Willingness to use HIV self-test kits and willingness to pay among urban antenatal clients in Cote d'Ivoire and Tanzania: a cross-sectional study

Acceptability, usability, and willingness to pay for HIV self-test kits distributed through community-based, PLHIV network-led and private practitioners models in India: Results from the STAR III Initiative

INTRODUCTION

HIV self-testing (HIVST) has been shown to increase the uptake of HIV testing and help achieve the UNAIDS 95-95-95 targets. This study assessed the acceptability, usability (ease of use and result interpretation) and the willingness to pay for HIVST kits distributed through three distribution models, namely the community-based, PLHIV network-led and private practitioners models, in India.

METHODS

This cross-sectional study was implemented across 14 states in India between September 2021 and June 2022. All participants could choose between blood-based or oral-fluid-based test kits. Participants were shown a test-kit usage demonstration video, and pre- and post-test counselling was provided for all. Participants were followed-up after testing, and if reported reactive, were further supported for linkage to confirmatory testing and antiretroviral therapy (ART) initiation.

RESULTS

Among the 90,605 participants found eligible, 88,080 (97%) accepted an HIVST kit. Among the 87,976 who reported using an HIVST kit, 45,207 (51%) preferred a blood-based kit, and 42,120 (48%) reported testing for the first time. For future testing, 77,064 (88%) reported preferring HIVST over other HIV testing methods. Among those who used the kit, 83,308 (95%) found the kit easy to use, and 83,237 (95%) reported that the test results were easy to interpret. Among those who preferred HIVST for future use, 52,136 (69%) were willing to pay for the kit, with 35,854 (69%) of those willing to pay less than US$ 1.20. Only one instance of social harm was reported, with a participant reporting suicidal tendencies due to discord with their partner. Out of 328 participants (0.4%) who tested reactive with HIVST, 291 (89%) were linked to confirmatory testing; of these, 254 were confirmed HIV positive, and 216 (85%) successfully initiated ART.

CONCLUSIONS

Overall, we report that nearly all participants were willing to accept HIVST, found the test kits easy to use and interpret, and about two-thirds were willing to pay for HIVST. Given the high levels of acceptance and the ability to reach a large proportion of first-time testers, HIVST in India could contribute to achieving the UNAIDS first 95 and ending the HIV epidemic.

Impact of voluntary testing on infectious disease epidemiology: A game theoretic approach

The World Health Organization recommends test-and-treat interventions to curb and even eliminate epidemics of HIV, viral hepatitis, and sexually transmitted infections (e.g., chlamydia, gonorrhea, syphilis and trichomoniasis). Epidemic models show these goals are achievable, provided the participation of individuals in test-and-treat interventions is sufficiently high. We combine epidemic models and game theoretic models to describe individual's decisions to get tested for infectious diseases within certain epidemiological contexts, and, implicitly, their voluntary participation to test-and-treat interventions. We develop three hybrid models, to discuss interventions against HIV, HCV, and sexually transmitted infections, and the potential behavioral response from the target population. Our findings are similar across diseases. Particularly, individuals use three distinct behavioral patterns relative to testing, based on their perceived costs for testing, besides the payoff for discovering their disease status. Firstly, if the cost of testing is too high, then individuals refrain from voluntary testing and get tested only if they are symptomatic. Secondly, if the cost is moderate, some individuals will test voluntarily, starting treatment if needed. Hence, the spread of the disease declines and the disease epidemiology is mitigated. Thirdly, the most beneficial testing behavior takes place as individuals perceive a per-test payoff that surpasses a certain threshold, every time they get tested. Consequently, individuals achieve high voluntary testing rates, which may result in the elimination of the epidemic, albeit on temporary basis. Trials and studies have attained different levels of participation and testing rates. To increase testing rates, they should provide each eligible individual with a payoff, above a given threshold, each time the individual tests voluntarily.

HIV pre-exposure prophylaxis initiation, persistence, and adherence during pregnancy through the postpartum period

OBJECTIVE

We evaluated pre-exposure prophylaxis (PrEP) initiation, persistence, and adherence measured via tenofovir-diphosphate (TFV-DP) concentrations in dried blood spots (DBS) among women offered PrEP during pregnancy.

METHODS

We prospectively analyzed data from participants in the PrIMA Study (NCT03070600) who were offered PrEP during the second trimester and followed through 9 months postpartum. At follow-up visits (monthly in pregnancy; 6 weeks, 6 months, 9 months postpartum), self-reported PrEP use was assessed, and DBS were collected for quantifying TFV-DP concentrations.

