1
|
Hu S, Jing F, Fan C, Dai Y, Xie Y, Zhou Y, Lv H, He X, Wu D, Tucker JD, Tang W. Social network strategies to distribute HIV self-testing kits: a global systematic review and network meta-analysis. J Int AIDS Soc 2024; 27:e26342. [PMID: 39048927 PMCID: PMC11269052 DOI: 10.1002/jia2.26342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 07/11/2024] [Indexed: 07/27/2024] Open
Abstract
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 1st January 2010 and 30th June 2023. Outcomes included uptake of HIV testing, HIV prevalence 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 Among the 4496 manuscripts identified, 39 studies fulfilled the inclusion criteria, including one quasi-experimental study, 22 randomized controlled trials and 16 observational studies. Networks HIVST testing was organized by peers (distributed to known peers, 15 studies), partners (distributed to their sexual partners, 16 studies) and peer educators (distributed to unknown peers, 8 studies). Among social networks, simulating the possibilities of ranking position, peer distribution had the highest uptake of HIV testing (84% probability), followed by partner distribution (80% probability) and peer educator distribution (74% probability). Pairwise meta-analysis showed that peer distribution (RR 2.29, 95% CI 1.54-3.39, 5 studies) and partner distribution (RR 1.76, 95% CI 1.50-2.07, 10 studies) also increased the probability of detecting HIV reactivity during testing within the key population when compared to the control. DISCUSSION All of the three social network distribution strategies enhanced the uptake of HIV testing compared to standard facility-based testing. 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.
Collapse
Affiliation(s)
- Siyue Hu
- Dermatology Hospital of Southern Medical UniversityGuangzhouChina
- School of Public HealthSouthern Medical UniversityGuangzhouChina
- University of North Carolina Project – ChinaGuangzhouChina
| | - Fengshi Jing
- Faculty of Data ScienceCity University of MacauTaipaChina
| | - Chengxin Fan
- University of North Carolina Project – ChinaGuangzhouChina
- School of Public HealthNanjing Medical UniversityNanjingChina
| | - Yifan Dai
- Dermatology Hospital of Southern Medical UniversityGuangzhouChina
- School of Public HealthSouthern Medical UniversityGuangzhouChina
- University of North Carolina Project – ChinaGuangzhouChina
| | - Yewei Xie
- Programme in Health Services and Systems Research, Duke‐NUS Medical SchoolSingapore
| | - Yi Zhou
- Zhuhai Center for Diseases Control and PreventionZhuhaiChina
| | - Hang Lv
- Zhuhai Center for Diseases Control and PreventionZhuhaiChina
| | - Xi He
- Zhuhai Xutong Voluntary Services CenterZhuhaiChina
| | - Dan Wu
- University of North Carolina Project – ChinaGuangzhouChina
- School of Public HealthNanjing Medical UniversityNanjingChina
- London School of Hygiene and Tropical MedicineLondonUK
| | - Joseph D. Tucker
- University of North Carolina Project – ChinaGuangzhouChina
- London School of Hygiene and Tropical MedicineLondonUK
| | - Weiming Tang
- Dermatology Hospital of Southern Medical UniversityGuangzhouChina
- University of North Carolina Project – ChinaGuangzhouChina
| |
Collapse
|
2
|
Kamitani E, Higa DH, Crepaz N, Wichser M, Mullins MM. Identifying Best Practices for Increasing HIV Pre-exposure Prophylaxis (PrEP) Use and Persistence in the United States: A Systematic Review. AIDS Behav 2024; 28:2340-2349. [PMID: 38743381 PMCID: PMC11199112 DOI: 10.1007/s10461-024-04332-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2024] [Indexed: 05/16/2024]
Abstract
A qualitative systematic review was conducted to evaluate pre-exposure prophylaxis (PrEP) interventions, describe characteristics of best practices for increasing PrEP use and persistence, and explore research gaps based on current PrEP interventions. We searched CDC's Prevention Research Synthesis (PRS) Project's cumulative HIV database (includes CINAHL, EMBASE, Global Health, MEDLINE, PsycInfo, and Sociological Abstracts) to identify PrEP intervention studies conducted in the U.S., published between 2000 and 2022 (last searched January 2023). Eligibility criteria include studies that evaluated PrEP interventions for persons testing negative for HIV infection, or for healthcare providers who prescribed PrEP; included comparisons between groups or pre/post; and reported at least one relevant PrEP outcome. Each eligible intervention was evaluated on the quality of study design, implementation, analysis, and strength of evidence (PROSPERO registration number: CRD42021256460). Of the 26 eligible interventions, the majority were focused on men who have sex with men (n = 18) and reported PrEP adherence outcomes (n = 12). Nine interventions met the criteria for Best Practices (i.e., evidence-based interventions, evidence-informed interventions). Five were digital health interventions while two implemented individual counseling, one offered motivational interviewing, and one provided integrated medical care with a PrEP peer navigator. Longer intervention periods may provide more time for intervention exposure to facilitate behavioral change, and engaging the community when developing, designing and implementing interventions may be key for effectiveness. For digital health interventions, two-way messaging may help participants feel supported. Research gaps included a lack of Best Practices for several populations (e.g., Black persons, Hispanic/Latino persons, persons who inject drugs, and women of color) and evidence for various intervention strategies (e.g., interventions for promoting provider's PrEP prescription behavior, peer support). These findings call for more collaborative work with communities to develop interventions that work and implement and disseminate Best Practices for increasing PrEP use and persistence in communities.
Collapse
Affiliation(s)
- Emiko Kamitani
- Division of HIV Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, GA, 30329-4027, USA.
| | - Darrel H Higa
- Division of HIV Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, GA, 30329-4027, USA
| | - Nicole Crepaz
- Division of HIV Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, GA, 30329-4027, USA
| | - Megan Wichser
- Division of HIV Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, GA, 30329-4027, USA
- SeKON Enterprise, Inc., Atlanta, GA, 30329, USA
| | - Mary M Mullins
- Division of HIV Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, GA, 30329-4027, USA
| |
Collapse
|
3
|
Chin JJ, Forbes N, Lim S, Takahashi LM. Correlates of HIV Testing Among Asian Immigrant Female Sex Workers in New York City and Los Angeles County. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2024; 36:182-197. [PMID: 38917302 DOI: 10.1521/aeap.2024.36.3.182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
This analysis examined correlates of HIV testing among Asian immigrant female sex workers in massage parlors. We interviewed 69 Chinese and Korean immigrant women who provided sexual services in massage parlors in New York City or Los Angeles County (2014-2016). Multivariable logistic regression results showed that participants who were younger, have lived in the U.S. for a longer period of time, had greater English proficiency, perceived higher HIV risk, or were living with an intimate partner were more likely to have had an HIV test. Disclosing sex work to a close friend was also positively associated with HIV testing at p < .1. These correlates may reflect differential access to information, systems, and social networks that would facilitate HIV testing, highlighting the importance of reducing social isolation and increasing HIV education, especially for older women who have come to the U.S. more recently. As the literature has indicated that Asian immigrant female sex workers experience high rates of intersectional stigma, efforts to mitigate these intersecting stigmas could further these objectives.
