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Kgotlaetsile K, Bogart LM, Phaladze N, Klein DJ, Mosepele M. Feasibility and Acceptability of Human Immunodeficiency Virus Self-Testing for Men of Middle-to-Upper Socioeconomic Status in Botswana: A Pilot Study at 4 Worksites in the Financial Sector. Open Forum Infect Dis 2024; 11:ofad661. [PMID: 38264095 PMCID: PMC10805380 DOI: 10.1093/ofid/ofad661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 12/18/2023] [Indexed: 01/25/2024] Open
Abstract
Background Although Botswana has made great progress in expanding human immunodeficiency virus (HIV) testing, men are less likely to be tested for HIV and test at a later stage compared with women. For Botswana to increase HIV testing coverage among men, HIV self-testing (HIVST) may be a promising supplement to standard, healthcare facility-based HIV testing. We conducted a pilot test of the feasibility and acceptability of HIVST for men of middle-to-upper socioeconomic status in Botswana. Methods Thirty-five men were recruited through 4 workplaces (banking sector). Wellness officers emailed all potentially eligible male employees about the opportunity to participate. Men were surveyed at baseline and follow-up on basic sociodemographic characteristics, HIV testing history, HIV stigma, use of the HIVST kit (at follow-up), and confirmatory testing and linkage to care if a preliminary positive result is obtained (at follow-up). Results All 35 men used the kit. The proportion who agreed with the statement that getting tested for HIV helps people feel better increased significantly from 80.7% at baseline to 100% at follow-up. In open-ended questions, men described the advantages of HIVST, including improved privacy and convenience, lowered HIV stigma, and enhanced control over testing. Concerns about HIVST included potential negative mental health consequences owing to not receiving pretest and posttest counseling, and not linking to care after a reactive result. Conclusions Results suggest that an intervention in which HIVST is discrete, private, and under men's control can help overcome stigma around HIV testing, resulting in a greater number of men tested.
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Affiliation(s)
- Keonayang Kgotlaetsile
- University of Botswana, Faculty of Medicine, & Boitekanelo College, Counselling Department, Gaborone, Botswana
| | - Laura M Bogart
- RAND Corporation, Santa Monica, California, USA
- Department of Psychiatry, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA
| | | | - David J Klein
- Faculty of Medicine, University of Botswana and Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Mosepele Mosepele
- Faculty of Medicine, University of Botswana and Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
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Yang B, Sloot R, Floyd S, Awoniyi D, Griffith S, Ayles H, Fidler S, Hayes R, Vermund SH, Bock P. Brief Report: How Do We Reach Men? Offering HIV Testing in Evenings and Weekends in the HPTN 071 (PopART) Community-Based Trial in South Africa. J Acquir Immune Defic Syndr 2023; 93:300-304. [PMID: 37001128 PMCID: PMC10313787 DOI: 10.1097/qai.0000000000003197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 03/06/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Unknown HIV status and consequent low antiretroviral treatment coverage among men living with HIV combined with high-risk behavior is a key driver of the HIV epidemic in high-burden settings. We investigated whether conducting household visits during nontraditional shifts increased the number of men recruited for community-based HIV testing, compared with traditional weekday shifts in the HPTN 071 (PopART) trial in South Africa. METHODS We used data captured during household visits among individuals aged 15 years or older in 6 communities in South Africa from September 2016 to September 2017. Successful recruitment required community HIV care providers (CHiPs) accessing a household member and completing the study questionnaire. Linear regression analysis compared mean successful recruitments between the different shift types stratified by sex. RESULTS During 187 days, 62,455 successful household visits were completed. Recruitment of men and women was higher in weekends, for men highest on Sundays (Coef: 11.2, 95% CI: 8.7 to 13.7), for women highest on Saturdays (Coef: 11.3, 95% CI: 7.6 to 15.1), indicating a mean of 11.2 more men recruited on Sunday shifts, compared with traditional weekday shifts was similar when comparing traditional weekday shifts with nontraditional weekday shifts for both men and women. CONCLUSION Conducting household visits during the weekends led to increased recruitment for participation in the PopART intervention among both men and women. This suggests that targeting households during the weekend can be an effective and easy-to-implement strategy to increase the number of men accessed for HIV testing that can be integrated into a wide range of community-based services.
