Acceptability and feasibility of using digital vending machines to deliver HIV self-tests to men who have sex with men

Qualitative evaluation of digital vending machines to improve access to STI and HIV testing in South West England: using a Person-Based Approach

OBJECTIVES

To report the development, implementation, acceptability and feasibility of vending machines offering HIV and sexually transmitted infection (STI) testing kits.

DESIGN

A qualitative study using the Person-Based Approach with patient and public involvement workshops and stakeholder involvement and interviews with machine users, sexual health service (SHS) staff, venue staff and local authority sexual health commissioners. Transcripts were analysed thematically.

SETTING

Bristol, North Somerset and South Gloucestershire (BNSSG).

PARTICIPANTS

15 machine users, 5 SHS staff, 3 venue staff and 3 local authority commissioners.

INTERVENTION

Four vending machines dispensing free HIV self-testing and STI self-sampling kits in publicly accessible venues across BNSSG were introduced to increase access to testing for groups at higher risk of HIV and STI infection who are less likely to access SHS clinic testing services (young people, people from black communities, and gay, bisexual and other men who have sex with men).

RESULTS

Machine users reported the service was convenient, easy to use and accessible; however, concerns regarding privacy related to machine placement within the venues and issues of maintenance were raised. Promotional material was inclusive and informative; however, awareness of the service through the promotional campaign was limited. Vending machines were acceptable to venue staff once clear processes for their management were agreed with the SHS. SHS staff identified challenges with the implementation of the service related to the limited involvement of the whole SHS team in the planning and development.

CONCLUSIONS

The codeveloped vending machine service was acceptable, addressing some barriers to testing. Resources and protected staff time are needed to support greater involvement of the whole SHS team and service providers in venues. Adopting a similarly robust coproduction approach to the implementation of the machines could avoid the challenges reported. The placement of the machines to assure users privacy and repeated, targeted promotion could encourage service use among target groups.

Acceptability of digital vending machines to access STI and HIV tests in two UK cities

OBJECTIVES

Prompt HIV and STI diagnosis and treatment is a public health priority and relies on accessible testing. Technology-based approaches to distribute test kits have the potential to increase access to testing. We evaluated the acceptability and uptake of vending machines in publicly available settings in Brighton and Hove (BH) and Bristol, North Somerset and South Gloucestershire (BNSSG), to distribute HIV rapid self-test and STI self-sample kits.

METHODS

Seven machines were installed in BH and four in BNSSG. User characteristics, proportion of kits returned and test results, taken from the machine database and clinic records, combined with online questionnaires completed by self-recruited users and analysed using Stata and SPSS.

RESULTS

2536 kits were dispensed over 12 months (April 2022 to March 2023). The STI self-sample kits were most popular (74% of vends). 78% of kits dispensed were among users aged 16-35 years and 56% identified as male. 68% and 59% of users had either not tested in the last 12 months or never tested for HIV and STIs, respectively. 51% of STI kits were returned via post, lower than the local online service (65%). 208 users completed questionnaires. Convenience, desire for instant access and increased confidentiality were the most common reasons for using machines. 92% of respondents thought the machines were user-friendly and 97% would recommend the service. Concerns about safety and privacy while using the machine were reported by 42% and 66% of respondents.

CONCLUSIONS

This study demonstrates that vending machines are an acceptable and effective means of accessing infrequent or never testers in the general population and can act as a horizontal intervention to tackle HIV and STIs. Research is needed to understand optimal machine locations to assure privacy and safety along with the long-term impact on sexual health services.

Counseling Supporting HIV Self-Testing and Linkage to Care Among Men Who Have Sex With Men: Systematic Review and Meta-Analysis

BACKGROUND

Counseling supporting HIV self-testing (HIVST) is helpful in facilitating linkage to care and promoting behavior changes among men who have sex with men (MSM). Different levels of counseling support for MSM HIVST users may lead to variance in the linkage to care.