Collapse
Affiliation(s)
- John J Chin
- Department of Urban Policy and Planning, Hunter College, City University of New York, New York, New York
| | - Nicola Forbes
- Department of Psychology, Fordham University, Bronx, New York
| | - Sahnah Lim
- Department of Population Health, NYU Grossman School of Medicine, New York University, New York, New York
| | - Lois M Takahashi
- College of Social Sciences, San Jose State University, San Jose, California
| |
Collapse
|
4
|
West BS, Darisheva M, McCrimmon T, Zholnerova N, Grigorchuk E, Starbird L, Terlikbayeva A, Primbetova S, Baiserkin B, Mussina Z, Kasymbekova S, Cordingley O, Frye VA. Scaling Up HIV Self-Testing and Linkage to Care Among Women Who Exchange Sex and/or Use Drugs in Kazakhstan. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2024; 36:216-228. [PMID: 38917303 DOI: 10.1521/aeap.2024.36.3.216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
HIV testing is the point of entry for linkage to treatment and prevention and is critically important to ending the HIV epidemic. HIV self-testing (HST) is an acceptable, user-controlled tool that can address testing barriers, which is especially important for populations who need to test frequently, like women who exchange or trade sex for money or other needed resources (WES) and women who use drugs. HST is feasible and acceptable among WES, but research among WES who also use drugs is limited, particularly in places like Kazakhstan, where HIV rates remain high and where scale-up of HST and pre-exposure prophylaxis (PrEP) is in process. To develop effective programming, there is a need to develop tailored services for WES and/or use drugs that address key barriers. We discuss opportunities to increase HST and linkage to services among WES and/or use drugs in Kazakhstan, with a focus on stigma reduction.
Collapse
Affiliation(s)
- Brooke S West
- School of Social Work, Columbia University, New York, New York
| | | | - Tara McCrimmon
- Sociomedical Sciences, Columbia University, New York, New York
| | | | | | - Laura Starbird
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - Baurzhan Baiserkin
- Kazakh Scientific Center of Dermatology and Infectious Diseases, Almaty, Kazakhstan
| | - Zhannat Mussina
- Kazakh Scientific Center of Dermatology and Infectious Diseases, Almaty, Kazakhstan
| | | | | | - Victoria A Frye
- School of Social Work, Columbia University, New York, New York
| |
Collapse
|
5
|
Mujwara D, Kelvin EA, Dahman B, George G, Nixon D, Adera T, Mwai E, Kimmel AD. The economic costs and cost-effectiveness of HIV self-testing among truck drivers in Kenya. Health Policy Plan 2024; 39:355-362. [PMID: 38441272 PMCID: PMC11005835 DOI: 10.1093/heapol/czae013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 02/06/2024] [Accepted: 02/28/2024] [Indexed: 04/11/2024] Open
Abstract
HIV status awareness is critical for ending the HIV epidemic but remains low in high-HIV-risk and hard-to-reach sub-populations. Targeted, efficient interventions are needed to improve HIV test-uptake. We examined the incremental cost-effectiveness of offering the choice of self-administered oral HIV-testing (HIVST-Choice) compared with provider-administered testing only [standard-of-care (SOC)] among long-distance truck drivers. Effectiveness data came from a randomized-controlled trial conducted at two roadside wellness clinics in Kenya (HIVST-Choice arm, n = 150; SOC arm, n = 155). Economic cost data came from the literature, reflected a societal perspective and were reported in 2020 international dollars (I$), a hypothetical currency with equivalent purchasing power as the US dollar. Generalized Poisson and linear gamma regression models were used to estimate effectiveness and incremental costs, respectively; incremental effectiveness was reported as the number of long-distance truck drivers needing to receive HIVST-Choice for an additional HIV test-uptake. We calculated the incremental cost-effectiveness ratio (ICER) of HIVST-Choice compared with SOC and estimated 95% confidence intervals (CIs) using non-parametric bootstrapping. Uncertainty was assessed using deterministic sensitivity analysis and the cost-effectiveness acceptability curve. HIV test-uptake was 23% more likely for HIVST-Choice, with six individuals needing to be offered HIVST-Choice for an additional HIV test-uptake. The mean per-patient cost was nearly 4-fold higher in HIVST-Choice (I$39.28) versus SOC (I$10.80), with an ICER of I$174.51, 95% CI [165.72, 194.59] for each additional test-uptake. HIV self-test kit and cell phone service costs were the main drivers of the ICER, although findings were robust even at highest possible costs. The probability of cost-effectiveness approached 1 at a willingness-to-pay of I$200 for each additional HIV test-uptake. HIVST-Choice improves HIV-test-uptake among truck drivers at low willingness-to-pay thresholds, suggesting that HIV self-testing is an efficient use of resources. Policies supporting HIV self-testing in similar high risk, hard-to-reach sub-populations may expedite achievement of international targets.
Collapse
Affiliation(s)
- Deo Mujwara
- Department of Health Policy, Virginia Commonwealth University, 830 East Main Street, Richmond, VA 23298, USA
- Analysis Group, Inc, 111 Huntington Ave 4th floor, Boston, MA 02199, USA
| | - Elizabeth A Kelvin
- Department of Epidemiology and Biostatistics & CUNY Institute for Implementation Science in Population Health, City University of New York, 205 East 42nd Street, New York, NY 10017, USA
| | - Bassam Dahman
- Department of Health Policy, Virginia Commonwealth University, 830 East Main Street, Richmond, VA 23298, USA
| | - Gavin George
- Health Economics and HIV and AIDS Research Division, University of KwaZulu-Natal, Westville Campus, Private Bag X54001, Durban 4000, South Africa
| | - Daniel Nixon
- Department of Internal Medicine, Division of Infectious Diseases, Virginia Commonwealth University, 1200 E Broad St, Richmond, VA 23219, USA
| | - Tilahun Adera
- Department of Family Medicine and Population Health, Division of Epidemiology, 1200 E. Broad Street, Richmond, VA 23298, USA
| | - Eva Mwai
- North Star Alliance, 8 Silanga Road, Nairobi, Kenya
| | - April D Kimmel
- Department of Health Policy, Virginia Commonwealth University, 830 East Main Street, Richmond, VA 23298, USA
- Department of Internal Medicine, Division of Infectious Diseases, Virginia Commonwealth University, 1200 E Broad St, Richmond, VA 23219, USA
| |
Collapse
|
6
|
Adeagbo OA, Badru OA, Nkfusai CN, Bain LE. Effectiveness of Linkage to Care and Prevention Interventions Following HIV Self-Testing: A Global Systematic Review and Meta-analysis. AIDS Behav 2024; 28:1314-1326. [PMID: 37668817 DOI: 10.1007/s10461-023-04162-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2023] [Indexed: 09/06/2023]
Abstract
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.
