Effect of HIV self-testing on the number of sexual partners among female sex workers in Zambia

Formalized peer referral to HIV pre-exposure prophylaxis supported with self-testing: a mixed-methods pilot study among young Kenyan women

Background

The uptake of daily oral HIV pre-exposure prophylaxis (PrEP)-a highly effective intervention-remains low among African adolescent girls and young women (AGYW) who could benefit. AGYW who initiate PrEP often do so through informal peer referral, which may be enhanced with formalized peer referral and peer-delivered HIV self-testing (HIVST). To understand the feasibility of this PrEP referral model among AGYW, we conducted a pilot study in Kenya.

Method

From March to May 2022, we recruited AGYW (≥16-24 years) using PrEP (i.e., "peer providers") from public healthcare clinics in Kiambu County and trained them on HIV prevention, HIVST use, and peer-supported linkage to clinic-based HIV services. Following training, peer providers received eight HIVST kits and were encouraged to refer four peers (i.e., "peer clients") to PrEP. We completed surveys with peer providers and clients one month following intervention delivery to assess PrEP initiation among peer clients. Later, we conducted focus group discussions (FGDs) with peer providers and clients to identify factors that facilitated or challenged intervention outcomes.

Results

We trained 16 peer providers (median age: 23 years, IQR 21-24) who reported delivering the intervention to 56 peer clients; 30 peer clients (median age: 21 years, IQR 19-22) contacted the study team and were enrolled. Most of the enrolled peer clients reported behaviors associated with HIV risk (e.g., condomless sex; 80%, 24/30) and were PrEP-naïve (87%, 26/30). At one-month, PrEP initiation among eligible PrEP-naïve peer clients was high, as reported by providers (78%, 43/55) and clients (85%, 22/26); recent HIVST use was also high among peer clients (provider report: 95%, 53/56; client report: 97%, 29/30). In the FGDs, participants reported that intervention outcomes were facilitated by close preexisting relationships, HIVST assistance, and being escorted to clinic-based HIV services by peer providers; intervention barriers included conflicting priorities and limited HIVST experience.

Conclusion

A formalized model of peer referral with HIVST delivery supported PrEP initiation among Kenyan AGYW. These findings demonstrate the potential for peer-delivered interventions to engage AGYW in HIV prevention services; however, more research is needed on the effectiveness and sustainability of this approach at scale.

Effectiveness of Linkage to Care and Prevention Interventions Following HIV Self-Testing: A Global Systematic Review and Meta-analysis

Over 38.4 million people were living with HIV globally in 2021. The HIV continuum includes HIV testing, diagnosis, linkage to combined antiretroviral therapy (cART), and retention in care. An important innovation in the HIV care continuum is HIV self-testing. There is a paucity of evidence regarding the effectiveness of interventions aimed at linking self-testers to care and prevention, including pre-exposure prophylaxis (PrEP). To bridge this gap, we carried out a global systematic review and meta-analysis to ascertain the effectiveness of interventions post-HIV self-testing regarding: (1) linkage to care or ART, (2) linkage to PrEP, and (3) the impact of HIV self-test (HIVST) interventions on sexual behaviors. We searched PubMed, Web of Science, SCOPUS, Cochrane Library, CINAHL Plus (EBSCO), MEDLINE (Ovid), Google Scholar, and ResearchGate. We included only published randomized controlled trials (RCTs) and quasi-experiment that compared HIVST to the standard of care (SoC). Studies with sufficient data were aggregated using meta-analysis on RevMan 5.4 at a 95% confidence interval. Cochrane's Q test was used to assess heterogeneity between the studies, while Higgins and Thompson's I2 was used to quantify heterogeneity. Subgroup analyses were conducted to identify the source of heterogeneity. Of the 2669 articles obtained from the databases, only 15 studies were eligible for this review, and eight were included in the final meta-analysis. Overall, linkage to care was similar between the HIVST arm and SoC (effect size: 0.92 [0.45-1.86]; I2: 51%; p: 0.04). In the population subgroup analysis, female sex workers (FSWs) in the HIVST arm were significantly linked to care compared to the SoC arm (effect size: 0.53 [0.30-0.94]; I2: 0%; p: 0.41). HIVST interventions did not significantly improve ART initiation in the HIVST arm compared to the SoC arm (effect size: 0.90 [0.45-1.79]; I2: 74%; p: < 0.001). We found that more male partners of women living with HIV in the SoC arm initiated PrEP compared to partners in the HIVST arm. The meta-analysis showed no difference between the HIVST and SoC arm regarding the number of clients (effect size: - 0.66 [1.35-0.02]; I2: 64%; p: 0.09) and non-clients FSWs see per night (effect size: - 1.45 [- 1.45 to 1.38]; I2: 93%; p: < 0.001). HIVST did not reduce the use of condoms during insertive or receptive condomless anal intercourse among MSM. HIVST does not improve linkage to care in the general population but does among FSWs. HIVST intervention does not improve linkage to ART nor significantly stimulate healthy sexual behaviors among priority groups. The only RCT that linked HIVST to PrEP found that PrEP uptake was higher among partners of women living with HIV in the SoC arm than in the HIVST arm. More RCTs among priority groups are needed, and the influence of HIVST on PrEP uptake should be further investigated.

Experience of social harms among female sex workers following HIV self-test distribution in Malawi: results of a cohort study

BACKGROUND

In Malawi, female sex workers (FSW) have high HIV incidence and regular testing is suggested. HIV self-testing (HIVST) is a safe and acceptable alternative to standard testing services. This study assessed; whether social harms were more likely to be reported after HIVST distribution to FSW by peer distributors than after facility-based HIV testing and whether FSW regretted HIVST use or experienced associated relationship problems.