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Affiliation(s)
- Blia Yang
- Desmond Tutu TB Centre, Stellenbosch University, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Cape Town, South Africa
| | - Rosa Sloot
- Desmond Tutu TB Centre, Stellenbosch University, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Cape Town, South Africa
| | - Sian Floyd
- London School of Hygiene and Tropical Medicine, Department of Infectious Disease Epidemiology, London, United Kingdom
| | - Dolapo Awoniyi
- Desmond Tutu TB Centre, Stellenbosch University, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Cape Town, South Africa
| | - Sam Griffith
- FHI360, Durham, North Carolina, United States of America
| | - Helen Ayles
- Zambia AIDS Related Tuberculosis Project, University of Zambia, Lusaka, Zambia
- London School of Hygiene and Tropical Medicine, Department of Clinical Research, London, United Kingdom
| | - Sarah Fidler
- Imperial College London, Department of Infectious Disease Epidemiology, London, United Kingdom
| | - Richard Hayes
- London School of Hygiene and Tropical Medicine, Department of Infectious Disease Epidemiology, London, United Kingdom
| | - Sten H. Vermund
- Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Peter Bock
- Desmond Tutu TB Centre, Stellenbosch University, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Cape Town, South Africa
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Nardell MF, Adeoti O, Peters C, Kakuhikire B, Govathson-Mandimika C, Long L, Pascoe S, Tsai AC, Katz IT. Men missing from the HIV care continuum in sub-Saharan Africa: a meta-analysis and meta-synthesis. J Int AIDS Soc 2022; 25:e25889. [PMID: 35324089 PMCID: PMC8944222 DOI: 10.1002/jia2.25889] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 02/01/2022] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION Men are missing along the HIV care continuum. However, the estimated proportions of men in sub-Saharan Africa meeting the UNAIDS 95-95-95 goals vary substantially between studies. We sought to estimate proportions of men meeting each of the 95-95-95 goals across studies in sub-Saharan Africa, describe heterogeneity, and summarize qualitative evidence on factors influencing care engagement. METHODS We systematically searched PubMed and Embase for peer-reviewed articles published between 1 January 2014 and 16 October 2020. We included studies involving men ≥15 years old, with data from 2009 onward, reporting on at least one 95-95-95 goal in sub-Saharan Africa. We estimated pooled proportions of men meeting these goals using DerSimonion-Laird random effects models, stratifying by study population (e.g. studies focusing exclusively on men who have sex with men vs. studies that did not), facility setting (healthcare vs. community site), region (eastern/southern Africa vs. western/central Africa), outcome measurement (e.g. threshold for viral load suppression), median year of data collection (before vs. during or after 2017) and quality criteria. Data from qualitative studies exploring barriers to men's HIV care engagement were summarized using meta-synthesis. RESULTS AND DISCUSSION We screened 14,896 studies and included 129 studies in the meta-analysis, compiling data over the data collection period. Forty-seven studies reported data on knowledge of serostatus, 43 studies reported on antiretroviral therapy use and 74 studies reported on viral suppression. Approximately half of men with HIV reported not knowing their status (0.49 [95% CI, 0.41-0.58; range, 0.09-0.97]) or not being on treatment (0.58 [95% CI, 0.51-0.65; range, 0.07-0.97]), while over three-quarters of men achieved viral suppression on treatment (0.79 [95% CI, 0.77-0.81; range, 0.39-0.97]. Heterogeneity was high, with variation in estimates across study populations, settings and outcomes. The meta-synthesis of 40 studies identified three primary domains in which men described risks associated with engagement in HIV care: perceived social norms, health system challenges and poverty. CONCLUSIONS Psychosocial and systems-level interventions that change men's perceptions of social norms, improve trust in and accessibility of the health system, and address costs of accessing care are needed to better engage men, especially in HIV testing and treatment.