Collapse
Affiliation(s)
- Oluwafemi Atanda Adeagbo
- Department of Community and Behavioral Health, University of Iowa, Iowa City, USA
- Department of Sociology, University of Johannesburg, Johannesburg, South Africa
| | - Oluwaseun Abdulganiyu Badru
- Department of Community and Behavioral Health, University of Iowa, Iowa City, USA.
- Usmanu Danfodiyo University Teaching Hospital, Sokoto, Sokoto State, Nigeria.
- Institute of Human Virology, Abuja, Nigeria.
| | - Claude Ngwayu Nkfusai
- Department of Public Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Clinton Health Access Initiative, Yaoundé, Cameroon
| | - Luchuo Engelbert Bain
- Department of Psychology, Faculty of Humanities, University of Johannesburg, Auckland Park, Johannesburg, South Africa
- International Development Research Centre, Ottawa, Canada
| |
Collapse
|
7
|
Mee P, Neuman M, Kumwenda M, Lora WS, Sikwese S, Sambo M, Fielding K, Indravudh PP, Hatzold K, Johnson C, Corbett EL, Desmond N. Experience of social harms among female sex workers following HIV self-test distribution in Malawi: results of a cohort study. BMC Infect Dis 2024; 22:978. [PMID: 38468208 PMCID: PMC10926537 DOI: 10.1186/s12879-024-09178-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 02/23/2024] [Indexed: 03/13/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Paul Mee
- Lincoln International Institute for Rural Health, College of Health and Science, University of Lincoln, Lincoln, UK.
| | - Melissa Neuman
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
- MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Moses Kumwenda
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Wezzie S Lora
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Simon Sikwese
- Pakachere Institute of Health and Development Communication, Blantyre, Malawi
| | - Mwiza Sambo
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Katherine Fielding
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
- MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Pitchaya P Indravudh
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Karin Hatzold
- Population Services International, Cape Town, South Africa
| | - Cheryl Johnson
- Global HIV, Hepatitis, STI Programmes, World Health Organization, Geneva, Switzerland
| | - Elizabeth L Corbett
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Nicola Desmond
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| |
Collapse
|
8
|
Zewdie KB, Ngure K, Mwangi M, Mwangi D, Maina S, Etyang L, Maina G, Ogello V, Owidi E, Mugo NR, Baeten JM, Mugwanya KK. Effect of differentiated direct-to-pharmacy PrEP refill visits supported with client HIV self-testing on clinic visit time and early PrEP continuation. J Int AIDS Soc 2024; 27:e26222. [PMID: 38446643 PMCID: PMC10935714 DOI: 10.1002/jia2.26222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 02/05/2024] [Indexed: 03/08/2024] Open
Abstract
INTRODUCTION Delivery of oral pre-exposure prophylaxis (PrEP) is being scaled up in Africa, but clinic-level barriers including lengthy clinic visits may threaten client continuation on PrEP. METHODS Between January 2020 and January 2022, we conducted a quasi-experimental evaluation of differentiated direct-to-pharmacy PrEP refill visits at four public health HIV clinics in Kenya. Two clinics implemented the intervention package, which included direct-to-pharmacy for PrEP refill, client HIV self-testing (HIVST), client navigator, and pharmacist-led rapid risk assessment and dispensing. Two other clinics with comparable size and client volume served as contemporaneous controls with the usual clinic flow. PrEP continuation was evaluated by visit attendance and pharmacy refill records, and time and motion studies were conducted to determine time spent in the clinics. Dried blood spots were collected to test for tenofovir-diphosphate (TFV-DP) at random visits. We used logistic regression to assess the intervention effect on PrEP continuation and the Wilcoxon rank sum test to assess the effect on clinic time. RESULTS Overall, 746 clients were enrolled, 366 at control clinics (76 during pre-implementation and 290 during implementation phase), and 380 at direct-to-pharmacy clinics (116 during pre-implementation and 264 during implementation phase). Prior to implementation, the intervention and control clinics were comparable on client characteristics (female: 51% vs. 47%; median age: 33 vs. 33 years) and PrEP continuation (35% vs. 37% at 1 month, and 37% vs. 39% at 3 months). The intervention reduced total time spent at the clinic by 35% (median of 51 minutes at control vs. 33 minutes at intervention clinics; p<0.001), while time spent on HIV testing (20 vs. 20 minutes; p = 0.50) and pharmacy (8 vs. 8 minutes; p = 0.8) was unchanged. PrEP continuation was higher at intervention versus the control clinics: 45% versus 33% at month 1, 34% versus 25% at month 3 and 23% versus 16% at month 6. TFV-DP was detected in 85% (61/72) of samples, similar by the study group (83% vs. 85%). CONCLUSIONS A client-centred PrEP delivery approach with direct-to-pharmacy PrEP refill visits plus client HIVST significantly reduced clinic visit time by more than one-third and improved PrEP continuation in public health HIV clinics in Kenya.