METHODS

Peer HIVST distributors, who were FSW, were recruited in Blantyre district, Malawi between February and July 2017. Among HIVST recipients a prospective cohort was recruited. Interviews were conducted at baseline and at end-line, 3 months later. Participants completed daily sexual activity diaries. End-line data were analysed using logistic regression to assess whether regret or relationship problems were associated with HIVST use. Sexual activity data were analysed using Generalised Estimating Equations to assess whether HIVST use was temporally associated with an increase in social harms.

RESULTS

Of 265 FSW recruited and offered HIVST, 131 completed both interviews. Of these, 31/131(23.7%) reported initial regret after HIVST use, this reduced to 23/131(17.6%) at the 3-month follow-up. Relationship problems were reported by 12/131(9.2%). Regret about HIVST use was less commonly reported in those aged 26-35 years compared to those aged 16-25 years (OR immediate regret-0.40 95% CI 0.16-1.01) (OR current regret-0.22 95% CI 0.07 - 0.71) and was not associated with the HIVST result. There was limited evidence that reports of verbal abuse perpetrated by clients in the week following HIVST use were greater than when there was no testing in the preceding week. There was no evidence for increases in any other social harms. There was some evidence of coercion to test, most commonly initiated by the peer distributor.

CONCLUSIONS

Little evidence was found that the peer distribution model was associated with increased levels of social harms, however programmes aimed at reaching FSW need to carefully consider possible unintended consequences of their service delivery approaches, including the potential for peer distributors to coerce individuals to test or disclose their test results and alternative distribution models may need to be considered.

Social Network Strategies to Distribute HIV Self-testing Kits: A Global Systematic Review and Network Meta-analysis

Introduction

Social network strategies, in which social networks are utilized to influence individuals or communities, are increasingly being used to deliver human immunodeficiency virus (HIV) interventions to key populations. We summarized and critically assessed existing research on the effectiveness of social network strategies in promoting HIV self-testing (HIVST).

Methods

Using search terms related to social network interventions and HIVST, we searched five databases for trials published between January 1st, 2010, and June 30th, 2023. Outcomes included uptake of HIV testing, HIV seroconversion, and linkage to antiretroviral therapy (ART) or HIV Care. We used network meta-analysis to assess the uptake of HIV testing through social network strategies compared with control methods. A pairwise meta-analysis of studies with a comparison arm that reported outcomes was performed to assess relative risks (RR) and their corresponding 95% confidence intervals (CI).

Results and discussion

Among the 3,745 manuscripts identified, 33 studies fulfilled the inclusion criteria, including one quasi-experimental study, 17 RCTs and 15 observational studies. Networks HIVST testing was organized by peers (distributed to known peers, 15 studies), partners (distributed to their sexual partners, 10 studies), and peer educators (distributed to unknown peers, 8 studies). The results showed that all of the three social network distribution strategies enhanced the uptake of HIV testing compared to standard facility-based testing. Among social networks, peer distribution had the highest uptake of HIV testing (79% probability, SUCRA 0.92), followed by partner distribution (72% probability, SUCRA 0.71), and peer educator distribution (66% probability, SUCRA 0.29). Pairwise meta-analysis showed that peer distribution (RR 2.29, 95% CI 1.54-3.39, 5 studies) and partner distribution (RR 1.45, 95% CI 1.05-2.02, 7 studies) also increased the probability of detecting HIV reactivity during testing within the key population when compared to the control. Linkage to ART or HIV Care remained comparable to facility-based testing across the three HIVST distribution strategies.

Conclusions

Network-based HIVST distribution is considered effective in augmenting HIV testing rates and reaching marginalized populations compared to facility-based testing. These strategies can be integrated with the existing HIV care services, to fill the testing gap among key populations globally.PROSPERO Number: CRD42022361782.

Drivers of HIV self-testing among female sex workers: Findings from a multi-state study in Malaysia

Background

Although research on HIV self-testing (HIVST) has rapidly increased, few studies have explored HIVST uptake in female sex workers (FSW), and none in Malaysia. Therefore, we endeavored to assess the willingness to use HIVST in this at-risk, vulnerable population.

Methods

A cross-sectional survey study was conducted among 113 HIV-negative Malaysian FSW in 2017. Participants were recruited using advertisements on social media, flyers, and direct referrals from community-based organizations. Data were collected using self-administered surveys. Multivariable logistic regression was used to identify correlates of willingness to use HIVST.

Results

Nearly a third of participants (30.1%) reported they would be willing to use HIVST. Multivariable analyses adjusting for Malay ethnicity, stable housing, living in Kuala Lumpur (KL), years in sex work, age of first sex work, childhood sexual assault, history of HIV testing, and previously in prison indicated that living in KL [adjusted odds ratio (aOR) = 5.214, p = 0.0137] was associated with a greater willingness to use HIVST. In contrast, having stable housing (aOR = 0.100, p = 0.0064) was negatively associated with willingness to use HIVST.

Conclusions

Our results indicate that HIVST may potentially enhance the uptake of HIV testing among FSWs living in an urban environment and experiencing unstable housing, but an overall willingness to use HIVST is low. These findings highlight the need for efforts to increase awareness of HIVST among FSWs and additional research on the effective implementation of HIVST for FSW.

Evidence and gap map report: Social and Behavior Change Communication (SBCC) interventions for strengthening HIV prevention and research among adolescent girls and young women (AGYW) in low- and middle-income countries (LMICs)

Background

Adolescent girls and young women (AGYW), aged 15-24 years, are disproportionately affected by HIV and other sexual and reproductive health (SRH) risks due to varying social, cultural, and economic factors that affect their choices and shape their knowledge, understanding, and practices with regard to their health. Socio-Behavioral Change Communication (SBCC) interventions targeted at strengthening the capabilities of individuals and their networks have supported the demand and uptake of prevention services and participation in biomedical research. However, despite growing global recognition of the domain, high-quality evidence on the effectiveness of SBCC remains scattered. This evidence and gap map (EGM) report characterizes the evidence base on SBCC interventions for strengthening HIV Prevention and Research among AGYW in low- and middle-income countries (LMICs), identifying evidence gaps and outlining the scope of future research and program design.

