Electronic vending machines for dispensing rapid HIV self-testing kits: a case study

Implementation determinants of HIV Self-Testing among young sexual minority men

BACKGROUND

HIV self-testing (HIVST) has shown the potential for reaching people with heightened vulnerability to HIV, including young sexual minority men (YSMM), yet implementation of HIVST among YSMM aged 17-24 is scarce as a prevention method. Moreover, despite the consistent finding that offering HIVST increases HIV testing rates, barriers remain that need to be reduced in order to maximize the potential of this biomedical technology. Such information is necessary to direct implementation efforts to increase HIVST among YSMM, including HIV counseling and linkage to care. The current study was therefore intended to investigate perspectives for HIVST among YSMM and how HIVST can be marketed to increase implementation.

METHODS

Between March and September 2020, we enrolled 41 YSMM to participate in one of nine online synchronous focus group discussions about their general experience with HIV preventive services. Guided by the Consolidated Framework (CFIR) for Implementation Research, we explored YSMM perspectives on facilitators and barriers to HIVST implementation. Data were analyzed using a deductive thematic content analysis approach.

RESULTS

Many participants had never used HIVST before their participation in this study (n = 30; 73.2%). Qualitative results exhibited a variety of implementation determinants across the five CFIR 2.0 domains. Barriers included concerns about the format in which the testing materials would be provided (i.e., nature of packaging) and about the method in which the sample would need to be collected, particularly for those who had the testing kit mailed to their home address. These reservations were nested in the fear of unwanted disclosure of their sexual behavior, namely among the respondents who had to cohabitate with family due to the COVID-19 pandemic. Participants also discussed the limited local resources for HIVST. Many participants suggested programs that could be implemented to support HIVST, such as collaborations with trusted community agencies.

CONCLUSIONS

Understanding YSMM' perspectives of HIVST may help identify implementation deficiencies within the delivery system and aid the development of implementation strategies to promote reach of HIVST.

Venues and methods to improve professional men's access to HIV self-testing and linkage to HIV prevention or treatment: a qualitative study

Background

HIV testing among men in sub-Saharan Africa is sub-optimal. Despite several strategies to improve access to underserved populations, evidence regarding engaging men in professional and formal occupations in HIV testing is limited. This study explored employed professional men’s preferences for uptake of HIV self-testing, and linkage to HIV care, or prevention services.

Methods

This was an explorative-descriptive qualitative study where a sample of 33 men from six Ugandan urban centres. Participants were purposively selected guided by the International Standard Classification of Occupations to participate in in-depth interviews. The data were collected using an interview guide and the sample size was determined by data saturation. Eligibility criteria included fulltime formal employment for over a year at that organization. The data were analyzed manually using thematic content analysis.

Results

Three categories emerged: uptake of HIV self-tests, process of HIV self-testing and linkage to post-test services. The different modes of distribution of HIV self-test kits included secondary distribution, self-tests at typically male dominated spaces, delivery to workplaces and technology-based delivery. The process of HIV self-testing may be optimized by providing collection bins, and mHealth or mobile phone applications. Linkage to further care or prevention services may be enhanced using medical insurance providers, giving incentives and tele counselling.

Conclusion

We recommend utilization of several channels for the uptake of HIV self-tests. These include distribution of test kits both to offices and men’s leisure and recreation ‘hot spots’, Additionally, female partners, peers and established men’s group including social media groups can play a role in improving the uptake of HIV self-testing. Mobile phones and digital technology can be applied in innovative ways for the return of test results and to strengthen linkage to care or prevention services. Partnership with medical insurers may be critical in engaging men in professional employment in HIV services.

HIV self-testing among men who have sex with men in China: a qualitative implementation research study

BACKGROUND

HIV self-testing (HIVST) may expand HIV testing, but there have been few pilot programmes among men who have sex with men (MSM). This purpose of this study was to evaluate HIVST implementation among MSM in China using qualitative methods.

METHODS

We undertook semistructured interviews among MSM and those organising HIVST programmes for MSM. Purposive sampling method was used to ensure men with different HIV serostatuses, ages and HIVST frequencies were included. Men were recruited from MSM community-based organisations and a local HIV clinic. An implementation science framework was used to interpret the findings. Two individuals used a standard code-based methodology to identify themes.