Collapse
Affiliation(s)
- Kidist Belay Zewdie
- Department of EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Kenneth Ngure
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
- Department of Community HealthJomo Kenyatta University of Agriculture and TechnologyNairobiKenya
| | - Margaret Mwangi
- Partners in Health Research and DevelopmentCenter for Clinical Research, Kenya Medical Research InstituteNairobiKenya
| | - Dominic Mwangi
- Partners in Health Research and DevelopmentCenter for Clinical Research, Kenya Medical Research InstituteNairobiKenya
| | - Simon Maina
- Partners in Health Research and DevelopmentCenter for Clinical Research, Kenya Medical Research InstituteNairobiKenya
| | - Lydia Etyang
- Partners in Health Research and DevelopmentCenter for Clinical Research, Kenya Medical Research InstituteNairobiKenya
| | - Gakuo Maina
- Partners in Health Research and DevelopmentCenter for Clinical Research, Kenya Medical Research InstituteNairobiKenya
| | - Vallery Ogello
- Partners in Health Research and DevelopmentCenter for Clinical Research, Kenya Medical Research InstituteNairobiKenya
| | - Emmah Owidi
- Partners in Health Research and DevelopmentCenter for Clinical Research, Kenya Medical Research InstituteNairobiKenya
| | - Nelly R. Mugo
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
- Partners in Health Research and DevelopmentCenter for Clinical Research, Kenya Medical Research InstituteNairobiKenya
| | - Jared M. Baeten
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
- Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Kenneth K. Mugwanya
- Department of EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| |
Collapse
|
9
|
McGee K, d'Elbée M, Dekova R, Sande LA, Dube L, Masuku S, Dlamini M, Mangenah C, Mwenge L, Johnson C, Hatzold K, Neuman M, Meyer-Rath G, Terris-Prestholt F. Costs of distributing HIV self-testing kits in Eswatini through community and workplace models. BMC Infect Dis 2024; 22:976. [PMID: 38424538 PMCID: PMC10902928 DOI: 10.1186/s12879-023-08694-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 10/10/2023] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND This study evaluates the implementation and running costs of an HIV self-testing (HIVST) distribution program in Eswatini. HIVST kits were delivered through community-based and workplace models using primary and secondary distribution. Primary clients could self-test onsite or offsite. This study presents total running economic costs of kit distribution per model between April 2019 and March 2020, and estimates average cost per HIVST kit distributed, per client self-tested, per client self-tested reactive, per client confirmed positive, and per client initiating antiretroviral therapy (ART). METHODS Distribution data and follow-up phone interviews were analysed to estimate implementation outcomes. Results were presented for each step of the care cascade using best-case and worst-case scenarios. A top-down incremental cost-analysis was conducted from the provider perspective using project expenditures. Sensitivity and scenario analyses explored effects of economic and epidemiological parameters on average costs. RESULTS Nineteen thousand one hundred fifty-five HIVST kits were distributed to 13,031 individuals over a 12-month period, averaging 1.5 kits per recipient. 83% and 17% of kits were distributed via the community and workplace models, respectively. Clients reached via the workplace model were less likely to opt for onsite testing than clients in the community model (8% vs 29%). 6% of onsite workplace testers tested reactive compared to 2% of onsite community testers. Best-case scenario estimated 17,458 (91%) clients self-tested, 633 (4%) received reactive-test results, 606 (96%) linked to confirmatory testing, and 505 (83%) initiated ART. Personnel and HIVST kits represented 60% and 32% of total costs, respectively. Average costs were: per kit distributed US$17.23, per client tested US$18.91, per client with a reactive test US$521.54, per client confirmed positive US$550.83, and per client initiating ART US$708.60. Lower rates for testing, reactivity, and linkage to care in the worst-case scenario resulted in higher average costs along the treatment cascade. CONCLUSION This study fills a significant evidence gap regarding costs of HIVST provision along the client care cascade in Eswatini. Workplace and community-based distribution of HIVST accompanied with effective linkage to care strategies can support countries to reach cascade objectives.
Collapse
Affiliation(s)
- Kathleen McGee
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
| | - Marc d'Elbée
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Linda A Sande
- Malawi Liverpool Wellcome Trust Research Programme, Blantyre, Malawi
| | | | - Sanele Masuku
- Population Services International, Mbabane, Eswatini
| | | | - Collin Mangenah
- Centre for Sexual Health and HIV/AIDS Research, Harare, Zimbabwe
| | | | - Cheryl Johnson
- World Health Organisation, Global HIV, Hepatitis and STI Programmes, Geneva, Switzerland
| | - Karin Hatzold
- Population Services International, Cape Town, South Africa
| | - Melissa Neuman
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Gesine Meyer-Rath
- Center for Global Heath and Development, Boston University School of Public Health, Boston, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Fern Terris-Prestholt
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
10
|
Mody A, Sohn AH, Iwuji C, Tan RKJ, Venter F, Geng EH. HIV epidemiology, prevention, treatment, and implementation strategies for public health. Lancet 2024; 403:471-492. [PMID: 38043552 DOI: 10.1016/s0140-6736(23)01381-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/28/2023] [Accepted: 06/29/2023] [Indexed: 12/05/2023]
Abstract
The global HIV response has made tremendous progress but is entering a new phase with additional challenges. Scientific innovations have led to multiple safe, effective, and durable options for treatment and prevention, and long-acting formulations for 2-monthly and 6-monthly dosing are becoming available with even longer dosing intervals possible on the horizon. The scientific agenda for HIV cure and remission strategies is moving forward but faces uncertain thresholds for success and acceptability. Nonetheless, innovations in prevention and treatment have often failed to reach large segments of the global population (eg, key and marginalised populations), and these major disparities in access and uptake at multiple levels have caused progress to fall short of their potential to affect public health. Moving forward, sharper epidemiologic tools based on longitudinal, person-centred data are needed to more accurately characterise remaining gaps and guide continued progress against the HIV epidemic. We should also increase prioritisation of strategies that address socio-behavioural challenges and can lead to effective and equitable implementation of existing interventions with high levels of quality that better match individual needs. We review HIV epidemiologic trends; advances in HIV prevention, treatment, and care delivery; and discuss emerging challenges for ending the HIV epidemic over the next decade that are relevant for general practitioners and others involved in HIV care.
Collapse
Affiliation(s)
- Aaloke Mody
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA.
| | - Annette H Sohn
- TREAT Asia, amfAR, The Foundation for AIDS Research, Bangkok, Thailand
| | - Collins Iwuji
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK; Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Rayner K J Tan
- University of North Carolina Project-China, Guangzhou, China; Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Francois Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Elvin H Geng
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| |
Collapse
|
11
|
Longo JDD, Woromogo SH, Diemer HSC, Tekpa G, Nambei WS, Grésenguet G. Young women who sell sex in Bangui, Central African Republic: a neglected group highly vulnerable to HIV. J Public Health (Oxf) 2023; 45:e630-e638. [PMID: 37477242 DOI: 10.1093/pubmed/fdad130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 06/09/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND The objectives of this study were to determine the association between the vulnerability factors linked to human immunodeficiency virus (HIV) and other sexually transmitted infection among the young women who sell sex (YWSS) group (15-24 years) and adult sex workers, engaged in consensual sex for money (AFSW). METHODS A cross-sectional study was conducted among AFSW involved in commercial sex transactions. Prevalence ratios (PR) analysis was carried out using log-binomial regression model. RESULTS The prevalence of HIV-1 was 29.4% among YWSS compared to 19.6% among female sex worker (PR = 1.43 [1.07-1.91]). Consistent condoms use last 3 months were very low at 22.3% and 41.2%, respectively (PR = 0.52 [0.37-0.74]), the low education level among YWSS versus AFSW (PR = 0.55 [0.40-0.76]); YWSS having been a victim of sexual violence in the last 12 months (PR = 2.00 [1.52-2.63]), were also more likely to be HIV positive. CONCLUSIONS The YWSS had a high prevalence of HIV, experienced other socioeconomic vulnerabilities and remain a key population for comprehensive HIV programs. To reach all YWSS, programs need to consider many outreach programs and address the shared determinants of HIV risk.