Objectives

The objectives of the proposed EGM are to: (a) identify and map existing EGMs in the use of diverse SBCC strategies to strengthen the adoption of HIV prevention measures and participation in research among AGYW in LMICs and (b) identify areas where more interventions and evidence are needed to inform the design of future SBCC strategies and programs for AGYW engagement in HIV prevention and research.

Methods

This EGM is based on a comprehensive search of systematic reviews and impact evaluations corresponding to a range of interventions and outcomes-aimed at engaging AGYW in HIV prevention and research - that were published in LMICs from January 2000 to April 2021. Based on guidance for producing a Campbell Collaboration EGM, the intervention and outcome framework was designed in consultation with a group of experts. These interventions were categorized across four broad intervention themes: mass-media, community-based, interpersonal, and Information Communication and Technology (ICT)/Digital Media-based interventions. They were further sub-categorized into 15 intervention categories. Included studies looked at 23 unique behavioral and health outcomes such as knowledge attitude and skills, relationship dynamics, household dynamics, health care services, and health outcomes and research engagement. The EGM is presented as a matrix in which the rows are intervention categories/sub-categories, and the columns are outcome domains/subdomains. Each cell is mapped to an intervention targeted at outcomes. Additional filters like region, country, study design, age group, funding agency, influencers, population group, publication status, study confidence, setting, and year of publication have been added.

Selection Criteria

To be eligible, studies must have tested the effectiveness of SBCC interventions at engaging AGYW in LMICs in HIV prevention and research. The study sample must have consisted of AGYW between the ages of 15-24, as defined by UNAIDS. Both experimental (random assignment) and quasi-experimental studies that included a comparison group were eligible. Relevant outcomes included those at the individual, influencer, and institutional levels, along with those targeting research engagement and prevention-related outcomes.

Results

This EGM comprises 415 impact evaluations and 43 systematic reviews. Interventions like peer-led interactions, counseling, and community dialogues were the most dominant intervention sub-types. Despite increased digital penetration use of media and technology-driven interventions are relatively less studied. Most of the interventions were delivered by peers, health care providers, and educators, largely in school-based settings, and in many cases are part of sex-education curricula. Evidence across geographies was mostly concentrated in Sub-Saharan Africa (70%). Most measured outcomes focused on disease-related knowledge dissemination and enhancing awareness of available prevention options/strategies. These included messaging around consistent condom use, limiting sexual partners, routine testing, and awareness. Very few studies were able to include psychographic, social, and contextual factors influencing AGYW health behaviors and decisions, especially those measuring the impact of social and gender norms, relationship dynamics, and household dynamics-related outcomes. Outcomes related to engagement in the research were least studied.

Conclusion

This EGM highlights that evidence is heavily concentrated within the awareness-intent spectrum of behavior change and gets lean for outcomes situated within the intent-action and the action-habit formation spectrum of the behavior change continuum. Most of the evidence was concentrated on increasing awareness, knowledge, and building risk perception around SRH domains, however, fewer studies focused on strengthening the agency and self-efficacy of individuals. Similarly, evidence on extrinsic factors-such as strengthening social and community norms, relationships, and household dynamics-that determine individual thought and action such as negotiation and life skills were also found to be less populated. Few studies explore the effectiveness of these interventions across diverse AGYW identities, like pregnant women and new mothers, sex workers, and people living with HIV, leading to limited understanding of the use of these interventions across multiple user segments including key influencers such as young men, partners, families, religious leaders, and community elders was relatively low. There is a need for better quality evidence that accounts for the diversity of experiences within these populations to understand what interventions work, for whom, and toward what outcome. Further, the evidence for use of digital and mass-media tools remains poorly populated. Given the increasing penetration of these tools and growing media literacy on one end, with widening gender-based gaps on the other, it is imperative to gather more high-quality evidence on their effectiveness. Timely evidence generation can help leverage these platforms appropriately and enable intervention designs that are responsive to changing communication ecologies of AGYW. SBCC can play a critical role in helping researchers meaningfully engage and collaborate with communities as equal stakeholders, however, this remains poorly evidenced and calls for investigation and investment. A full list of abbreviations and acronyms are available in Supporting Information: Appendix F.

Shifting the power: scale-up of access to point-of-care and self-testing for sexually transmitted infections in low-income and middle-income settings

PURPOSE OF REVIEW

Point-of-care (POC) testing for sexually transmitted infections (STIs) can provide complementary coverage to existing HIV testing services in LMICs. This review summarizes current and emerging technologies for detecting STIs in LMICs, with an emphasis on women, discharge-causing infections (chlamydia, gonorrhoea, trichomoniasis, and syphilis), true POC, self-testing, ethics, and economic considerations related to equitable access.

RECENT FINDINGS

The WHO have recently adapted guidelines for treatment of STIs in women that advise the use of true-POC or near-POC tests to improve case finding. The number of rapid, sensitive, and specific POC diagnostics for STIs has increased significantly over the past 10 years, although adoption of these in low-income and middle-income countries (LMICs) remains limited. Barriers to POC adoption by patients include the cost of tests, the inconvenience of lengthy clinic visits, low perceived risk, stigma, lack of partner notification, and lack of trust in healthcare providers. Lowering the cost of true POC lateral flow devices, interfacing these with digital or eHealth technologies, and enabling self-testing/self-sampling will overcome some of these barriers in LMICs. Ensuring linkage of diagnostic tests to subsequent care remains one of the major concerns about self-testing, irrespective of geography, although available evidence from HIV self-testing suggests that linkage to care is similar to that for facility-based testing.

SUMMARY

Increasing access to sensitive STI true POC tests will strengthen reproductive healthcare in LMICs. Although HIV self-testing is demonstrably useful in LMICs, there is an urgent need for randomized trials evaluating the utility and cost-effectiveness of similar tests for other sexually transmitted infections.