RESULTS

Forty-two MSM and six stakeholders were interviewed. Our data showed many MSM and stakeholders preferred HIVST to facility-based testing. Most men reported that HIVST empowered MSM and informed sexual decision making. Many men noted that decreasing the HIVST price may increase demand. Some men noted that HIVST could be scaled up through social media and by modifying bulky packaging. Minimal adverse events were reported.

CONCLUSIONS

HIVST may expand HIV testing and promote empowerment of MSM. Minimal adverse outcomes were noted, but further implementation research is needed.

Feasibility of HIV self-testing: experiences of people seeking HIV testing in rural and urban KwaZulu-Natal, South Africa

HIV status awareness is a rate limiting step in HIV treatment and prevention initiatives aimed at addressing the global HIV epidemic. Uptake of HIV testing remains suboptimal despite global campaigns aimed at improving uptake. HIV self-testing (HIVST) displays the potential to increase uptake of HIV testing in public health care facilities, which are the main access points for HIV testing, but evidence to support this notion is limited. Therefore, this study determined the factors that influence the feasibility of introducing HIVST into public facilities in KwaZulu-Natal, South Africa, through a mixed method crossover study design, implemented among 40 consenting adults who were either regular HIV testers or HIV testing naïve. Qualitative assessments were conducted using a topic guide centred on the feasibility of HIVST. Usability of HIVST was quantitatively assessed by means of a HIVST usability assessment checklist. Technical, environmental and economic factors were found to influence HIVST feasibility. The majority of participants were able to conduct unsupervised HIVST but training may be required for those unable to follow instructions. Accessibility of HIVST was associated with affordability and convenience. Environmental factors such as storage and location to perform the test and a disposal kit require further consideration in limited resource settings due to lack of privacy and confidentiality. While we demonstrated that HIVST is feasible, and identified factors that may influence its feasibility, these factors require further consideration in primary health care facilities in resource limited settings prior to scale-up.

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

BACKGROUND

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

SETTING

Seattle, Washington.

METHODS

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

RESULTS

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

CONCLUSIONS

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

A need for implementation science to optimise the use of evidence-based interventions in HIV care: A systematic literature review

To improve health outcomes in people living with HIV, adoption of evidence-based interventions (EBIs) using effective and transferable implementation strategies to optimise the delivery of healthcare is needed. ViiV Healthcare's Positive Pathways initiative was established to support the UNAIDS 90-90-90 goals. A compendium of EBIs was developed to address gaps within the HIV care continuum, yet it was unknown whether efforts existed to adapt and implement these EBIs across diverse clinical contexts. Therefore, this review sought to report on the use of implementation science in adapting HIV continuum of care EBIs. A systematic literature review was undertaken to summarise the evaluation of implementation and effectiveness outcomes, and report on the use of implementation science in HIV care. Ten databases were reviewed to identify studies (time-period: 2013-2018; geographic scope: United States, United Kingdom, France, Germany, Italy, Spain, Canada, Australia and Europe; English only publications). Studies were included if they reported on people living with HIV or those at risk of acquiring HIV and used interventions consistent with the EBIs. A broad range of study designs and methods were searched, including hybrid designs. Overall, 118 publications covering 225 interventions consistent with the EBIs were identified. These interventions were evaluated on implementation (N = 183), effectiveness (N = 81), or both outcomes (N = 39). High variability in the methodological approaches was observed. Implementation outcomes were frequently evaluated but use of theoretical frameworks was limited (N = 13). Evaluations undertaken to assess effectiveness were inconsistent, resulting in a range of measures. This review revealed extensive reporting on implementation science as defined using evaluation outcomes. However, high variability was observed in how implementation outcomes and effectiveness were defined, quantified, and reported. A more specific and consistent approach to conducting and reporting on implementation science in HIV could facilitate achievement of UNAIDS 90-90-90 targets.

Perceived acceptability of and willingness to use syringe vending machines: results of a cross-sectional survey of out-of-service people who inject drugs in Tbilisi, Georgia

BACKGROUND

The growing HIV epidemic in Eastern Europe and Central Asia has been driven by high rates of injection drug use. The Republic of Georgia has among the highest injection drug use rates globally, with a prevalence of 2.24%. The reach of evidence-based HIV prevention interventions like needle and syringe programs (NSP) among people who inject drugs (PWID) has remained below rates that could significantly impact the epidemic. Syringe vending machines (SVM) are an effective and cost-effective supplement to standard NSP; if acceptable to PWID, SVM could reach hard-to-reach PWID and cover geographic areas where fixed or mobile NSPs do not operate. The aim of this study was to assess the perceived acceptability of SVM among out-of-service (harm reduction or substance use treatment) PWID in Tbilisi, Georgia.