Collapse
Affiliation(s)
- Jean de Dieu Longo
- National Reference Centre for Sexually Transmitted Diseases and Antiretroviral Therapy, Bangui, Central African Republic
- Department of Public Health, Faculty of Health Sciences, Unit for Research and Intervention in Public Health, Bangui, Central African Republic
| | - Sylvain Honoré Woromogo
- Department of Public Health, Faculty of Health Sciences, Unit for Research and Intervention in Public Health, Bangui, Central African Republic
- Communicable Diseases Unit, Inter-State Centre for Higher Education in Public Health of Central Africa, Brazzaville, Republic of Congo
| | - Henri Saint-Calvaire Diemer
- National Reference Centre for Sexually Transmitted Diseases and Antiretroviral Therapy, Bangui, Central African Republic
- Department of Public Health, Faculty of Health Sciences, Unit for Research and Intervention in Public Health, Bangui, Central African Republic
| | - Gaspard Tekpa
- Department of Infectious and Tropical Diseases, University Hospital of Friendship, Bangui, Central African Republic
| | | | - Gérard Grésenguet
- National Reference Centre for Sexually Transmitted Diseases and Antiretroviral Therapy, Bangui, Central African Republic
- Department of Public Health, Faculty of Health Sciences, Unit for Research and Intervention in Public Health, Bangui, Central African Republic
| |
Collapse
|
12
|
Hu S, Jing F, Fan C, Dai Y, Xie Y, Zhou Y, Lv H, He X, Wu D, Tucker JD, Tang W. Social Network Strategies to Distribute HIV Self-testing Kits: A Global Systematic Review and Network Meta-analysis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.11.05.23298135. [PMID: 37986939 PMCID: PMC10659482 DOI: 10.1101/2023.11.05.23298135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
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.
Collapse
Affiliation(s)
- Siyue Hu
- Dermatology Hospital of Southern Medical University, Guangzhou, China
- School of Public Health, Southern Medical University, Guangzhou, China
- University of North Carolina Project – China, Guangzhou, China
| | - Fengshi Jing
- Faculty of Data Science, City University of Macau, Taipa, Macao SAR, China
| | - Chengxin Fan
- University of North Carolina Project – China, Guangzhou, China
- School of Public Health, Nanjing Medical University, Nanjing, China
| | - Yifan Dai
- Dermatology Hospital of Southern Medical University, Guangzhou, China
- School of Public Health, Southern Medical University, Guangzhou, China
- University of North Carolina Project – China, Guangzhou, China
| | - Yewei Xie
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Yi Zhou
- Zhuhai Center for Diseases Control and Prevention, Zhuhai, China
| | - Hang Lv
- Zhuhai Center for Diseases Control and Prevention, Zhuhai, China
| | - Xi He
- Zhuhai Xutong Voluntary Services Center, Zhuhai, China
| | - Dan Wu
- University of North Carolina Project – China, Guangzhou, China
- School of Public Health, Nanjing Medical University, Nanjing, China
- London School of Hygiene and Tropical Medicine, London, UK
| | - Joseph D. Tucker
- University of North Carolina Project – China, Guangzhou, China
- London School of Hygiene and Tropical Medicine, London, UK
| | - Weiming Tang
- Dermatology Hospital of Southern Medical University, Guangzhou, China
- University of North Carolina Project – China, Guangzhou, China
| |
Collapse
|
13
|
Wairimu N, Malen RC, Reedy AM, Mogere P, Njeru I, Culquichicón C, McGowan M, Gao F, Baeten JM, Ngure K, Ortblad KF. Peer PrEP referral + HIV self-test delivery for PrEP initiation among young Kenyan women: study protocol for a hybrid cluster-randomized controlled trial. Trials 2023; 24:705. [PMID: 37925450 PMCID: PMC10625301 DOI: 10.1186/s13063-023-07734-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/16/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND Oral HIV pre-exposure prophylaxis (PrEP) for HIV prevention is highly effective, but uptake remains low in Africa, especially among young women who are a priority population for HIV prevention services. HIV self-testing (HIVST) has been proven to increase HIV testing in diverse populations but has been underutilized to support linkage to HIV prevention services. Most young women who initiate PrEP in Africa do so through informal peer referral. We wanted to test a model of formalized peer referral enhanced with HIVST delivery among young Kenyan women. METHODS The Peer PrEP Trial is a two-arm hybrid effectiveness-implementation cluster-randomized controlled trial being conducted in central Kenya. Eligible participants (i.e., peer providers, n = 80) are women (≥ 16-24 years) refilling or initiating PrEP at public healthcare clinics who can identify at least four peers who could benefit from PrEP and not enrolled in another HIV study. Peer providers will be 1:1 randomized to (1) formal peer PrEP referral + HIVST delivery, where they will be encouraged to refer four peers (i.e., peer clients, ≥ 16-24 years) using educational materials and HIVST kits (two per peer client), or (2) informal peer PrEP referral, where they are encouraged to refer four peer clients using informal word-of-mouth referral. In both arms, peer providers will deliver a standard PrEP referral card with information on nearby public clinics delivering PrEP services. Peer providers will complete surveys at baseline and 3 months; peer clients will complete surveys at 3 months. Our primary outcome is PrEP initiation among peer clients, as reported by peer providers at 3 months. Secondary outcomes include PrEP continuation (any refilling), HIV testing (past 3 months), sexual behaviors (past month), and PrEP adherence (past month) among peer clients, as reported by both peer providers and clients at 3 months. Implementation outcomes will include participants' perceived acceptability, appropriateness, and feasibility of the intervention as well assessments of the intervention's fidelity and cost. DISCUSSION Evidence from this trial will help us understand how HIVST could support health systems by facilitating linkage to PrEP services among young women who could benefit in Kenya and similar settings. TRIAL REGISTRATION ClinicalTrials.gov NCT04982250. Registered on July 29, 2021.