OBJECTIVE

This study aims to synthesize evidence on counseling supporting MSM HIVST users and to conduct a meta-analysis to quantify the proportion of MSM HIVST users who were linked to care.

METHODS

A systematic search was conducted using predefined eligibility criteria and relevant keywords to retrieve studies from the MEDLINE, Global Health, Web of Science, Embase, APA PsycINFO, and Scopus databases. This search encompassed papers and preprints published between July 3, 2012, and June 30, 2022. Studies were eligible if they reported counseling supporting HIVST or quantitative outcomes for linkage to care among MSM and were published in English. The screening process and data extraction followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The quality of the included studies was assessed by the National Institutes of Health quality assessment tool. Data were extracted using random effects models to combine the proportion of HIVST users who were linked to care. Subgroup analyses and metaregression were conducted to assess whether linkage to care varied according to study characteristics. All analyses were performed with R (version 4.2.1; R Foundation for Statistical Computing) using the metafor package.

RESULTS

A total of 55 studies published between 2014 and 2021, including 43 observational studies and 12 randomized controlled trials, were identified. Among these studies, 50 (91%) provided active counseling support and 5 (9%) provided passive counseling support. In studies providing active counseling support, most MSM HIVST users were linked to various forms of care, including reporting test results (97.2%, 95% CI 74.3%-99.8%), laboratory confirmation (92.6%, 95% CI 86.1%-96.2%), antiretroviral therapy initiation (90.8%, 95% CI 86.7%-93.7%), and referral to physicians (96.3%, 95% CI 85%-99.2%). In studies providing passive counseling support, fewer MSM HIVST users were linked to laboratory confirmation (78.7%, 95% CI 17.8%-98.4%), antiretroviral therapy initiation (79.1%, 95% CI 48.8%-93.7%), and referral to physicians (79.1%, 95% CI 0%-100%). Multivariate metaregression indicated that a higher number of essential counseling components, a smaller sample size (<300), and the use of mobile health technology to deliver counseling support were associated with better linkage to care. The quality of the studies varied from fair to good with a low to high risk of bias.

CONCLUSIONS

Proactively providing counseling support for all users, involving a higher number of essential components in the counseling support, and using mobile health technology could increase the linkage to care among MSM HIVST users.

TRIAL REGISTRATION

PROSPERO CRD42022346247; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=346247.

Trends and associated factors in HIV testing among heterosexual men and women in Melbourne, Australia, 2011-2020

BACKGROUND

Despite the increase in the proportion of HIV notifications attributed to heterosexuals in Australia, little is known about their HIV testing behaviours. We investigated the trends and factors associated with HIV testing behaviours among heterosexuals.

METHODS

We analysed the trend and proportion of heterosexuals attending the centre for the first time between 2011 and 2020, who had ever tested and tested for HIV in the past 12months and the median number of months since their last HIV test. We identified factors associated with HIV testing behaviours using univariable and multivariable logistic regressions.

RESULTS

Of the 78652 heterosexuals included, 53.1% were men and 46.9% were women. Overall, the proportion of heterosexuals who had ever tested for HIV was 40.8%, with a declining testing trend from 40.2% in 2011 to 36.5% in 2020 (P trend <0.001). Overall, the proportion of heterosexuals tested for HIV in the past 12months was 15.7%, with no significant change from 15.3% in 2011 to 14.7% in 2020 (P trend =0.489). The median number of months since the last HIV test decreased from 18.0 (IQR 6.9-37.3) in 2011 to 15.0 (IQR 6.4-32.5) in 2020 (P trend <0.001). Individuals who had condomless sex with casual partners (aOR 0.92, 95% CI 0.88-0.96) and who were diagnosed with a sexually transmitted infection (aOR 0.88, 95% CI 0.84-0.93) were less likely to have ever tested for HIV.

CONCLUSIONS

HIV testing was low among heterosexuals, and individuals who engaged in condomless sex and had another sexually transmitted infection were less likely to be tested. To reduce HIV transmission, strategies to improve HIV testing among heterosexuals are needed.