RESULTS

In total, 2949 participants were included in the analysis. At enrollment, median age was 24 years [interquartile range IQR) 21-29], gestational age 24 weeks (IQR 20-28), and 4% had a known partner living with HIV. Overall, 405 (14%) participants initiated PrEP in pregnancy with higher frequency among those with risk factors for HIV acquisition, including >2 lifetime sexual partners, syphilis during pregnancy, forced sex, and intimate partner violence ( P  < 0.05). At 9 months postpartum, 58% of PrEP initiators persisted with PrEP use, of which 54% self-reported not missing any PrEP pills in the last 30 days. Among DBS randomly selected from visits where participants persisted with PrEP ( n  = 427), 50% had quantifiable TFV-DP. Quantifiable TFV-DP was twice as likely in pregnancy than postpartum [adjusted risk ratio (aRR) = 1.90, 95% confidence interval (CI) 1.40-2.57, P  < 0.001]. Having a partner known to be living with HIV was the strongest predictor of PrEP initiation, persistence, and quantifiable TFV-DP ( P  < 0.001).

CONCLUSIONS

PrEP persistence and adherence waned postpartum, though over half of PrEP initiators persisted through 9-months postpartum. Interventions should prioritize increasing knowledge of partner HIV status and sustaining adherence in the postpartum period.

Assessing preferences for HIV pre-exposure prophylaxis (PrEP) delivery services via online pharmacies in Kenya: protocol for a discrete choice experiment

INTRODUCTION

Pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV acquisition, but coverage remains low in high prevalence settings. Initiating and continuing PrEP via online pharmacies is a promising strategy to expand PrEP uptake but little is known about user preferences for this strategy. We describe methods for a discrete choice experiment (DCE) to assess preferences for PrEP delivery from an online pharmacy.

METHODS AND ANALYSIS

This cross-sectional study is conducted in Nairobi, Kenya, in partnership with MYDAWA, a private online pharmacy retailer with a planned sample size of >400 participants. Eligibility criteria are: ≥18 years, not known HIV-positive and interested in PrEP. Initial DCE attributes and levels were developed via literature review and stakeholder meetings. We conducted cognitive interviews to assess participant understanding of the DCE survey and refined the design. The final DCE used a D-efficient design and contained four attributes: PrEP eligibility assessment, HIV test type, clinical consultation type and user support options. Participants are presented with eight scenarios consisting of two hypothetical PrEP delivery services. The survey was piloted among 20 participants before being advertised on the MYDAWA website on pages displaying products indicating HIV risk (eg, HIV self-test kits). Interested participants call a study number and those screened eligible meet a research assistant in a convenient location to complete the survey. The DCE will be analysed using a conditional logit model to assess average preferences and mixed logit and latent class models to evaluate preference heterogeneity among subgroups.

ETHICS AND DISSEMINATION

This study was approved by the University of Washington Human Research Ethics Committee (STUDY00014011), the Kenya Medical Research Institute, Nairobi County (EOP/NMS/HS/128) and the Scientific and Ethics Review Unit in Kenya (KEMRI/RES/7/3/1). Participation in the DCE is voluntary and subject to completion of an electronic informed consent. Findings will be shared at international conferences and peer-reviewed publications, and via engagement meetings with stakeholders.

'If there is joy… I think it can work well': a qualitative study investigating relationship factors impacting HIV self-testing acceptability among pregnant women and male partners in Uganda

OBJECTIVES

Secondary distribution of HIV self-test (HIVST) kits from pregnant women attending antenatal care (ANC) to their male partners is shown to increase HIV couples testing and disclosure, and is being scaled up in sub-Saharan Africa. Understanding couples-level barriers and facilitators influencing HIVST uptake is critical to designing strategies to optimise intervention coverage.

DESIGN

To investigate these couples-level barriers and facilitiators, we conducted focus group discussions and in-depth interviews. Transcripts were analysed thematically and the interdependence model of communal coping and health behaviour change was adapted to explore factors impacting HIVST acceptability.

SETTING

We recruited pregnant women attending two public ANC clinics in Kampala, Uganda, and male partners of pregnant women between April 2019 and February 2020.

PARTICIPANTS

We conducted gender-stratified focus group discussions (N=14) and in-depth interviews (N=10) with pregnant women with and without HIV attending ANC, and male partners of pregnant women (N=122 participants).

INTERVENTION

We evaluated pregnant women's and male partners' perceptions of HIVST secondary distribution in Uganda, leveraging the interdependence model of communal coping and health behaviour change.

PRIMARY AND SECONDARY OUTCOME MEASURES

Key areas of focus included HIVST interest and acceptability, perspectives on HIV status disclosure to partners and gender roles.