Collapse
Affiliation(s)
- Njeri Wairimu
- Partners in Health and Research Development, Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Rachel C Malen
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, USA
| | - Adriana M Reedy
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, USA
| | - Peter Mogere
- Partners in Health and Research Development, Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Irene Njeru
- Partners in Health and Research Development, Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Carlos Culquichicón
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
| | - Maureen McGowan
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Fei Gao
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, USA
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Center, Seattle, USA
| | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
| | - Kenneth Ngure
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Katrina F Ortblad
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, USA.
| |
Collapse
|
14
|
Logie CH, Okumu M, Berry I, Hakiza R, Baral SD, Musoke DK, Nakitende A, Mwima S, Kyambadde P, Loutet M, Batte S, Lester R, Neema S, Newby K, Mbuagbaw L. Findings from the Tushirikiane mobile health (mHealth) HIV self-testing pragmatic trial with refugee adolescents and youth living in informal settlements in Kampala, Uganda. J Int AIDS Soc 2023; 26:e26185. [PMID: 37850816 PMCID: PMC10583643 DOI: 10.1002/jia2.26185] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 10/09/2023] [Indexed: 10/19/2023] Open
Abstract
INTRODUCTION Urban refugee youth remain underserved by current HIV prevention strategies, including HIV self-testing (HIVST). Examining HIVST feasibility with refugees can inform tailored HIV testing strategies. We examined if HIVST and mobile health (mHealth) delivery approaches could increase HIV testing uptake and HIV status knowledge among refugee youth in Kampala, Uganda. METHODS We conducted a three-arm pragmatic controlled trial across five informal settlements grouped into three sites in Kampala from 2020 to 2021 with peer-recruited refugee youth aged 16-24 years. The intervention was HIVST and HIVST + mHealth (HIVST with bidirectional SMS), compared with standard of care (SOC). Primary outcomes were self-reported HIV testing uptake and correct status knowledge verified by point-of-care testing. Some secondary outcomes included: depression, HIV-related stigma, and adolescent sexual and reproductive health (SRH) stigma at three time points (baseline [T0], 8 months [T1] and 12 months [T2]). We used generalized estimating equation regression models to estimate crude and adjusted odds ratios comparing arms over time, adjusting for age, gender and baseline imbalances. We assessed study pragmatism across PRECIS-2 dimensions. RESULTS We enrolled 450 participants (50.7% cisgender men, 48.7% cisgender women, 0.7% transgender women; mean age: 20.0, standard deviation: 2.4) across three sites. Self-reported HIV testing uptake increased significantly from T0 to T1 in intervention arms: HIVST arm: (27.6% [n = 43] at T0 vs. 91.2% [n = 135] at T1; HIVST + mHealth: 30.9% [n = 47] at T0 vs. 94.2% [n = 113] at T1]) compared with SOC (35.5% [n = 50] at T0 vs. 24.8% [ = 27] at T1) and remained significantly higher than SOC at T2 (p<0.001). HIV status knowledge in intervention arms (HIVST arm: 100% [n = 121], HIVST + mHealth arm: 97.9% [n = 95]) was significantly higher than SOC (61.5% [n = 59]) at T2. There were modest changes in secondary outcomes in intervention arms, including decreased depression alongside increased HIV-related stigma and adolescent SRH stigma. The trial employed both pragmatic (eligibility criteria, setting, organization, outcome, analysis) and explanatory approaches (recruitment path, flexibility of delivery flexibility, adherence flexibility, follow-up). CONCLUSIONS Offering HIVST is a promising approach to increase HIV testing uptake among urban refugee youth in Kampala. We share lessons learned to inform future youth-focused HIVST trials in urban humanitarian settings.
Collapse
Affiliation(s)
- Carmen H. Logie
- Factor‐Inwentash Faculty of Social WorkUniversity of TorontoTorontoOntarioCanada
- Women's College Research InstituteWomen's College HospitalTorontoOntarioCanada
- United Nations University Institute for Water, Environment & HealthHamiltonOntarioCanada
- Centre for Gender & Sexual Health EquityVancouverBritish ColumbiaCanada
| | - Moses Okumu
- School of Social WorkUniversity of Illinois Urbana‐ChampaignUrbanaIllinoisUSA
- School of Social SciencesUganda Christian UniversityMukonoUganda
| | - Isha Berry
- Dalla Lana School of Public HealthUniversity of TorontoTorontoOntarioCanada
| | - Robert Hakiza
- Young African Refugees for Integral Development (YARID)KampalaUganda
| | - Stefan D. Baral
- Johns Hopkins Bloomberg School of Public HealthJohns Hopkins UniversityBaltimoreMarylandUSA
| | | | | | - Simon Mwima
- School of Social WorkUniversity of Illinois Urbana‐ChampaignUrbanaIllinoisUSA
- National AIDS and STI Control Programme, Ministry of HealthKampalaUganda
| | - Peter Kyambadde
- National AIDS and STI Control Programme, Ministry of HealthKampalaUganda
- Most at Risk Population InitiativeMulago HospitalKampalaUganda
| | - Miranda Loutet
- Dalla Lana School of Public HealthUniversity of TorontoTorontoOntarioCanada
| | - Shamilah Batte
- Organization for Gender Empowerment and Rights Advocacy (OGERA Uganda)KampalaUganda
| | - Richard Lester
- Department of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Stella Neema
- Department of Sociology and AnthropologyMakerere UniversityKampalaUganda
| | - Katie Newby
- Centre for Research in Psychology and Sport SciencesSchool of Life and Medical SciencesUniversity of HertfordshireHatfieldUK
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and ImpactMcMaster UniversityHamiltonOntarioCanada
- Department of AnesthesiaMcMaster UniversityHamiltonOntarioCanada
- Department of PediatricsMcMaster UniversityHamiltonOntarioCanada
- Biostatistics Unit, Father Sean O'Sullivan Research CentreSt Joseph's HealthcareHamiltonOntarioCanada
- Centre for Development of Best Practices in Health (CDBPH)Yaoundé Central HospitalYaoundéCameroon
- Division of Epidemiology and BiostatisticsDepartment of Global HealthStellenbosch UniversityCape TownSouth Africa
| |
Collapse
|
15
|
Cordingley O, McCrimmon T, West BS, Darisheva M, Primbetova S, Terlikbaeva A, Gilbert L, El-Bassel N, Frye V. Preferences for an HIV Self-Testing Program Among Women who Engage in sex Work and use Drugs in Kazakhstan, Central Asia. RESEARCH ON SOCIAL WORK PRACTICE 2023; 33:296-304. [PMID: 37426726 PMCID: PMC10328443 DOI: 10.1177/10497315221128594] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
Purpose Women engaged in sex work (WESW) who use drugs face barriers to HIV testing. HIV self-testing (HST) may empower sex workers to learn their HIV status; however, it is not scaled up among WESW in Kazakhstan. This study aimed to explore barriers and facilitators to traditional HIV testing and HST among this population. Method We conducted 30 in-depth interviews (IDIs) and four focus groups (FGs) with Kazakhstani WESW who use drugs. Pragmatic analysis was used to explore key themes from qualitative data. Results Participants welcomed HST due to its potential to overcome logistical challenges by accessing HIV testing, as well as the stigma that WESW faces in traditional HIV testing. Participants desired emotional and social support for HST, and for linkage to HIV care and other services. Discussion HST among women who exchange sex and use drugs can be successfully implemented to mitigate stigma and barriers to HIV testing.