METHODOLOGY

Participants were recruited using respondent-driven sampling (RDS) to participate in cross-sectional, face-to-face interviews. We conducted individual interviews using a structured questionnaire that covered participants' socio-demographics, drug use practices, and perceived acceptability of SVM. Uni-variate analyses were employed for data analysis.

RESULTS

The final sample (n = 149) was almost exclusively male with a mean age of 42.2 years and mean years of injection drug use of 14.4 years. Heroin, buprenorphine, and stimulants were the main drugs injected. Eighty-five percent of the sample had never received any harm reduction services, and 30% had never been tested for HIV. Fifteen percent of the sample reported sharing injection equipment with others during last month. All but one participant agreed that PWID would benefit from SVM and 145 (97%) said they would personally use SVM. Ninety percent of those sampled stated that they would use HIV self-tests if available from vending machines. The most highly endorsed features of SVM were provision of free injection equipment, no need to deal with pharmacies, uninterrupted 24/7 access, and availability of HIV self-testing kits.

DISCUSSION

Perceived acceptability of syringe vending machines was extremely high among PWID not currently receiving any harm reduction or treatment services, with strong support indicated for uninterrupted free access to sterile injection equipment, privacy, and anonymity. Introducing SVM in Georgia holds the potential to deliver significant public health benefits by attracting hard-to-reach PWID, reducing unsafe injection behavior, and contributing to HIV testing uptake and linkage to care.

Development of an Agent-Based Model to Investigate the Impact of HIV Self-Testing Programs on Men Who Have Sex With Men in Atlanta and Seattle

BACKGROUND

In the United States HIV epidemic, men who have sex with men (MSM) remain the most profoundly affected group. Prevention science is increasingly being organized around HIV testing as a launch point into an HIV prevention continuum for MSM who are not living with HIV and into an HIV care continuum for MSM who are living with HIV. An increasing HIV testing frequency among MSM might decrease future HIV infections by linking men who are living with HIV to antiretroviral care, resulting in viral suppression. Distributing HIV self-test (HIVST) kits is a strategy aimed at increasing HIV testing. Our previous modeling work suggests that the impact of HIV self-tests on transmission dynamics will depend not only on the frequency of tests and testers' behaviors but also on the epidemiological and testing characteristics of the population.

OBJECTIVE

The objective of our study was to develop an agent-based model to inform public health strategies for promoting safe and effective HIV self-tests to decrease the HIV incidence among MSM in Atlanta, GA, and Seattle, WA, cities representing profoundly different epidemiological settings.

METHODS

We adapted and extended a network- and agent-based stochastic simulation model of HIV transmission dynamics that was developed and parameterized to investigate racial disparities in HIV prevalence among MSM in Atlanta. The extension comprised several activities: adding a new set of model parameters for Seattle MSM; adding new parameters for tester types (ie, regular, risk-based, opportunistic-only, or never testers); adding parameters for simplified pre-exposure prophylaxis uptake following negative results for HIV tests; and developing a conceptual framework for the ways in which the provision of HIV self-tests might change testing behaviors. We derived city-specific parameters from previous cohort and cross-sectional studies on MSM in Atlanta and Seattle. Each simulated population comprised 10,000 MSM and targeted HIV prevalences are equivalent to 28% and 11% in Atlanta and Seattle, respectively.

RESULTS

Previous studies provided sufficient data to estimate the model parameters representing nuanced HIV testing patterns and HIV self-test distribution. We calibrated the models to simulate the epidemics representing Atlanta and Seattle, including matching the expected stable HIV prevalence. The revised model facilitated the estimation of changes in 10-year HIV incidence based on counterfactual scenarios of HIV self-test distribution strategies and their impact on testing behaviors.

CONCLUSIONS

We demonstrated that the extension of an existing agent-based HIV transmission model was sufficient to simulate the HIV epidemics among MSM in Atlanta and Seattle, to accommodate a more nuanced depiction of HIV testing behaviors than previous models, and to serve as a platform to investigate how HIV self-tests might impact testing and HIV transmission patterns among MSM in Atlanta and Seattle. In our future studies, we will use the model to test how different HIV self-test distribution strategies might affect HIV incidence among MSM.