Strategies to increase HIV testing among men who have sex with men and transgender women: an integrative review

BACKGROUND

Men who have sex with men (MSM) and transgender women (TGW) are disproportionately affected by HIV, with much higher incidence and prevalence rates than in the general population in different countries. There are several barriers to testing among MSM and TGW, such as low risk perception, anticipation of HIV-related stigma, discrimination of sexual orientation, in addition to difficulties related to care and access to health services. Therefore, analyzing the available evidence of the effectiveness of strategies for scaling up HIV testing among key populations is essential to point out potential knowledge gaps which may need to be addressed and develop public health policies to promote testing and early diagnosis of HIV infection.

METHODS

An integrative review was carried out to evaluate strategies for scaling up HIV testing in these populations. Search strategy was performed on eight electronic databases, without language restriction. We included clinical trials, quasi-experimental studies, and non-randomized studies. Study selection and data extraction were both performed independently by pairs and disagreements were solved by a third revisor. The screening of the studies was carried out through the selection of titles/abstracts and the reading of the full texts of the pre-selected studies based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Data extraction was performed using a structured form.

RESULTS

Thirty-seven publications referring to 35 studies were included, mostly being carried out in the United States of America and Australia. No studies were found evaluating disaggregated data on TGW. The studies were grouped into four types of intervention strategies: self-test distribution system (n = 10), organization of health services (n = 9), peer education (n = 6), and social marketing campaign (n = 10). Strategies that focused on the first three groups, combined or not, were more effective in increasing HIV testing among MSM.

CONCLUSIONS

Considering the diversity of interventions and the methodological heterogeneity of the included studies, strategies especially involving self-test distribution systems, associated with new information and communication technologies, should be evaluated in different communities and social contexts. Research evaluating specific studies on TGW population is still needed.

Increasing access to HIV testing for men who have sex with men in Japan using digital vending machine technology

Background: In Japan, most new HIV cases are reported amongst men who have sex with men (MSM); thus, there is an urgent need for further widespread testing of MSM. The use of Digital Vending Machines (DVM) in the UK offering HIV test kits targeting MSM show promising results. Digital Vending Machines could be useful to promote and increase the uptake of testing in Japan, although no studies have yet been conducted. We aimed to assess the acceptability and feasibility of distributing HIV test kits using DVMs exploring needs and concerns as well as preferred types of test kits and locations.

Methods: Fifty-four individuals participated in workshops and meetings with a further 224 MSM answering a quantitative survey assessing HIV testing and prevention needs.

Results: Amongst MSM who had never been tested, 73% showed willingness to purchase tests from DVMs. Responses were broadly positive about DVMs but there were concerns regarding being seen receiving test kits from the machines and linkage to confirmatory testing and appropriate care.

Conclusions: Using DVMs to distribute HIV test kits in Japan was found to be both acceptable and feasible and may have the potential to increase access to testing for MSM. Future large-scale evaluation studies are required.

Law, human rights and gender in practice: an analysis of lessons from implementation of self-care interventions for sexual and reproductive health

Self-care interventions for health are becoming increasingly available, and among the preferred options, including during the COVID-19 pandemic. This research assessed the extent of attention to laws and policies, human rights and gender in the implementation of self-care interventions for sexual and reproductive health (SRH), to identify where additional efforts to ensure an enabling environment for their use and uptake will be useful. A literature review of relevant studies published between 2010 and 2020 was conducted using PubMed, Scopus and Web of Science. Relevant data were systematically abstracted from 61 articles. In March–April 2021, semi-structured interviews were conducted with 10 key informants, selected for their experience implementing self-care interventions for SRH, and thematically analysed. Laws and policies, rights and gender are not being systematically addressed in the implementation of self-care interventions for SRH. Within countries, there is varied attention to the enabling environment including the acceptability of interventions, privacy, informed consent and gender concerns as they impact both access and use of specific self-care interventions, while other legal considerations appear to have been under-prioritised. Operational guidance is needed to develop and implement supportive laws and policies, as well as to ensure the incorporation of rights and gender concerns in implementing self-care interventions for SRH.