Collapse
Affiliation(s)
- Olivia Cordingley
- School of Social Work, Columbia University School of Social Work, New York, NY, USA
| | - Tara McCrimmon
- Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Brooke S. West
- School of Social Work, Columbia University School of Social Work, New York, NY, USA
| | | | | | | | - Louisa Gilbert
- School of Social Work, Columbia University School of Social Work, New York, NY, USA
| | - Nabila El-Bassel
- School of Social Work, Columbia University School of Social Work, New York, NY, USA
| | - Victoria Frye
- Department of Community Health and Social Medicine, CUNY School of Medicine, New York, NY, USA
| |
Collapse
|
16
|
Bose DL, Hundal A, Singh S, Singh S, Seth K, Hadi SU, Saran A, Joseph J, Goyal K, Salve S. 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). CAMPBELL SYSTEMATIC REVIEWS 2023; 19:e1297. [PMID: 36911864 PMCID: PMC9831290 DOI: 10.1002/cl2.1297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
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.
Collapse
|
17
|
Lapsley R, Beima-Sofie K, Moraa H, Manyeki V, Mung’ala C, Kohler PK, Simoni JM, Farquhar C, Inwani I, McClelland RS, Otiso L, Masyuko S, Bukusi D, Wilson KS. "They have given you the morale and confidence:" adolescents and young adults want more community-based oral HIV self-testing options in Kenya. AIDS Care 2023; 35:392-398. [PMID: 35468010 PMCID: PMC9592677 DOI: 10.1080/09540121.2022.2067315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 04/13/2022] [Indexed: 10/18/2022]
Abstract
Community-based delivery of oral HIV self-testing (HIVST) may expand access to testing among adolescents and young adults (AYA). Eliciting youth perspectives can help to optimize these services. We conducted nine focus group discussions (FGDs) with HIV negative AYA aged 15-24 who had completed oral HIVST following community-based distribution through homes, pharmacies, and bars. FGDs were stratified by distribution point and age (15-17, 18-24). Participants valued HIVST because it promoted greater autonomy and convenience compared to traditional clinic-based testing. AYA noted how HIVST could encourage positive behavior change, including using condoms to remain HIV negative. Participants recommended that future testing strategies include individualized, ongoing support during and after testing. Support examples included access to trained peer educators, multiple community-based distribution points, and post-test support via phones and websites. Multiple distribution points and trained peer educators' involvement in all steps of distribution, testing, and follow-up can enhance future community-based HIVST programs.
Collapse
Affiliation(s)
- Robert Lapsley
- Department of Global Health, University of Washington, Seattle, USA
| | | | - Hellen Moraa
- University of Nairobi/Kenyatta National Hospital, Nairobi, Kenya
| | - Vivianne Manyeki
- University of Nairobi/Kenyatta National Hospital, Nairobi, Kenya
| | - Carol Mung’ala
- University of Nairobi/Kenyatta National Hospital, Nairobi, Kenya
| | - Pamela K. Kohler
- Department of Global Health, University of Washington, Seattle, USA
- Department of Child, Family, and Population Health, Nursing, University of Washington, Seattle, USA
| | - Jane M. Simoni
- Department of Global Health, University of Washington, Seattle, USA
- Department of Psychology, University of Washington, Seattle, USA
| | - Carey Farquhar
- Department of Global Health, University of Washington, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
| | | | - R. Scott McClelland
- Department of Global Health, University of Washington, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
| | | | - Sarah Masyuko
- National AIDS and STI Control Program (NASCOP), Nairobi, Kenya
| | | | - Kate S. Wilson
- Department of Global Health, University of Washington, Seattle, USA
| |
Collapse
|
18
|
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. Curr Opin Infect Dis 2023; 36:49-56. [PMID: 36753705 DOI: 10.1097/qco.0000000000000895] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
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.
Collapse
|
19
|
Kelvin EA, Romo ML, George G, Mantell JE, Mwai E, Kinyanjui S, Nyaga EN, Odhiambo JO, Govender K. Evaluating effect modification by HIV testing history to understand the mechanisms behind the impact of announcing HIV self-testing availability in a clinic system in Kenya. Front Public Health 2023; 10:880070. [PMID: 36684866 PMCID: PMC9853377 DOI: 10.3389/fpubh.2022.880070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 11/24/2022] [Indexed: 01/09/2023] Open
Abstract
Background In sub-Saharan Africa, truckers and female sex workers (FSWs) have high HIV risk and face challenges accessing HIV testing. Adding HIV self-testing (HIVST) to standard of care (SOC) programs increases testing rates. However, the underlying mechanisms are not fully understood. HIVST may decrease barriers (inconvenient clinic hours, confidentiality concerns) and thus we would expect a greater impact among those not accessing SOC testing (barriers prevented previous testing). As a new biomedical technology, HIVST may also be a cue to action (the novelty of a new product motivates people to try it), in which case we might expect the impact to be similar by testing history. Methods We used data from two randomized controlled trials evaluating the announcement of HIVST availability via text-message to male truckers (n = 2,260) and FSWs (n = 2,196) in Kenya. Log binomial regression was used to estimate the risk ratio (RR) for testing ≤ 2 months post-announcement in the intervention vs. SOC overall and by having tested in the previous 12-months (12m-tested); and we assessed interaction between the intervention and 12m-tested. We also estimated risk differences (RD) per 100 and tested additive interaction using linear binomial regression. Results We found no evidence that 12m-tested modified the HIVST impact. Among truckers, those in the intervention were 3.1 times more likely to test than the SOC (p < 0.001). Although testing was slightly higher among those not 12m-tested (RR = 3.5, p = 0.001 vs. RR = 2.7, p = 0.020), the interaction was not significant (p = 0.683). Among FSWs, results were similar (unstratified RR = 2.6, p < 0.001; 12m-tested: RR = 2.7, p < 0.001; not 12m-tested: RR = 2.5, p < 0.001; interaction p = 0.795). We also did not find significant interaction on the additive scale (truckers: unstratified RD = 2.8, p < 0.001; 12m-tested RD = 3.8, p = 0.037; not 12m-tested RD = 2.5, p = 0.003; interaction p = 0.496. FSWs: unstratified RD = 9.7, p < 0.001; 12m-tested RD = 10.7, p < 0.001, not 12m-tested RD = 9.1, p < 0.001; interaction p = 0.615). Conclusion The impact of HIVST was not significantly modified by 12m-tested among truckers and FSWs on the multiplicative or additive scales. Announcing the availability of HIVST likely served primarily as a cue to action and testing clinics might maximize the HIVST benefits by holding periodic HIVST events to maintain the cue to action impact rather than making HIVST continually available.
