make large-scale, mail-out, and HIV self-testing programs expensive. COVID-19 pandemic has accelerated the public demand for self-testing - HIV self-test programs should capitalize on this to increase the proportion of at-risk people who know their status and are linked to care to contribute to ending the HIV epidemic.