RESULTS

Participants felt that predisposing factors, including trust, communication, fear of partner and infidelity, would influence women's decisions to deliver HIVST kits to partners, and subsequent communal coping behaviours such as couples HIV testing and disclosure. Pregnancy was described as a critical motivator for men's HIVST uptake, while HIV status of pregnant women was influential in couples' communal coping and health-enhancing behaviours. Generally, participants felt HIV-negative women would be more likely to deliver HIVST, while women with HIV would be more hesitant due to concerns about discovery of serodifference and relationship dissolution. Participants stressed the importance of counsellor availability throughout the process including guidance on how women should approach their partners regarding HIVST and post-test support in case of a positive test.

CONCLUSIONS

HIV-negative women in relationships with positive predisposing factors may be most likely to deliver HIVST and leverage interdependent coping behaviours. Women with HIV or those in relationships with negative predisposing factors may benefit from targeted counselling and disclosure support before and after HIVST kit distribution. Results can help support policy guidelines for HIVST kit distribution.

Acceptability, feasibility, and accuracy of blood-based HIV self-testing: A cross-sectional study in Ho Chi Minh City, Vietnam

HIV self-testing (HIVST) is an effective approach to increase testing uptake. While oral fluid-based HIVST has been rapidly scaled, use of blood-based HIVST remains limited. We evaluated the acceptability, feasibility, and accuracy of blood-based HIVST among lay users in Ho Chi Minh City (HCMC), Vietnam. We conducted a cross-sectional study among HIV testing clients at the HCMC Pasteur Institute from March 2019 to October 2020. Participants received one HIVST kit and performed the test in front of an observer. The observer used product-specific questionnaires to collect information on the HIVST process, test results, experiences. The participants' interpretations of HIVST results were compared to health staff's interpretations and gold standard laboratory EIA reference tests. Of 2,399 participants who accepted HIVST, 64.7% were men, 62.1% aged 25-49 years, 53.5% had a higher education level, 41.4% were employed, and 35.6% were first-time testers. The vast majority (94.4%) desired to use the test in the future, and 93.9% reported willingness to recommend the test. The majority (90.8%) of participants successfully completed the self-test. One factor associated with successful completion was higher education level (aOR = 1.85; 95% CI: 1.32-2.61); while participants self-testing with SURE CHECK (aOR = 0.21; 95% CI: 0.12-0.37), INSTI (aOR = 0.23; 95% CI: 0.13-0.39), and BioSURE (aOR = 0.29; 95% CI: 0.17-0.51) or being unemployed, retired, or doing housework (aOR = 0.45; 95% CI: 0.25-0.82) were less likely to perform the test successfully. Agreement of positive and negative HIVST results as interpreted by participants and health staff was high (98.1% and 99.9%, respectively). Sensitivity and specificity of the evaluated HIVST were 96.43% (95% CI: 93.62-99.23) and 99.9% (95% CI: 99.75-100), respectively. Our findings confirm that blood-based HIVST is highly acceptable, feasible, and accurate. This evidence informs scale-up of HIVST to increase uptake of essential HIV prevention and treatment services.

Effects of a multimedia campaign on HIV self-testing and PrEP outcomes among young people in South Africa: a mixed-methods impact evaluation of 'MTV Shuga Down South'

Introduction

Innovative HIV technologies can help to reduce HIV incidence, yet uptake of such tools is relatively low among young people. To create awareness and demand among adolescents and young adults, a new campaign of the pan-African MTV Shuga series (‘Down South 2’; DS2), featured storylines and messages about HIV self-testing (HIVST) and pre-exposure prophylaxis (PrEP) through television, radio and accompanying multimedia activities in 2019–2020.

Methods

We conducted a mixed-methods evaluation of the new MTV Shuga series among 15–24 years old in Eastern Cape, South Africa, in 2020. Quantitative and qualitative methods were used to investigate complementary evaluations questions, namely, whether and how the DS2 campaign works. A web-based survey, promoted via social media platforms of schools, universities and communities, assessed exposure to MTV Shuga and knowledge of HIV status; secondary outcomes included awareness and uptake of HIVST and PrEP. We used multivariable logistic regression to estimate associations between exposure to DS2 and each outcome, adjusting for sociodemographic factors, media assets and exposure to other media campaigns. An embedded qualitative evaluation explored mechanisms of DS2’s impact through deductive and inductive thematic analysis of in-depth individual and group interviews.

