Unintended uses, meanings, and consequences: HIV self-testing among female sex workers in urban Uganda

A Digital Sexual Health Education Web Application for Resource-Poor Regions in Kenya: Implementation-Oriented Case Study Using the Intercultural Research Model

BACKGROUND

Developing a digital educational application focused on sexual health education necessitates a framework that integrates cultural considerations effectively. Drawing from previous research, we identified the problem and essential requirements to incorporate cultural insights into the development of a solution.

OBJECTIVE

This study aims to explore the Solution Room of the self-established Intercultural Research Model, with a focus on creating a reusable framework for developing and implementing a widely accessible digital educational tool for sexual health. The study centers on advancing from a low-fidelity prototype (She!Masomo) to a high-fidelity prototype (We!Masomo), while evaluating its system usability through differentiation. This research contributes to the pursuit of Sustainable Development Goals 3, 4, and 5.

METHODS

The research methodology is anchored in the Solution Room of the self-expanded Intercultural Research Model, which integrates cultural considerations. It uses a multimethod, user-centered design thinking approach, focusing on extensive human involvement for the open web-based application. This includes gathering self-assessed textual user feedback, conducting a System Usability Scale (SUS) analysis, and conducting 4 face-to-face semistructured expert interviews, following COREQ (Consolidated Criteria for Reporting Qualitative Research) guidelines.

RESULTS

Based on the identified limitations of the low-fidelity prototype, She!Masomo (SUS score 67), which were highlighted through textual user feedback (63/77) and prototype feature comparisons, iterative development and improvement were implemented. This process led to the creation of an enhanced high-fidelity prototype (We!Masomo). The improved effectiveness of the enhanced prototype was evaluated using the qualitative SUS analysis (82/90), resulting in a favorable score of 77.3, compared with the previous SUS score of 67 for the low-fidelity prototype. Highlighting the importance of accessible digital educational tools, this study conducted 4 expert interviews (4/4) and reported e-survey results following the CHERRIES (Checklist for Reporting Results of Internet E-Surveys) guideline. The digital educational platform, We!Masomo, is specifically designed to promote universal and inclusive free access to information. Therefore, the developed high-fidelity prototype was implemented in Kenya.

CONCLUSIONS

The primary outcome of this research provides a comprehensive exploration of utilizing a case study methodology to advance the development of digital educational web tools, particularly focusing on cultural sensitivity and sensitive educational subjects. It offers critical insights for effectively introducing such tools in regions with limited resources. Nonetheless, it is crucial to emphasize that the findings underscore the importance of integrating culture-specific components during the design phase. This highlights the necessity of conducting a thorough requirement engineering analysis and developing a low-fidelity prototype, followed by an SUS analysis. These measures are particularly critical when disseminating sensitive information, such as sexual health, through digital platforms.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12905-023-02839-6.

"The targets…are driving the agenda and that probably needs to change": stakeholder perspectives on HIV partner notification in sub-Saharan Africa

BACKGROUND

Voluntary assisted partner notification (VAPN) in HIV contact tracing is a globally recommended strategy to identify persons who have been exposed to HIV and link them to HIV testing and follow-up. However, there is little understanding about how VAPN is experienced by stakeholders in sub-Saharan African (SSA) contexts. We conducted a multi-level and multi-national qualitative analysis evaluating stakeholder perspectives surrounding VAPN implementation to inform the development of future VAPN policies.

METHOD

We conducted in-depth interviews (IDIs) with VAPN stakeholders at global (n = 5), national (n = 6), and community level (n = 4) across a total of seven SSA countries. Eligible participants were ≥ 18 years old and had experience developing, implementing, or overseeing VAPN policies in SSA. We sought to understand stakeholder's perspectives on policy development, implementation, and perceived outcomes (barriers and facilitators). Interviews were audio recorded, transcribed, and analyzed thematically using a combination of inductive and deductive approaches.