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Affiliation(s)
- Maria F Nardell
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Oluwatomi Adeoti
- Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Carson Peters
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Bernard Kakuhikire
- Faculty of Business and Management Sciences, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Caroline Govathson-Mandimika
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa
- Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence Long
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa
- Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Sophie Pascoe
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa
- Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Alexander C Tsai
- Harvard Medical School, Boston, Massachusetts, USA
- Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, USA
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ingrid T Katz
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Global Health Institute, Cambridge, Massachusetts, USA
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Bogart LM, Kgotlaetsile K, Phaladze N, Mosepele M. HIV self-testing may overcome stigma and other barriers to HIV testing among higher-socioeconomic status men in Botswana: A qualitative study. AFRICAN JOURNAL OF AIDS RESEARCH : AJAR 2021; 20:297-306. [PMID: 34905451 PMCID: PMC8717737 DOI: 10.2989/16085906.2021.2000450] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
In Botswana, HIV prevalence is 20.3% among those between 15 and 49 years old, and in sub-Saharan Africa, higher income has been associated with increased HIV risk. We qualitatively explored barriers to HIV testing and acceptability of HIV self-testing (HIVST) among higher socio-economic status (SES) men in Botswana. Twenty higher SES men (10 tested, 10 not tested recently) participated in semi-structured interviews and 10 men participated in asynchronous online focus groups (FGs) about HIV testing barriers and HIVST acceptability. Results indicated that stigma, inconvenience and perceived lack of confidentiality were barriers to HIV testing, as were masculinity-related concerns (e.g. fear of losing status if they accessed testing or were found to be HIV positive). Men said that HIVST reduced barriers to testing and that test kits could be placed in public spaces for pick-up and used in private. Overall, HIVST was seen as acceptable and feasible among higher SES men in Botswana.
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Affiliation(s)
| | | | | | - Mosepele Mosepele
- Faculty of Health Sciences, University of Botswana, Gaborone, Botswana
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
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Spielman KL, Soler-Hampejsek E, Muula AS, Tenthani L, Hewett PC. Depressive symptoms, HIV-related stigma and ART adherence among caregivers of children in vulnerable households in rural southern Malawi. PLoS One 2021; 16:e0247974. [PMID: 33667258 PMCID: PMC7935323 DOI: 10.1371/journal.pone.0247974] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 02/17/2021] [Indexed: 02/05/2023] Open
Abstract
Background Few studies have explored the association between depressive symptoms, HIV infection and stigma in vulnerable populations. The objective of this study is to examine factors associated with depressive symptoms among caregivers living in vulnerable households in Malawi and assess how reported depressive symptoms and other factors affect ART adherence among caregivers who report testing positive for HIV and currently on ART. Methods We interviewed 818 adult caregivers of children aged 0–17 years living in vulnerable households in 24 health facility catchment areas in five districts in rural southern Malawi in 2016–2017. Vulnerable households had either economic and food insecurity, or chronic illness. Questions on five depressive symptoms were used. ART adherence was self-report of not forgetting to take ART medication in the last week. Perceived and anticipated measures of stigma were used. Multivariable linear and logistic regressions documented relationships between depressive symptoms, self-reported HIV status, HIV-related stigma, and ART adherence. Results Most caregivers were women (86.2%); about one third had no spouse or live-in partner. Fifty-seven percent of caregivers reported having three or more depressive symptoms. Forty-one percent of caregivers reported testing positive for HIV. Self-reported HIV positive status was associated with depressive symptoms (adjusted coeff = 0.355, p-value <0.001), which were in turn associated with poorer ART adherence among caregivers (aOR 0.639, p-value = 0.023). HIV-related stigma was also associated with depressive symptoms for caregivers who reported having HIV (coeff = 0.302, p-value = 0.028) and those who reported testing negative for HIV (coeff = 0.187, p-value <0.001). Having social support was associated with lower depressive symptoms (coeff = -0.115, p = 0.007). HIV-related stigma, having social support, and other socio-demographic characteristics were not found to be associated with ART adherence. Conclusions Addressing mental health among caregivers in vulnerable households may be an important step toward achieving viral suppression among vulnerable populations living with HIV in Malawi. Integrating depression screening into HIV care and treatment protocols could be a promising intervention to improve longer-term outcomes.