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

Background

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

Methods

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

Results

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

Conclusion

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

HIV self-testing with digital supports as the new paradigm: A systematic review of global evidence (2010-2021)

BACKGROUND

HIV self-testing (HIVST) is recommended by the WHO as an innovative strategy to reach UNAIDS targets to end HIV by 2030. HIVST with digital supports is defined as the use of digital interventions (e.g., website-based, social media, mobile HIVST applications (apps), text messaging (SMS), digital vending machines (digital VMs)) to improve the efficiency and impact of HIVST. HIVST deployment and integration in health services is an emerging priority. We conducted a systematic review aiming to close the gap in evidence that summarizes the impact of digitally supported HIVST and to inform policy recommendations.

METHODS

We searched PubMed and Embase for articles and abstracts on HIVST with digital supports published during the period February 1st, 2010 to June 15th, 2021, following Cochrane guidelines and PRISMA methodology. We assessed feasibility, acceptability, preference, and impact outcomes across all populations and study designs. Metrics reported were willingness to use HIVST, preferences for HIVST delivery, proportion of first-time testers, HIVST uptake, HIVST kit return rate, and linkage to care. Heterogeneity of the interventions and reported metrics precluded us from conducting a meta-analysis.

FINDINGS

46 studies were narratively synthesized, of which 72% were observational and 28% were RCTs. Half of all studies (54%, 25/46) assessed web-based innovations (e.g., study websites, videos, chatbots), followed by social media (26%, 12/46), HIVST-specific apps (7%, 3/46), SMS (9%, 4/46), and digital VMs (4%, 2/46). Web-based innovations were found to be acceptable (77-97%), preferred over in-person and hybrid options by more first-time testers (47-48%), highly feasible (93-95%), and were overall effective in supporting linkage to care (53-100%). Social media and app-based innovations also had high acceptability (87-95%) and linkage to care proportions (80-100%). SMS innovations increased kit return rates (54-94%) and HIVST uptake among hard-to-reach groups. Finally, digital VMs were highly acceptable (54-93%), and HIVST uptake was six times greater when using digital VMs compared to distribution by community workers.

INTERPRETATION

HIVST with digital supports was deemed feasible, acceptable, preferable, and was shown to increase uptake, engage first-time testers and hard-to-reach populations, and successfully link participants to treatment. Findings pave the way for greater use of HIVST interventions with digital supports globally.

Technology-Delivered Intervention Strategies to Bolster HIV Testing

Since the beginning of the HIV epidemic, there have been more than 75 million cases. Currently, there about 1.2 million living with HIV in the USA. Despite current testing recommendations, test rates continue to be suboptimal. Investigators have studied the use of digital technology to promote HIV testing, especially among high-risk populations. PURPOSE OF REVIEW: This non-systematic review provides an overview of the scientific research between 2015 and 2020 focused on the use of digital technology to bolster HIV testing and suggests novel technologies for exploration. RECENT FINDINGS: A total of 40 studies were included in the review that span a wide range of available technology. Studies effectively increased HIV testing among study participants. Generally, participants in the intervention/exposure groups had significantly higher rates of HIV test uptake compared to participants in the comparison groups at study follow-up. For a variety of reasons (e.g., differences in ways the technologies were used and study design), no digital tool clearly performed better than others, but each have the capacity to increase outreach and self-testing. An exploration of the potential use of nascent technologies is also discussed, as well as the authors' experiences using a number of these technologies in our research.

#Testathome: Implementing 2 Phases of a HIV Self-Testing Program Through Community-Based Organization Partnerships in New York City

BACKGROUND

Access to human immnodeficiency virus (HIV) testing in New York City (NYC) has increased, but disparities in testing rates still exist among most communities impacted by HIV. HIV self-tests (HIVSTs) present an opportunity to address testing barriers, but HIV-affected communities experience difficulties accessing HIVSTs, including lack of awareness and cost. To support increased access to HIVSTs, the NYC Health Department launched a partnership with select organizations to pilot distribution of free HIVSTs in 2 phases among priority populations across NYC.