RESULTS

Between December 2019 and October 2020 we conducted 15 IDIs. While participants agreed that VAPN resulted in a high yield of people newly diagnosed with HIV; they noted numerous barriers surrounding VAPN implementation across global, national, and community levels, the majority of which were identified at community level. Barriers at global and national level included high target setting, contradictory laws, and limited independent research disenfranchising the experiences of implementing partners. The barriers identified at community level included client-level challenges (e.g., access to healthcare facilities and fear of adverse events); healthcare worker challenges (e.g., high workloads); limited data infrastructure; and cultural/gender norms that hindered women from engaging in HIV testing and VAPN services. In response to these barriers, participants shared implementation facilitators to sustain ethical implementation of VAPN services (e.g., contact tracing methods) and increase its yield (e.g., HIV self-testing integrated with VAPN services).

CONCLUSION

Overall, stakeholders perceived VAPN implementation to encounter barriers across all implementation levels (global to community). Future VAPN policies should be designed around the barriers and facilitators identified by SSA stakeholders to maximize the implementation of (ethical) HIV VAPN services and increase its impact in sub-Saharan African settings.

A feasibility study of the use of HIV self-tests in young men who have sex with men

Studies on HIV self-testing (HIV-ST) have been limited to adults (age 18+). The study assessed use of HIV-ST among a diverse group of young men who have sex with men (YMSM) in the United States (US) and assessed differences in uptake by demographic characteristics and requirements for parental consent. This study demonstrated feasibility of HIV-ST for YMSM as young as 14 years of age, which suggests potential for increasing HIV testing in this young age group and promoting health equity.

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.

Understanding how social support influences peer-delivered HIV prevention interventions among Ugandan female sex workers: a case study from HIV self-testing

BACKGROUND

Female sex workers (FSWs) have tightly connected peer networks and remain at high risk of HIV acquisition. Peer delivery of HIV prevention interventions, such as HIV self-testing (HIVST), is a recommended implementation strategy for increasing intervention uptake and continuation among FSWs. We analyzed qualitative data from a peer-delivered HIVST intervention among FSWs in urban Uganda to understand the ways social support within this peer network can motivate or discourage the uptake of peer-delivered HIVST.

METHODS

Between February and April 2017, we conducted in-depth interviews (IDIs) with FSWs (n = 30) and focus group discussions (FGDs) with FSW peer educators (PEs, n = 5) finishing participation in a four-month randomized implementation trial testing models of peer-delivered HIVST in Kampala. FSW participants were ≥ 18 years old, self-reported exchanging sex for money or goods (past month) and had not recently tested for HIV (past 3 months). FSW PEs either directly distributed HIVST kits to participants or provided coupons exchangeable for HIVST kits from specified healthcare facilities. In the IDIs and FGDs, we asked participants to share their experiences receiving or delivering peer-delivered HIVST, respectively. Using a hybrid deductive and inductive coding approach, we arranged findings along the dimensions of an established social support theory: informational, instrumental, and emotional support.

RESULTS

The median age of participants was 30 years (IQR: 27-33) and PEs was 33 years (IQR: 29-37). We found that social support within FSW peer networks both motivated and discouraged uptake of peer-delivered HIVST. For example, sharing positive HIVST experiences (informational support), directly delivering HIVST kits (instrumental support), and encouraging linkage to care (emotional support) motivated HIVST uptake among FSWs. Conversely, the spread of misinformation (informational support), limited HIVST kit availability fostering mistrust of PEs (instrumental support), and fear of social exclusion following HIV status disclosure (emotional support) discouraged HIVST uptake among FSWs.

CONCLUSIONS

In Uganda, social support (e.g., informational, instrumental, and emotional support) among FSW peers can work in ways that both motivate and discourage peer-delivered intervention uptake. Future FSW peer-delivered HIV prevention interventions should be designed around the dimensions of social support within FSW peer networks to maximize initial and repeat intervention delivery and uptake.