HIV Self-testing and Risk Behaviors Among Men Who Have Sex With Men in 23 US Cities, 2017

IMPORTANCE

HIV self-testing (HIVST) is a promising strategy to expand the HIV care continuum, particularly among priority populations at high risk of HIV infection. However, little is known about HIVST uptake among men who have sex with men (MSM) outside of clinical trial settings.

OBJECTIVE

To evaluate HIVST use among urban MSM in the US who reported testing within the past 12 months.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional study of adult MSM in the 2017 National HIV Behavioral Surveillance system, which used venue-based sampling methods to collect data related to HIV testing, receipt of prevention services, and risk factors for HIV, was conducted at 588 venues in 23 urban areas in the contiguous US and Puerto Rico. All participants were offered HIV testing. Adult cisgender MSM who reported HIV-negative or unknown HIV status and obtained HIV testing in the past 12 months were included. Data for this study were collected between June 4, 2017, and December 22, 2017, and analyzed between October 23, 2020, and August 20, 2021.

MAIN OUTCOMES AND MEASURES

Self-reported HIVST in the past year. Adjusted prevalence ratios (aPRs) using survey weights were calculated to assess factors associated with HIVST.

RESULTS

A total of 6563 MSM in 23 urban areas met inclusion criteria, of whom 506 (7.7%) individuals reported HIVST in the past year. The median age of self-testers was 29 (IQR, 25-35) years, 52.8% had completed college, and 37.9% reported non-Hispanic White race. One self-tester reported seroconverting in the prior 12 months, and an additional 10 self-testers were diagnosed with HIV during the survey. HIVST was associated with sexual orientation disclosure (aPR, 10.27; 95% CI, 3.45-30.60; P < .001), perceived discrimination against people with HIV (aPR, 1.53; 95% CI, 1.09-2.03; P = .01), younger age (aPR, 0.74; 95% CI, 0.66-0.84; P < .001), higher educational level (aPR, 1.20; 95% CI, 1.04-1.37; P = .01), and higher income levels (aPR, 1.18; 95% CI, 1.04-1.32; P = .009). No association was noted with condomless anal sex (aPR, 0.96; 95% CI, 0.88-1.06, P = .88), sexually transmitted infections (aPR, 0.96; 95% CI, 0.70-1.30; P = .77), or preexposure prophylaxis use (aPR, 0.99; 95% CI, 0.75-1.30; P = .92).

CONCLUSIONS AND RELEVANCE

In this study, HIVST was relatively uncommon in this sample of urban MSM. HIVST may not be reaching those with lower socioeconomic status or who have not disclosed their sexual identity. The findings of this study suggest that efforts to increase HIVST should focus on engaging underserved and vulnerable subgroups of MSM.

Effectiveness of linkage to care and prevention interventions following HIV self-testing: a global systematic review and meta-analysis protocol

INTRODUCTION

Early identification of persons living with HIV (PLWH) is crucial to institute timely treatment to prevent HIV-related morbidity and mortality. The convenience, flexibility and confidentiality of HIV self-testing enhance the acceptability of HIV testing and early detection of PLWH. However, persons who tested positive after a self-test are more likely to present late for treatment. This review seeks to evaluate the effectiveness of interventions to improve linkage to care and prevention after self-testing.

METHODS AND ANALYSIS

We will search PubMed, Embase, Web of Science, Cochrane Library, PsycInfo, Global Health Library, ClinicalTrials.gov and current controlled trials for all randomised and non-randomised studies published from 1 January 2010 to 31 July 2022 without language restriction. Two review authors will independently screen and select articles (based on the eligibility criteria for this review), extract data and assess the risk of bias in the included studies. Study-specific estimates will be converted to log risk ratios and weighted by the inverse of the variance of the log risk ratio before pooling into a fixed-effect model. The Cochrane's Q χ2 test and the I2 statistic will be used to assess and quantify heterogeneity in the included studies, respectively. The Egger's test and funnel plots will be used to assess publication bias. Sensitivity analysis will be conducted using leave-one-out analysis to assess the impact of outliers on the overall summary intervention effect.

ETHICS AND DISSEMINATION

No ethical clearance is needed for the current study as it will be based on already published articles. We will publish the findings of this study in international peer-reviewed journals and present them at conferences.

A Cross-Sectional Assessment of HIV Self-Testing Preferences and Uptake Among Key Populations in Phnom Penh, Cambodia

Offering HIV self-testing services to key populations in Cambodia expanded HIV testing access to a large proportion of individuals with no prior testing history and resulted in high rates of new HIV case detection and subsequent linkages to HIV treatment.

Background:

HIV self-testing (HIVST) is recommended by the World Health Organization, but implementation remains limited. This cross-sectional study evaluated HIVST uptake among female entertainment workers (EWs), men who have sex with men (MSM), and transgender women in Phnom Penh, Cambodia, to inform national implementation.

Methods:

Between December 2018 and September 2019, individuals reached through community outreach or via online advertising were offered HIVST or referrals to facility-based testing. Participants opting for HIVST could choose between test kits employing oral-fluid or finger-prick-based sample collection; and between an “assisted” option in which outreach staff offered instructions and assistance and an “unassisted” option in which participants received a kit with instructions for use. A structured questionnaire was administered to facilitate descriptive statistics and tests for associations between participant characteristics and HIV testing preferences and outcomes.

Results:

Among 1,241 eligible individuals; 1,210 (97.5%) provided responses for analysis. Of these, 1,203 (99.4%) were recruited through outreach; 7 (0.6%) through online advertising. Among those recruited by outreach, 1,186 (98.6%) opted for assisted HIVST, and 1,065 (88.5%) opted for oral-fluid versus finger-prick testing. All individuals recruited through online advertisements opted for unassisted oral-fluid testing. Among all participants, 455 (37.6%) were MSM, 325 (26.9%) were transgender women, 430 (35.5%) were female EWs, and overall, 71.7% reported never previously testing for HIV. A total of 84 participants (6.9%) received reactive screening results and 81 (97.5%) were linked to treatment.