Vending machines in commercial sex venues to increase HIV self-testing among men who have sex with men

BACKGROUND

Commercial sex venues (CSV), bathhouses and sex clubs, have a long history of serving a high-risk population. In those facilities, patrons engage in multiple sexual encounters and often in high-risk sexual behaviors. Designing prevention interventions specifically for CSVs could be an effective way to increase testing and control HIV transmission.

METHODS

In collaboration with the AIDS Healthcare Foundation (AHF), our team distributed free HIV self-test kits using vending machines located at two CSVs in Los Angeles, California. Test kit dispensing rate was monitored remotely. Patrons receiving a test kit were surveyed regarding their testing experience, test result and follow up. Linkage to care was offered to participants.

RESULTS

During 18 months, 1,398 kits were dispensed. The survey was completed by 110 patrons (response rate =7.9%). Among those who reported that they used the test kit (n=96), 17 (17.7%) participants reported a first-time reactive HIV result. At the time of the survey, six participants with reactive results reported seeking confirmatory testing and linkage to care and four had initiated treatment. Two participants requested linkage-to-care assistance. Participants reported valuing the privacy and convenience of the vending machine but were skeptical on the accuracy of their result. The startup cost, including the purchase of two vending machines, was $10,000 and the recurring cost (monitoring, test kits, personnel) was $33.81 per kit vended.

CONCLUSIONS

While survey response was low, our results demonstrate that an intervention using vending machines and HIV self-test kits in CSVs was acceptable, feasible, used by the CSV patrons and can help identify new HIV cases.

Availability, Accessibility, and Price of Rapid HIV Self-Tests, New York City Pharmacies, Summer 2013

We conducted an in-person survey of New York City (NYC) pharmacies to assess the availability, accessibility, and price of the over-the-counter, rapid HIV self-test kit. NYC pharmacies were stratified into high, moderate and low morbidity neighborhoods by the HIV diagnosis rate of the neighborhood in which the pharmacy was located. A random sample of 500 pharmacies was taken [250 from high morbidity neighborhoods (HighMN) and 250 from low morbidity neighborhoods (LowMN)]. Pharmacies were excluded if: closed during survey, non-retail, or >10 min walk from subway. Project staff visited pharmacies to determine kit availability (in pharmacy on day of survey), accessibility (not locked/behind counter), and price (marked on shelf/product). Of 361 pharmacies (161 LowMN; 200 HighMN), kits were available in 27 % and accessible in 10 %; there was no difference by neighborhood. Kits were most often kept behind the pharmacy counter; this was more common in HighMN than in LowMN. Kits were kept solely behind the pharmacy counter in 52 %. Median price was US $42.99 without variability across neighborhoods. The rapid HIV self-test had limited availability and access in retail pharmacies. The high median price measured suggests that cost remained a barrier.

Factors associated with patients who prefer HIV self-testing over health professional testing in an emergency department-based rapid HIV screening program

Kiosk-facilitated HIV self-testing has been shown to be accurate and well accepted by emergency department (ED) patients. We investigated factors associated with patients who preferred self-testing over testing performed by health professionals in an ED-based HIV screening program. This opt-in program evaluation studied 332 patients in an inner-city academic ED from February 2012 to April 2012, when a kiosk-based HIV self-testing program was standard of care. The first kiosk in the 2-stage system registered patients and assessed their interest in screening, while the second kiosk gathered demographic and risk factor information and also provided self-testing instructions. Patients who declined to self-test were offered testing by staff. Broad eligibility included patients aged 18-64 years who were not critically ill, English-speaking, able to provide informed consent, and registered during HIV program operational hours. Data were analyzed using descriptive statistical analysis and Chi squared tests; 160 (48.2%) of 332 patients consenting to testing chose to use a kiosk to guide them performing self-testing. Patients aged 25-29 years and those whose primary ED diagnosis was not infectious disease-related were more likely to prefer HIV self-testing (OR = 2.19, 95% CI: 1.17-4.10; OR = 1.79, 95% CI: 1.03-3.12). HIV self-testing in the ED could serve as a complementary testing approach to the conventional modality.