Results

Among 3431 online survey participants, 43% had engaged with MTV Shuga and 24% with DS2 specifically. Knowledge of HIV status was higher among those exposed to DS2 (71%) vs those who were not (39%; adjusted OR=2.26 (95% CI 1.78 to 2.87)). Exposure was also associated with increased awareness of HIVST (60% vs 28%; aOR=1.99 (1.61 to 2.47)) and use of HIVST (29% vs 10%; aOR=2.49 (1.95 to 3.19)). One-third of respondents were aware of PrEP, with higher proportions among those exposed versus non-exposed to DS2 (52% vs 27%; aOR=1.90 (1.53 to 2.35)). Qualitative insights identified mechanisms by which DS2 increased awareness, confidence and motivation to use HIVST and PrEP, but had less influence on service access.

Conclusions

We found evidence consistent with a positive causal impact of the MTV Shuga DS2 campaign on HIV prevention outcomes among young people in a high-prevalence setting. As diverse testing and PrEP technologies become accessible, an immersive edutainment campaign can help to expand HIV prevention choices and close age and gender gaps in HIV testing and prevention goals.

Perspectives of Policymakers on the Introduction and Scale-Up of HIV Self-Testing and Implication for National HIV Programming in Ghana

Background: HIV self-testing (HIVST) has the potential to greatly increase HIV testing uptake, particularly among key populations (KPs) at higher risk for HIV. Studies have shown high acceptability and feasibility of HIVST among various target populations globally. However, less is known about the perspectives of policymakers, who are critical to the success of HIVST implementation. Their views on barriers to the introduction and scale-up of self-testing are critical to understand in order for HIVST to become part of the national HIV guidelines. We sought to understand policymakers' perspectives of challenges and facilitators to the introduction of HIVST at the client and structural levels.

Method: Key informant interviews (KIIs) were conducted with national and regional level policymakers involved in the HIV response. Twenty policymakers were purposively selected from Greater Accra (capital) and Brong-Ahafo (outlying) regions. Qualitative content analysis was used to arrive at the results after the verbatim transcripts were coded.

Results: Client-level challenges included lack of pre-test counseling, the need for confirmatory testing if reactive, potential for poor linkage to care and treatment, and client-level facilitator from policy makers' perspectives included increase testing modality that would increase testing uptake. Structural-level challenges mentioned by policymakers were lack of a national policy and implementation guidelines on HIVST, cost of HIVST kits, supply chain management of HIVST commodities, data monitoring and reporting of positive cases. The structural-level appeal of HIVST to policymakers were the reduced burden on health system and HIVST's contribution to achieving testing targets. Despite the challenges mentioned, policymakers unanimously favored and called for the introduction of HIVST in Ghana.

Conclusions: Findings indicate that a non-conventional HIV testing strategy such as HIVST is highly acceptable to policymakers. However, successful introduction of HIVST hinges on having national guidelines in place and stakeholder consultations to address various individual and structural -level implementation issues.

Implementation outcomes of HIV self-testing in low- and middle- income countries: A scoping review

INTRODUCTION

HIV self-testing (HIV-ST) is an effective means of improving HIV testing rates. Low- and middle-income countries (LMIC) are taking steps to include HIV-ST into their national HIV/AIDS programs but very few reviews have focused on implementation in LMIC. We performed a scoping review to describe and synthesize existing literature on implementation outcomes of HIV-ST in LMIC.

METHODS

We conducted a systematic search of Medline, Embase, Global Health, Web of Science, and Scopus, supplemented by searches in HIVST.org and other grey literature databases (done 23 September 2020) and included articles if they reported at least one of the following eight implementation outcomes: acceptability, appropriateness, adoption, feasibility, fidelity, cost, penetration, or sustainability. Both quantitative and qualitative results were extracted and synthesized in a narrative manner.

RESULTS AND DISCUSSION

Most (75%) of the 206 included articles focused on implementation in Africa. HIV-ST was found to be acceptable and appropriate, perceived to be convenient and better at maintaining confidentiality than standard testing. The lack of counselling and linkage to care, however, was concerning to stakeholders. Peer and online distribution were found to be effective in improving adoption. The high occurrence of user errors was a common feasibility issue reported by studies, although, diagnostic accuracy remained high. HIV-ST was associated with higher program costs but can still be cost-effective if kit prices remain low and HIV detection improves. Implementation fidelity was not always reported and there were very few studies on, penetration, and sustainability.

CONCLUSIONS

Evidence supports the acceptability, appropriateness, and feasibility of HIV-ST in the LMIC context. Costs and user error rates are threats to successful implementation. Future research should address equity through measuring penetration and potential barriers to sustainability including distribution, cost, scale-up, and safety.