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Affiliation(s)
| | | | | | | | - Paul C. Hewett
- Population Council, Washington, DC, United State of America
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Dzinamarira T, Mulindabigwi A, Mashamba-Thompson TP. Co-creation of a health education program for improving the uptake of HIV self-testing among men in Rwanda: nominal group technique. Heliyon 2020; 6:e05378. [PMID: 33163663 PMCID: PMC7610321 DOI: 10.1016/j.heliyon.2020.e05378] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/15/2020] [Accepted: 10/27/2020] [Indexed: 11/29/2022] Open
Abstract
Objective This study sought to collaborate with key stakeholders to reach a consensus regarding the predominant barriers preventing the uptake of HIV testing services (HTS) by men and co-create an acceptable educational program to improve the knowledge of HIV self-testing (HIVST) among men in Rwanda. Methods We employed the nominal group technique to identify a consensus regarding the predominant barriers currently impeding the male uptake of HTS. The health education program content was guided by the ranked barriers. We applied Mezirow's Transformational Learning Theory for curriculum development. Results Eleven key barriers currently impeding the male uptake of HTS were identified in the nominal group process. The stakeholders co-created an interactive, structured curriculum containing information on the health locus of control; HIV etiology, transmission, diagnosis, status disclosure benefits, care and treatment services; and an overview of the HIVST background and test procedure to address multiple barriers. Conclusion Key stakeholders co-created a comprehensive health education program tailored to men, which integrates education about health beliefs, HIV/AIDS and HIVST. Further studies to assess the effectiveness of the program are needed. It is anticipated that the intervention will improve the uptake of HIVST among men in Kigali, Rwanda.
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Affiliation(s)
- Tafadzwa Dzinamarira
- Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, 4001, South Africa
| | | | - Tivani Phosa Mashamba-Thompson
- Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, 4001, South Africa.,CIHR Canadian HIV Trials Network, Vancouver, BC, Canada.,Department of Public Health, University of Limpopo, Polokwane, Limpopo Province, South Africa
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7
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Neary J, Njuguna IN, Cranmer LM, Otieno VO, Mugo C, Okinyi HM, Benki-Nugent S, Richardson BA, Stern J, Maleche-Obimbo E, Wamalwa DC, John-Stewart GC, Wagner AD. Newly diagnosed HIV positive children: a unique index case to improve HIV diagnosis and linkage to care of parents. AIDS Care 2020; 32:1400-1405. [PMID: 32019333 DOI: 10.1080/09540121.2020.1719027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Newly diagnosed HIV positive children may be unique index cases to identify undiagnosed parents. Data was used from the Pediatric Urgent Start of HAART (NCT02063880) trial, which enrolled hospitalized, ART-naïve, HIV positive children ages 0-12 years in Kenya. Exact McNemar's tests were used to compare proportions of mothers and fathers tested for HIV, linked to care, and on ART at baseline and 6 months. This analysis included 87 newly diagnosed children with HIV who completed 6 months of follow-up. Among 83 children with living mothers, there were improvements in maternal linkage to care and treatment comparing baseline to 6 months (36% vs. 78%; p < 0.0001 and 22% vs. 52%; p < 0.0001). Among 80 children with living fathers, there were increases from baseline to 6 months in the number of fathers who knew the child's HIV status (34% vs. 78%; p < 0.0001), fathers ever tested for HIV (43% vs. 65%; p < 0.0001), fathers ever tested HIV positive (21% vs. 43%; p < 0.0001), fathers ever linked to care (15% vs. 35%; p < 0.0001), and fathers ever initiated on ART (11% vs. 23%; p = 0.0039). Newly diagnosed HIV positive children can be important index cases to identify parents with undiagnosed HIV or poor engagement in care.