Feasibility of using GrindrTM to distribute HIV self-test kits to men who have sex with men in Los Angeles, California

Background: Our study aimed to determine if Grindr™ is an effective means of reaching high-risk men who have sex with men (MSM) for HIV testing. In Los Angeles (LA), Black and Latino MSM have the highest rate of HIV infection, and Black MSM in LA are four-fold more likely than white MSM to not know they are infected with HIV. Those MSM are also major users of social networking apps. Grindr™ was used to provide access to free HIV self-testing. Methods: Free HIV self-test kits were advertised on Grindr™ from 13 October to 11 November 2014, consisting of 300 000 banner ads and three broadcast messages targeting a high-risk HIV population in LA. Eligible participants, Black or Latino, MSM and who were aged ≥18 years of age, were invited to take a survey 2 weeks after test delivery. Results: The website received 4389 unique visitors and 333 test requests, of which 247 (74%) were requests for mailed tests, 58 (17%) were for vouchers and 28 (8%) were for vending machines. Of the 125 participants, 74% reported at least one episode of condomless anal intercourse in the past 3 months, 29% last tested for HIV over 1 year ago and 9% had never been tested. Conclusions: It was feasible to use Grindr™ to distribute HIV self-test kits. Users are willing to provide personal information in exchange for a free self-test and found self-tests acceptable and easy to use. HIV self-testing promotion through apps has a high potential to reach untested high-risk populations.

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

OBJECTIVES

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

METHODS

We reviewed the literature on evaluating HIVST among key populations.

RESULTS

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

CONCLUSION

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

Piloting an HIV self-test kit voucher program to raise serostatus awareness of high-risk African Americans, Los Angeles

Background

Up to half of all new HIV cases in Los Angeles may be caused by the 20-30% of men who have sex with men (MSM) with unrecognized HIV infection. Racial/ethnic minority MSM are at particularly high risk for being sero-unaware and due to stigma and poor healthcare access might benefit from novel private, self-testing methods, such as the recently FDA-approved OraQuick® In-Home HIV Test.

Methods

From July-November 2013, we undertook a pilot study to examine the feasibility of a voucher program for free OraQuick® tests targeting African American MSM in Los Angeles. We determined feasibility based on: (1) the establishment of a voucher redemption and third-party payment system, (2) the willingness of community-based organizations (CBOs) to disseminate vouchers, and (3) the collection of user demographics, test and linkage-to-care results with an anonymous telephone survey.

Results

We partnered with Walgreens® to create a voucher and third-party reimbursement system for free OraQuick® tests. Voucher distribution was divided into two periods. In total, 641 vouchers were supplied to CBOs: 274 (42.7%) went to clients and of those 53 (19.3%) were redeemed. Fifty (18.2%) of the 274 clients were surveyed: 44 (88%) were African American, 39 (78%) reported being likely to repeat voucher use, 44 (88%) reported reviewing pre-test information, and 37 (74%) the post-test information. Three (6%) of 50 survey respondents reported newly testing HIV-positive of whom all (100%) reported seeking medical care. Two withheld their results, both of whom also sought medical care.

Conclusions

Developing and partnering with a commercial pharmacy to institute a voucher system to facilitate HIV self-testing with linkage-to-care was feasible. Our findings suggest the voucher program was associated with increasing the identification of new cases of HIV infection with high rates of linkage to care. Expanded research and evaluation of voucher programs for HIV self-test kits among high-risk groups is warranted.

Arguments for and against HIV self-testing

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

Acceptability of using electronic vending machines to deliver oral rapid HIV self-testing kits: a qualitative study

Introduction

Rates of unrecognized HIV infection are significantly higher among Latino and Black men who have sex with men (MSM). Policy makers have proposed that HIV self-testing kits and new methods for delivering self-testing could improve testing uptake among minority MSM. This study sought to conduct qualitative assessments with MSM of color to determine the acceptability of using electronic vending machines to dispense HIV self-testing kits.

Materials and Methods

African American and Latino MSM were recruited using a participant pool from an existing HIV prevention trial on Facebook. If participants expressed interest in using a vending machine to receive an HIV self-testing kit, they were emailed a 4-digit personal identification number (PIN) code to retrieve the test from the machine. We followed up with those who had tested to assess their willingness to participate in an interview about their experience.

Results

Twelve kits were dispensed and 8 interviews were conducted. In general, participants expressed that the vending machine was an acceptable HIV test delivery method due to its novelty and convenience.

Discussion

Acceptability of this delivery model for HIV testing kits was closely associated with three main factors: credibility, confidentiality, and convenience. Future research is needed to address issues, such as user-induced errors and costs, before scaling up the dispensing method.

After the clinic? Researching sexual health technology in context

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