Conclusion:

Uptake of HIVST was high, and most participants preferred oral-fluid over finger-prick-based testing. Many individuals (72%) who had never previously accessed HIV testing services participated in HIVST, with high rates of reactivity.

Formative assessment to identify perceived benefits and barriers of HIV oral self-testing among female sex workers, service providers, outreach workers, and peer educators to inform scale-up in Kenya

In Kenya, HIV prevalence estimates among female sex workers (FSWs) are almost five times higher than among women in the general population. However, only 68% of infected FSWs are aware of their HIV-positive status. We aimed to identify perceived benefits, opportunities, and barriers of HIV self-testing (HIVST) in improving testing coverage among FSWs. Twenty focus group discussions were conducted with 77 service providers, 42 peer educators (PEs) and outreach workers, and 37 FSWs attending drop-in centers (DiCEs) in four regions of Kenya. An additional 8 FSWs with HIV-negative or unknown status-completed in-depth interviews. Data were analyzed thematically. Acceptability of HIVST was high, with cited benefits including confidentiality, convenience, and ease of use. Barriers included absence of counseling, potential for inaccurate results, fear of partner reaction, possible misuse, and fear that HIVST could lead to further stigmatization. PEs and DiCEs were the preferred models for distributing HIVST kits. FSWs wanted kits made available free or at a nominal cost (100 Kenya Shillings or ∼USD 1). Linkage to confirmatory testing, the efficiency of distributing HIVST kits using peers and DiCEs, and the types and content of effective HIVST messaging require further research.

A Systematic Review of HIV Testing Implementation Strategies in Sub-Saharan African Countries

HIV/AIDS remains a looming presence in public health across the world, particularly in Sub-Saharan Africa. The HIV Care Cascade hinges on testing and knowledge of HIV status. Though significant advances have been made in diagnosing people living with HIV (PLHIV), limitations in understanding which strategies are best suited to certain regions or populations have contributed to the uneven distribution in the success of various HIV testing strategies. Here, we present a conceptual framework that outlines effective HIV testing strategies for four target groups. This framework is based on a systematic literature review of articles published from January 1st, 2008, to December 31st, 2019. The effectiveness of HIV testing strategies depends on various factors including the setting, type of test and service providers. Multiple strategies are needed to reach the UNAIDS target of 95% of individuals knowing their HIV status. Expansion of community-based approaches, self-testing and HIV testing services in antenatal care will further improve the state of HIV testing in Sub-Saharan Africa.

Process evaluation of peer-to-peer delivery of HIV self-testing and sexual health information to support HIV prevention among youth in rural KwaZulu-Natal, South Africa: qualitative analysis

OBJECTIVE

Peer-to-peer (PTP) HIV self-testing (HIVST) distribution models can increase uptake of HIV testing and potentially create demand for HIV treatment and pre-exposure prophylaxis (PrEP). We describe the acceptability and experiences of young women and men participating in a cluster randomised trial of PTP HIVST distribution and antiretroviral/PrEP promotion in rural KwaZulu-Natal.

METHODS

Between March and September 2019, 24 pairs of trained peer navigators were randomised to two approaches to distribute HIVST packs (kits+HIV prevention information): incentivised-peer-networks where peer-age friends distributed packs within their social network for a small incentive, or direct distribution where peer navigators distributed HIVST packs directly. Standard-of-care peer navigators distributed information without HIVST kits. For the process evaluation, we conducted semi-structured interviews with purposively sampled young women (n=30) and men (n=15) aged 18-29 years from all arms. Qualitative data were transcribed, translated, coded manually and thematically analysed using an interpretivist approach.

RESULTS

Overall, PTP approaches were acceptable and valued by young people. Participants were comfortable sharing sexual health issues they would not share with adults. Coupled with HIVST, peer (friends) support facilitated HIV testing and solidarity for HIV status disclosure and treatment. However, some young people showed limited interest in other sexual health information provided. Some young people were wary of receiving health information from friends perceived as non-professionals while others avoided sharing personal issues with peer navigators from their community. Referral slips and youth-friendly clinics were facilitators to PrEP uptake. Family disapproval, limited information, daily pills and perceived risks were major barriers to PrEP uptake.

CONCLUSION

Both professional (peer navigators) and social network (friends) approaches were acceptable methods to receive HIVST and sexual health information. Doubts about the professionalism of friends and overly exclusive focus on HIVST information materials may in part explain why HIVST kits, without peer navigators support, did not create demand for PrEP.

Willingness to use and distribute HIV self-test kits to clients and partners: A qualitative analysis of female sex workers’ collective opinion and attitude in Côte d’Ivoire, Mali, and Senegal

Background:

In West Africa, female sex workers are at increased risk of HIV acquisition and transmission. HIV self-testing could be an effective tool to improve access to and frequency of HIV testing to female sex workers, their clients and partners. This article explores their perceptions regarding HIV self-testing use and the redistribution of HIV self-testing kits to their partners and clients.

Methods:

Embedded within ATLAS, a qualitative study was conducted in Côte-d’Ivoire, Mali, and Senegal in 2020. Nine focus group discussions were conducted. A thematic analysis was performed.

Results:

A total of 87 participants expressed both positive attitudes toward HIV self-testing and their willingness to use or reuse HIV self-testing. HIV self-testing was perceived to be discreet, confidential, and convenient. HIV self-testing provides autonomy from testing by providers and reduces stigma. Some perceived HIV self-testing as a valuable tool for testing their clients who are willing to offer a premium for condomless sex. While highlighting some potential issues, overall, female sex workers were optimistic about linkage to confirmatory testing following a reactive HIV self-testing. Female sex workers expressed positive attitudes toward secondary distribution to their partners and clients, although it depended on relationship types. They seemed more enthusiastic about secondary distribution to their regular/emotional partners and regular clients with whom they had difficulty using condoms, and whom they knew enough to discuss HIV self-testing. However, they expressed that it could be more difficult with casual clients; the duration of the interaction being too short to discuss HIV self-testing, and they fear violence and/or losing them.