METHODS

Organizations that were diverse in their missions, experiences, capacities and populations served were recruited through a formal application process. The program initially launched with 10 organization partners (phase 1); as the pilot continued, partners identified necessary revisions to the program and launched a second phase in year 2. Both phases included outreach to NYC priority populations, HIVST distribution/redemption, and a follow-up survey.

RESULTS

From March 2017 to August 2019, organizations distributed 75 HIVSTs during phase 1 and 252 during phase 2. All intended priority populations were reached, notably, those who had never tested before: 35% in phase 1 and 12% in phase 2. Over half of the follow-up survey respondents reported testing sooner. Respondents reported liking the HIVST because it did not require a visit to a clinic (84%) and preferred an HIVST to testing in a clinic (92%).

CONCLUSIONS

Through 2 phases of implementation, this innovative partnership was able to reach and offer HIVSTs to priority populations across NYC. This program supports the feasibility of distributing HIVSTs through close partnerships with diverse organizations.

Acceptability of HIV self-testing is low among men who have sex with men who have not tested for HIV: a study with respondent-driven sampling in Brazil

BACKGROUND

Brazil has many people living with HIV (PLWH) who are unaware of their serostatus. The public health system has recently added HIV self-testing (HIVST) for key populations such as men who have sex with men (MSM). This study estimates HIVST acceptability among Brazilian MSM and explores factors associated with acceptability among MSM who have never tested for HIV or who had a previous negative result.

METHODS

Respondent-driven sampling (RDS) was used to recruit 4176 MSM in 12 Brazilian cities in 2016 to this biological and behavioral surveillance study. We excluded from this analysis all MSM who were aware of their positive HIV serostatus. Descriptive, bivariate and multivariate analyses were conducted. Overall proportions were weighted with Gile's estimator in RDS Analyst software and 95% confidence intervals were calculated. The analyses of HIVST acceptability were stratified by prior HIV testing (never or one or more times).

RESULTS

For this analysis, 3605 MSM were included. The acceptability of HIVST was 49.1%, lower among those who had never tested for HIV (42.7%) compared to those who had a previous HIV negative test (50.1%). In the subgroup of MSM who had never tested for HIV, those who reported discrimination or who had a medical appointment in the last 12 months reported higher HIVST acceptability. Among MSM who had a previous negative HIV test, only those reporting condomless receptive anal sex reported higher HIVST acceptability. In addition, we observed that high levels of knowledge of HIV/AIDS, taking part in lesbian, gay, bisexual, and transgender nongovernmental organizations (LGBT-NGO), or complete secondary or incomplete higher undergraduate education reported higher acceptability.

CONCLUSIONS

The acceptability of HIVST was low among MSM, especially among those who never tested for HIV. Given access to HIVST in Brazil, we point to the need for programs that enhance promotion of testing addressed to MSM.

The Preferred Qualities of Human Immunodeficiency Virus Testing and Self-Testing Among Men Who Have Sex With Men: A Discrete Choice Experiment

OBJECTIVES

Human immunodeficiency virus self-testing (HIVST) is a promising approach to improve HIV testing coverage. We aimed to understand HIV testing preferences of men who have sex with men (MSM) to optimize HIVST implementation.

METHODS

Discrete choice experiments (DCEs) were conducted among HIV-negative MSM living in Australia and aged ≥18 years. Men completed 1 of 2 DCEs: DCETest for preferred qualities of HIV testing (price, speed, window period, test type, and collector of specimen) and DCEKits for preferred qualities of HIVST kits (price, location of access, packaging, and usage instructions). Latent class conditional logit regression was used to explore similarities (or "classes") in preference behavior.