HIV self-testing and oral pre-exposure prophylaxis are empowering for sex workers and their intimate partners: a qualitative study in Uganda

Introduction

HIV self‐testing (HIVST) and oral pre‐exposure prophylaxis (PrEP) are complementary, evidence‐based, self‐controlled HIV prevention tools that may be particularly appealing to sex workers. Understanding how HIVST and PrEP are perceived and used by sex workers and their intimate partners could inform prevention delivery for this population. We conducted qualitative interviews to examine ways in which HIVST and PrEP use influence prevention choices among sex workers in Uganda.

Methods

Within a randomized trial of HIVST and PrEP among 110 HIV‐negative cisgender women, cisgender men and transgender women sex workers (NCT03426670), we conducted 40 qualitative interviews with 30 sex workers and 10 intimate partners (June 2018 to January 2020). Sex worker interviews explored (a) experiences of using HIVST kits; (b) how HIVST was performed with sexual partners; (c) impact of HIVST on PrEP pill taking; and (d) sexual risk behaviours after HIVST. Partner interviews covered (i) introduction of HIVST; (ii) experiences of using HIVST; (iii) HIV status disclosure; and (iv) HIVST's effect on sexual behaviours. Data were analysed using an inductive content analytic approach centering on descriptive category development. Together, these categories detail the meaning of HIVST and PrEP for these qualitative participants.

Results

Using HIVST and PrEP was empowering for this group of sex workers and their partners. Three types of empowerment were observed: (a) economic; (b) relational; and (c) sexual health. (i) Using HIVST and PrEP made sex without condoms safer. Sex workers could charge more for condomless sex, which was empowering economically. (ii) Self‐testing restored trust in partners’ fidelity upon being reunited after a separation. This trust, in combination with condomless sex made possible by PrEP use, restored intimacy, empowering partnered relationships. (iii) HIVST and PrEP enabled sex workers to take control of their HIV prevention efforts and avoid the stigma of public clinic visits. In this way they were empowered to protect their sexual health.

Conclusions

In this sample, sex workers’ use of HIVST and PrEP benefitted not only prevention efforts, but also economic and relational empowerment. Understanding these larger benefits and communicating them to stakeholders could strengthen uptake and use of combination prevention interventions in this marginalized population.

The unintended consequences of COVID-19 mitigation measures matter: practical guidance for investigating them

BACKGROUND

COVID-19 has led to the adoption of unprecedented mitigation measures which could trigger many unintended consequences. These unintended consequences can be far-reaching and just as important as the intended ones. The World Health Organization identified the assessment of unintended consequences of COVID-19 mitigation measures as a top priority. Thus far, however, their systematic assessment has been neglected due to the inattention of researchers as well as the lack of training and practical tools.

MAIN TEXT

Over six years our team has gained extensive experience conducting research on the unintended consequences of complex health interventions. Through a reflexive process, we developed insights that can be useful for researchers in this area. Our analysis is based on key literature and lessons learned reflexively in conducting multi-site and multi-method studies on unintended consequences. Here we present practical guidance for researchers wishing to assess the unintended consequences of COVID-19 mitigation measures. To ensure resource allocation, protocols should include research questions regarding unintended consequences at the outset. Social science theories and frameworks are available to help assess unintended consequences. To determine which changes are unintended, researchers must first understand the intervention theory. To facilitate data collection, researchers can begin by forecasting potential unintended consequences through literature reviews and discussions with stakeholders. Including desirable and neutral unintended consequences in the scope of study can help minimize the negative bias reported in the literature. Exploratory methods can be powerful tools to capture data on the unintended consequences that were unforeseen by researchers. We recommend researchers cast a wide net by inquiring about different aspects of the mitigation measures. Some unintended consequences may only be observable in subsequent years, so longitudinal approaches may be useful. An equity lens is necessary to assess how mitigation measures may unintentionally increase disparities. Finally, stakeholders can help validate the classification of consequences as intended or unintended.

CONCLUSION

Studying the unintended consequences of COVID-19 mitigation measures is not only possible but also necessary to assess their overall value. The practical guidance presented will help program planners and evaluators gain a more comprehensive understanding of unintended consequences to refine mitigation measures.