Conclusion:

Overall, female sex workers have positive attitudes toward HIV self-testing use and are willing to redistribute to their regular partners and clients. However, they are reluctant to promote such use with their casual clients. HIV self-testing can improve access to HIV testing for female sex workers and the members of their sexual and social network.

Feasibility and acceptability of a peer-led HIV self-testing model among female sex workers in Malawi: a qualitative study

Objectives

HIV testing is the gateway to HIV prevention and care services. Female sex workers (FSW) may benefit from HIV self-testing (HIVST), which offers greater control and confidentiality than other approaches. However, FSW also have unique vulnerabilities, making it critical to understand their perspective of HIVST to best contextualise HIVST to their needs. This study explored feasibility and acceptability of providing oral fluid-based peer-led HIVST to FSW to inform tailored HIVST delivery approaches.

Design

Qualitative study.

Setting

Malawi.

Participants

Thirty-nine FSW who had obtained a HIVST kit and eight peer distributors.

Results

Peer distributors’ accounts suggested that peer-led HIVST is feasible. Overall, FSW spoke positively about peer-led HIVST and younger FSW preferred it to facility-based HIV testing. FSW highlighted both greater control of their testing experience and that HIVST could allow them to avoid discriminatory attitudes frequently experienced in public facilities. Some also felt that HIVST kits could enable them to establish the HIV status of their sexual partners, better informing their decisions about condomless sex. Despite overall acceptance of HIVST, a few expressed doubts in the procedure. Some FSW already aware of their HIV-positive status reported using HIVST. A few accounts suggested peer pressure to self-test predominantly from peer distributors.

Conclusions

This study enabled us to explore feasibility and acceptability of peer-led HIVST among FSW, as well as potential shortcomings of the HIV testing modality. Peer distributors are a welcome additional model. However, they should avoid distribution in actual venues. Programmes should ensure a range of testing options are available and expand peer’s representation. Study findings will be used to tailor the HIVST distribution model to ensure its enhanced uptake among key populations in general and FSW, specifically.

Feasibility of oral HIV self-testing in female sex workers in Gaborone, Botswana

BACKGROUND

Oral HIV self-testing (HIVST) may be useful for increasing testing in persons at elevated risk of acquiring HIV.

METHODS

We conducted a pilot study to evaluate the feasibility (defined by uptake) of HIVST among FSW in Gaborone, Botswana. FSW age 18 years and above were recruited through a non-governmental organization serving FSW. FSW with unknown or negative HIV status at screening performed HIVST in the study clinic following brief training. FSW testing HIV-negative were each given two test kits to take home: one kit to perform unassisted HIVST and another to share with others. Feasibility (use) of HIVST (and sharing of test kits with others) was assessed in these women at a study visit four months later.

RESULTS

Two hundred FSW were screened. Their average age was 34 years (range 18-59), and 115 (58%) were HIV-positive. Eighty-five (42%) tested HIV-negative at entry and were eligible to take part in the HIVST pilot study. All 85 (100%) agreed to take home HIVST kits. Sixty-nine (81%) of these 85 participants had a follow-up visit, 56 (81%) of whom reported performing HIVST at a mean of three and half months after the initial visit. All 56 participants who performed HIVST reported negative HIVST results. Fifty (73%) of the 69 participants who took HIVST kits home shared them with others. Of the 50 women sharing HIVST kits, 25 (50%) shared with their non-client partners, 15 with a family member, 8 with friends, and 3 with a client. One participant did not test herself but shared both her test kits. Most participants 53/56 (95%) found oral HIVST very easy to use whilst 3/56 (5%) felt it was fairly easy.

CONCLUSION

Oral HIVST is feasible among FSW in Gaborone, Botswana. The majority of FSW used the HIVST kits themselves and also shared extra HIVST kits with other individuals.

Does community-based distribution of HIV self-tests increase uptake of HIV testing? Results of pair-matched cluster randomised trial in Zambia

OBJECTIVES

Ending HIV by 2030 is a global priority. Achieving this requires alternative HIV testing strategies, such as HIV self-testing (HIVST) to reach all individuals with HIV testing services (HTS). We present the results of a trial evaluating the impact of community-based distribution of HIVST in community and facility settings on the uptake of HTS in rural and urban Zambia.

DESIGN

Pair-matched cluster randomised trial.

METHODS

In catchment areas of government health facilities, OraQuick HIVST kits were distributed by community-based distributors (CBDs) over 12 months in 2016-2017. Within matched pairs, clusters were randomised to receive the HIVST intervention or standard of care (SOC). Individuals aged ≥16 years were eligible for HIVST. Within communities, CBDs offered HIVST in high traffic areas, door to door and at healthcare facilities. The primary outcome was self-reported recent testing within the previous 12 months measured using a population-based survey.

RESULTS

In six intervention clusters (population 148 541), 60 CBDs distributed 65 585 HIVST kits. A recent test was reported by 66% (1622/2465) in the intervention arm compared with 60% (1456/2429) in SOC arm (adjusted risk ratio 1.08, 95% CI 0.94 to 1.24; p=0.15). Uptake of the HIVST intervention was low: 24% of respondents in the intervention arm (585/2493) used an HIVST kit in the previous 12 months. No social harms were identified during implementation.

CONCLUSION

Despite distributing a large number of HIVST kits, we found no evidence that this community-based HIVST distribution intervention increased HTS uptake. Other models of HIVST distribution, including secondary distribution and community-designed distribution models, provide alternative strategies to reach target populations.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT02793804).