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Affiliation(s)
- Jillian Neary
- Departments of Global Health, University of Washington, Seattle, WA, USA
| | - Irene N Njuguna
- Departments of Epidemiology, University of Washington, Seattle, WA, USA.,Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Lisa M Cranmer
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | | | - Cyrus Mugo
- Departments of Global Health, University of Washington, Seattle, WA, USA.,Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Hellen M Okinyi
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Sarah Benki-Nugent
- Departments of Global Health, University of Washington, Seattle, WA, USA
| | - Barbra A Richardson
- Departments of Global Health, University of Washington, Seattle, WA, USA.,Departments of Biostatistics, University of Washington, Seattle, WA, USA
| | - Joshua Stern
- Departments of Biostatistics, University of Washington, Seattle, WA, USA
| | | | - Dalton C Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Grace C John-Stewart
- Departments of Global Health, University of Washington, Seattle, WA, USA.,Departments of Epidemiology, University of Washington, Seattle, WA, USA.,Departments of Medicine, University of Washington, Seattle, WA, USA.,Departments of Pediatrics, University of Washington, Seattle, WA, USA
| | - Anjuli D Wagner
- Departments of Global Health, University of Washington, Seattle, WA, USA
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Falling Short of the First 90: HIV Stigma and HIV Testing Research in the 90-90-90 Era. AIDS Behav 2020; 24:357-362. [PMID: 31907675 DOI: 10.1007/s10461-019-02771-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Harrington BJ, Turner AN, Chemey E, Esber A, Kwiek J, Norris AH. Who Has Yet to Test? A Risk Score for Predicting Never Having Tested for Human Immunodeficiency Virus Among Women and Men in Rural Malawi. Sex Transm Dis 2019; 46:416-421. [PMID: 31095104 PMCID: PMC6589335 DOI: 10.1097/olq.0000000000000989] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Human immunodeficiency virus (HIV) status awareness is important for preventing onward HIV transmission, and is one of the Joint United Nations Programme on HIV and AIDS (UNAIDS) 90-90-90 goals. Efforts to scale up HIV testing have generally been successful, but identifying at-risk individuals who have never tested for HIV-a population necessary to reach improved HIV status awareness-remains challenging. METHODS Using data from a community-based cohort of people living in rural central Malawi, we identified demographic, socioeconomic, and sexual health correlates of never having tested for HIV. Correlates were assigned values from the logistic regression model to develop a risk score that identified who had never tested for HIV. RESULTS Among 1310 ever sexually active participants, 7% of the women and 13% of the men had never tested for HIV. Of those who had tested for HIV, about 30% had tested more than 12 months ago. For women, younger age and poorer sexual health knowledge were correlated with never having tested for HIV, and the c-statistic for the risk score was 0.83. For men, their partner having not tested for HIV, low socioeconomic status, and poor sexual health knowledge were correlated with never testing for HIV (c-statistic, 0.81). Among those with a score of 3 or greater, the sensitivity and specificity for never having tested for HIV were 81% and 77% for women, and 82% and 66% for men, respectively. CONCLUSIONS About 10% of participants had never tested for HIV. This risk score could help health professionals to identify never testers to increase HIV status awareness in line with 90-90-90 goals.
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Affiliation(s)
- Bryna J. Harrington
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Abigail Norris Turner
- Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA
- College of Public Health, The Ohio State University, Columbus, Ohio, USA
- Child Legacy International, Umoyo wa Thanzi Research Program, Lilongwe, Malawi
| | - Elly Chemey
- Child Legacy International, Umoyo wa Thanzi Research Program, Lilongwe, Malawi
| | - Allahna Esber
- College of Public Health, The Ohio State University, Columbus, Ohio, USA
| | - Jesse Kwiek
- Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA
- Department of Microbiology, The Ohio State University, Columbus, Ohio, USA
| | - Alison H. Norris
- College of Public Health, The Ohio State University, Columbus, Ohio, USA
- Child Legacy International, Umoyo wa Thanzi Research Program, Lilongwe, Malawi
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