RESULTS

Overall, the study recruited 1606 men: 62% born in Australia, who had an average age of 36.0 years (SD 11.7), and a self-reported median of 4 (interquartile range 2-8) sexual partners in the last 6 months. The respondents to DCETest was described by 4 classes: "prefer shorter window period" (36%), "prefer self-testing" (27%), "prefer highly accurate tests" (22%), and "prefer low prices" (15%). Respondents to DCEKits were described by 4 classes: "prefer low prices" (48%), "prefer retail access (from pharmacy or online stores)" (29%), "prefer access at sex venues" (15%), and "prefer to buy from healthcare staff" (12%). Preferences varied by when someone migrated to Australia, age, frequency of testing, and number of sexual partners.

CONCLUSION

A subset of MSM, particularly infrequent testers, value access to HIVST. Expanding access to HIVST kits through online portals and pharmacies and at sex venues should be considered.

Exploring Mechanisms of Action: Using a Testing Typology to Understand Intervention Performance in an HIV Self-Testing RCT in England and Wales

SELPHI involves two interventions: A provides one HIV self-testing (HIVST) kit; B offers 3-monthly repeat HIVST kits if participants report ongoing risk. A logic model underpinned by the Behaviour Change Wheel informed the design of the intervention. SELPHI recruited 10,135 cis-men and trans people in England and Wales, all reporting anal sex with a man. This paper explores how the interventions were experienced and the mechanisms of action leading to impact for different groups of trial participants. In-depth interviews with 37 cis-men who have sex with men (MSM) were used to inductively categorise participants based on sexual and HIV testing histories. Themes relating to intervention experiences and impacts were mapped onto SELPHI-hypothesised intermediate outcomes to consider intervention impacts. Three groups were identified: ‘inexperienced testers’ engaged with SELPHI to overcome motivational and social and physical opportunity testing barriers. For ‘pro self-testers’, testing frequency was constrained by psychological and social barriers and lack of opportunity. ‘Opportunistic adopters’ engaged in HIVST for novelty and convenience. Perceived impacts for inexperienced testers were most closely aligned with the logic model, but for opportunistic adopters there was little evidence of impact. Distinctive groups were discernible with divergent intervention experiences. Using COM-B as a model for understanding behaviour change in relation to HIVST, our results indicate how HIVST interventions could be adapted to respond to different needs based on the target population’s demographic and behavioural features.

HIV self-testing intervention experiences and kit usability: results from a qualitative study among men who have sex with men in the SELPHI (Self-Testing Public Health Intervention) randomized controlled trial in England and Wales

Objectives

SELPHI (HIV Self‐Testing Public Health Intervention) is the largest randomized controlled trial (RCT) of HIV self‐testing (HIVST) in a high‐income setting to date, and has recruited 10 000 men who have sex with men (cis‐ and transgender) and transgender women who have sex with men. This qualitative substudy aimed to explore how those utilizing self‐tests experience HIVST and the implications for further intervention development and scale‐up. This is the first qualitative study in Europe investigating experiences of HIVST among intervention users, and the first globally examining the experience of using blood‐based HIVST.

Methods

Thirty‐seven cisgender MSM SELPHI participants from across England and Wales were purposively recruited to the substudy, in which semi‐structured interviews were used to explore testing history, HIVST experiences and intervention preferences. Interviews were audio‐recorded, transcribed and analysed through a framework analysis.

Results

Men accessed the intervention because HIVST reduced barriers related to convenience, stigma and privacy concerns. Emotional responses had direct links to acceptability. Supportive intervention components increased engagement with testing and addressed supportive concerns. HIVST facilitated more frequent testing, with the potential to reduce sexually transmitted infection (STI) screening frequency. Substudy participants with an HIV‐positive result (n = 2) linked to care promptly and reported very high acceptability. Minor adverse outcomes (n = 2; relationship discord and fainting) did not reduce acceptability. Ease of use difficulties were with the lancet and the test processing stage.

Conclusions

Intervention components shaped acceptability, particularly in relation to overcoming a perceived lack of support. The intervention was broadly acceptable and usable; participants expressed an unexpected degree of enthusiasm for HIVST, including those with HIV‐positive results and individuals with minor adverse outcomes.