Peer-led HIV care and the UNAIDS 90-90-90 treatment targets in Tigrai, Ethiopia: a cluster randomised trial and economic evaluation of teach-test-link-trace model (TTLT) trial protocol

INTRODUCTION

This study will evaluate the acceptability and effectiveness of a new intervention programme called teach-test-link-trace (TTLT) model in Tigrai, Ethiopia, where peer educators counsel about HIV (teach), perform house-to-house HIV testing (test) through pinprick HIV testing (H2H) or OraQuick HIV self-testing (HIVST), link HIV-positive patients to HIV care (link) and trace lost patients house-to-house (trace).

METHODS AND ANALYSIS

The four-arm cluster randomised trial will be conducted in five phases: Phase 1 will assess the acceptability of the TTLT model using a cross-sectional survey among adults aged 18 years irrespective of HIV status in 6909 households from 40 villages (kebeles). Phase 2 will assess effectiveness of the TTLT model through comparing intervention and control groups among HIV negative or unknown HIV status. The intervention groups will receive one of the three home-based interventions provided by peer educators: (1) demonstrate and distribute OraQuick HIV self-testing kits (HIVST), (2) perform pinprick HIV testing (H2H) and (3) offer a choice to either receive HIVST or H2H. The control group will receive the standard care in which nurses counsel and refer eligible household members to nearby health facilities to access existing HIV testing services. The primary outcomes of the interventions are proportion of individuals who know of their HIV status (first 90), link to HIV care and treatment (second 90) and meet virological suppression (third 90). We will perform process evaluation through qualitative interviews in phase 3, economic evaluation for cost-effectiveness analysis in phase 4 and a sustainability exit strategy using nominal group technique in phase 5. We will apply descriptive and inferential statistics for quantitative studies, and thematic framework analysis for qualitative studies.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Southern Adelaide Clinical Health Research Ethics Committee (SAC HREC), South Australia, and findings will be disseminated through publications, conference presentations, media release and policy briefs.

TRIAL REGISTRATION NUMBER

ACTRN12620000570987p.

Diagnostic Infectious Diseases Testing Outside Clinics: A Global Systematic Review and Meta-analysis

BACKGROUND

Most people around the world do not have access to facility-based diagnostic testing, and the gap in availability of diagnostic tests is a major public health challenge. Self-testing, self-sampling, and institutional testing outside conventional clinical settings are transforming infectious disease diagnostic testing in a wide range of low- and middle-income countries (LMICs). We examined the delivery models of infectious disease diagnostic testing outside clinics to assess the impact on test uptake and linkage to care.

METHODS

We conducted a systematic review and meta-analysis, searching 6 databases and including original research manuscripts comparing testing outside clinics with conventional testing. The main outcomes were test uptake and linkage to care, delivery models, and adverse outcomes. Data from studies with similar interventions and outcomes within thematic areas of interest were pooled, and the quality of evidence was assessed using GRADE. This study was registered in PROSPERO (CRD42019140828).We identified 10 386 de-duplicated citations, and 76 studies were included. Data from 18 studies were pooled in meta-analyses. Studies focused on HIV (48 studies), chlamydia (8 studies), and multiple diseases (20 studies). HIV self-testing increased test uptake compared with facility-based testing (9 studies: pooled odds ratio [OR], 2.59; 95% CI, 1.06-6.29; moderate quality). Self-sampling for sexually transmitted infections increased test uptake compared with facility-based testing (7 studies: pooled OR, 1.74; 95% CI, 0.97-3.12; moderate quality). Conclusions.  Testing outside of clinics increased test uptake without significant adverse outcomes. These testing approaches provide an opportunity to expand access and empower patients. Further implementation research, scale-up of effective service delivery models, and policies in LMIC settings are needed.

Willingness to Use HIV Self-Testing and Associated Factors Among Transgender Women in Malaysia

Background: While global research on the implementation of HIV self-testing (HIVST) has increased exponentially, few studies have assessed information on HIVST uptake factors (i.e., willingness, preferences) in transgender women (TW) and none in the Malaysian context. We therefore sought to assess willingness to use HIVST among this understudied key population. Methods: A cross-sectional survey was conducted among 361 HIV-negative Malaysian TW in 2017. Participants were recruited using flyers, announcements through social media, and direct referral from staff members of the community-based organizations serving the TW communities. Multivariable logistic regression was used to identify correlates of willingness to use HIVST. Results: Nearly half of the participants (47.6%) reported that they would be willing to use HIVST. Multivariable analysis showed that willingness to use HIVST was positively associated with having experienced sexual assault in childhood (adjusted odds ratio [aOR]=3.239, p<0.001), having ever used mobile phone or apps to find sex work clients (aOR=1.677, p=0.040), and having engaged in condomless sex in the past 6 months (aOR=1.886, p=0.018). In contrast, living in Kuala Lumpur (aOR=0.559, p=0.032), having higher number of sex work clients per day (aOR=0.927, p=0.004), and current depressive symptoms (aOR=0.576, p=0.026) were negatively associated with willingness to use HIVST. Conclusions: Findings in this study suggest that TW in our sample were moderately willing to use HIVST. Especially important here is the increased interest in HIVST among TW who are at higher risk for HIV infection. Overall, our findings underscore the need for additional research on how to most effectively implement HIVST for key populations, including TW, such that uptake and retention in regular HIV screening is sustained.

Few Aggressive or Violent Incidents are Associated with the Use of HIV Self-tests to Screen Sexual Partners Among Key Populations

Men who have sex with men and transgender women who had multiple sexual partners in the prior 3 months participated in ISUM, a randomized, controlled trial of self- and partner-testing in New York City and San Juan, PR. Only 2% of screened participants were ineligible to enroll due to anticipating they would find it very hard to avoid or handle violence. The intervention group received free rapid HIV self-test kits. During the trial, 114 (88%) of intervention participants who were assessed at follow-up used self-tests with at least one potential partner. Only 6% of participants who asked a partner in person to test reported that at least one of their partners got physically violent, some in the context of sex work. In total, 16 (2%) partners reacted violently. Post-trial, only one participant reported finding it very hard to handle violence, and none found it very hard to avoid potential violence.

The Effect of HIV Self-Testing Delivery Models on Female Sex Workers' Sexual Behaviors: A Randomized Controlled Trial in Urban Uganda

HIV self-testing increases recent and frequent HIV testing among female sex workers (FSWs) in urban Uganda. Using results from a randomized controlled trial, we aim to establish the effect of HIV self-testing delivery models on FSWs’ sexual behaviors in this setting. Clusters of one peer educator and eight participants were 1:1:1 randomized to: (1) direct provision of an HIV self-test, (2) provision of a coupon for facility collection of an HIV self-test, or (3) referral to standard-of-care HIV testing services. Sexual behaviors were self-reported at 1 and 4 months. From October to November 2016, 960 participants were enrolled and randomized. At 4 months, there were no statistically significant differences in participants’ sexual behaviors, including inconsistent condom use, across study arms. We do not find any changes in sexual risk-taking among FSWs in response to the delivery of HIV self-tests. Routine policies for HIV self-testing are likely a behaviorally safe component of comprehensive HIV prevention strategies.

The impact and cost-effectiveness of community-based HIV self-testing in sub-Saharan Africa: a health economic and modelling analysis

INTRODUCTION

The prevalence of undiagnosed HIV is declining in Africa, and various HIV testing approaches are finding lower positivity rates. In this context, the epidemiological impact and cost-effectiveness of community-based HIV self-testing (CB-HIVST) is unclear. We aimed to assess this in different sub-populations and across scenarios characterized by different adult HIV prevalence and antiretroviral treatment programmes in sub-Saharan Africa.

METHODS

The synthesis model was used to address this aim. Three sub-populations were considered for CB-HIVST: (i) women having transactional sex (WTS); (ii) young people (15 to 24 years); and (iii) adult men (25 to 49 years). We assumed uptake of CB-HIVST similar to that reported in epidemiological studies (base case), or assumed people use CB-HIVST only if exposed to risk (condomless sex) since last HIV test. We also considered a five-year time-limited CB-HIVST programme. Cost-effectiveness was defined by an incremental cost-effectiveness ratio (ICER; cost-per-disability-adjusted life-year (DALY) averted) below US$500 over a time horizon of 50 years. The efficiency of targeted CB-HIVST was evaluated using the number of additional tests per infection or death averted.

RESULTS

In the base case, targeting adult men with CB-HIVST offered the greatest impact, averting 1500 HIV infections and 520 deaths per year in the context of a simulated country with nine million adults, and impact could be enhanced by linkage to voluntary medical male circumcision (VMMC). However, the approach was only cost-effective if the programme was limited to five years or the undiagnosed prevalence was above 3%. CB-HIVST to WTS was the most cost-effective. The main drivers of cost-effectiveness were the cost of CB-HIVST and the prevalence of undiagnosed HIV. All other CB-HIVST scenarios had an ICER above US$500 per DALY averted.

CONCLUSIONS

CB-HIVST showed an important epidemiological impact. To maximize population health within a fixed budget, CB-HIVST needs to be targeted on the basis of the prevalence of undiagnosed HIV, sub-population and the overall costs of delivering this testing modality. Linkage to VMMC enhances its cost-effectiveness.

Diagnosis of Human Immunodeficiency Virus Infection

HIV diagnostics have played a central role in the remarkable progress in identifying, staging, initiating, and monitoring infected individuals on life-saving antiretroviral therapy. They are also useful in surveillance and outbreak responses, allowing for assessment of disease burden and identification of vulnerable populations and transmission "hot spots," thus enabling planning, appropriate interventions, and allocation of appropriate funding. HIV diagnostics are critical in achieving epidemic control and require a hybrid of conventional laboratory-based diagnostic tests and new technologies, including point-of-care (POC) testing, to expand coverage, increase access, and positively impact patient management. In this review, we provide (i) a historical perspective on the evolution of HIV diagnostics (serologic and molecular) and their interplay with WHO normative guidelines, (ii) a description of the role of conventional and POC testing within the tiered laboratory diagnostic network, (iii) information on the evaluations and selection of appropriate diagnostics, (iv) a description of the quality management systems needed to ensure reliability of testing, and (v) strategies to increase access while reducing the time to return results to patients. Maintaining the central role of HIV diagnostics in programs requires periodic monitoring and optimization with quality assurance in order to inform adjustments or alignment to achieve epidemic control.

Sources of social support and sexual behaviour advice for young adults in rural South Africa

Introduction

While young people in sub-Saharan Africa (SSA) are at greatest risk of HIV acquisition, uptake of HIV prevention interventions among them has been limited. Interventions delivered through social connections have changed behaviour in many settings, but not to date in SSA. There is little systematic evidence on whom young SSA adults turn to for advice. We therefore conducted an exploratory cross-sectional study from whom young rural South Africans received support and sexual behaviour-specific advice.

Methods

We asked 119 18–34  year olds in rural KwaZulu-Natal about the important people in their lives who provided emotional, informational, financial, physical, social or other support. We also asked whether they had discussed sex or HIV prevention with each contact named. We used descriptive statistics and logistic regression to analyse support and advice provision patterns.

Results

Respondents named 394 important contacts, each providing a mean of 1.7 types of support. Most contacts were relatives, same-gender friends or romantic partners. Relatives provided most informational, financial and physical support; friends and partners more social support and sexual advice. Respondents reported discussing sexual matters with 60% of contacts. Sources of support changed with age, from friends and parents, towards siblings and partners.

Discussion

Sexual health interventions for young adults in rural South Africa may be able to harness friend and same-generation kin social ties through which sex is already discussed, and parental ties through which other forms of support are transmitted. The gender-segregated nature of social connections may require separate interventions for men and women.