Collapse
Affiliation(s)
- Elizabeth A. Kelvin
- Department of Epidemiology and Biostatistics, CUNY Graduate School of Public Health and Health Policy, City University of New York, New York, NY, United States
- CUNY Institute for Implementation Science in Population Health, City University of New York, New York, NY, United States
| | - Matthew L. Romo
- Department of Epidemiology and Biostatistics, CUNY Graduate School of Public Health and Health Policy, City University of New York, New York, NY, United States
- CUNY Institute for Implementation Science in Population Health, City University of New York, New York, NY, United States
| | - Gavin George
- Health Economics and HIV and AIDS Research Division, University of KwaZulu-Natal, Durban, South Africa
- Division of Social Medicine and Global Health, Lund University, Lund, Sweden
| | - Joanne E. Mantell
- HIV Center for Clinical and Behavioral Studies, Gender, Sexuality and Health Area, Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, United States
| | - Eva Mwai
- North Star Alliance, Nairobi, Kenya
| | | | | | | | - Kaymarlin Govender
- Health Economics and HIV and AIDS Research Division, University of KwaZulu-Natal, Durban, South Africa
| |
Collapse
|
20
|
Rosadiño JDT, Pagtakhan RG, Briñes MT, Dinglasan JLG, Cruz DP, Corciega JOL, Pagtakhan AB, Regencia ZJG, Baja ES. Implementation of unassisted and community-based HIV Self-Testing (HIVST) during the COVID-19 pandemic among Men-who-have-sex-with-Men (MSM) and Transgender Women (TGW): A demonstration study in Metro Manila, Philippines. PLoS One 2023; 18:e0282644. [PMID: 36893109 PMCID: PMC9997871 DOI: 10.1371/journal.pone.0282644] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 02/17/2023] [Indexed: 03/10/2023] Open
Abstract
OBJECTIVE The study aimed to demonstrate the feasibility of an unassisted and community-based HIV self-testing (HIVST) distribution model and to evaluate its acceptability among men-having-sex-with-men (MSM) and transgender women (TGW). METHODS Our demonstration study focused on implementing the HIVST distribution model in Metro Manila, Philippines. Convenience sampling was done with the following inclusion criteria: MSM or TGW, at least 18 years old, and had no previous HIV diagnosis. Individuals taking HIV pre-exposure prophylaxis, on antiretroviral therapy, or female sex at birth were excluded. The implementation of the study was done online using a virtual assistant and a delivery system via courier due to COVID-19-related lockdowns. Feasibility was measured by the number of HIVST kits successfully delivered and utilized and the HIV point prevalence. Moreover, acceptability was evaluated by a 10-item system usability scale (SUS). HIV prevalence was estimated with linkage to care prioritized for reactive participants. RESULTS Out of 1,690 kits distributed, only 953 (56.4%) participants reported their results. Overall, HIV point prevalence was 9.8%, with 56 (60.2%) reactive participants linked to further testing. Furthermore, 261 (27.4%) of respondents self-reported, and 35 (13.4%) of the reactive participants were first-time testers. The HIVST service had an overall median and interquartile range (IQR) SUS score of 82.5 (IQR: 75.0, 90.0), rendering the HIVST kits very acceptable. CONCLUSIONS Our study suggests the acceptability and feasibility of HIVST among the MSM and TGW in Metro Manila, Philippines, regardless of their age or HIV testing experience. In addition, other platforms of information dissemination and service delivery of HIVST should be explored, including access to online instructional videos and printed materials, which may facilitate easier use and interpretation of results. Furthermore, due to our study's limited number of TGW respondents, a more targeted implementation strategy to reach the TGW population is warranted to increase their access and uptake of HIVST.
Collapse
Affiliation(s)
- John Danvic T. Rosadiño
- LoveYourself Inc., Mandaluyong City, Philippines
- Faculty of Management and Development Studies, University of the Philippines Open University, Los Baños, Laguna, Philippines
| | | | - Matthew T. Briñes
- LoveYourself Inc., Mandaluyong City, Philippines
- College of Medicine, Pamantasan ng Lungsod ng Maynila, Manila, Philippines
| | | | - Denis P. Cruz
- LoveYourself Inc., Mandaluyong City, Philippines
- Faculty of Management and Development Studies, University of the Philippines Open University, Los Baños, Laguna, Philippines
| | | | - Aeronne B. Pagtakhan
- LoveYourself Inc., Mandaluyong City, Philippines
- Nursing Department, Centro Escolar University Makati, Makati City, Philippines
| | - Zypher Jude G. Regencia
- Department of Clinical Epidemiology, College of Medicine, University of the Philippines Manila, Paz Mendoza Building, UPCM, Manila, Philippines
- Institute of Clinical Epidemiology, National Institutes of Health, University of the Philippines Manila, Manila, Philippines
| | - Emmanuel S. Baja
- Department of Clinical Epidemiology, College of Medicine, University of the Philippines Manila, Paz Mendoza Building, UPCM, Manila, Philippines
- Institute of Clinical Epidemiology, National Institutes of Health, University of the Philippines Manila, Manila, Philippines
- * E-mail:
| |
Collapse
|
21
|
Ma P, Shoki R, Su X, Ota E. Implementation strategies to promote linkage to care for key populations after HIV self-testing: a scoping review. JOURNAL OF GLOBAL HEALTH REPORTS 2022. [DOI: 10.29392/001c.55764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background In human immunodeficiency virus (HIV) care, key populations are sex workers, people who inject drugs, prisoners, transgender people, and men who have sex with men (MSM), who are at high risk and burden of HIV infection but face barriers to HIV prevention, treatment, and health services. HIV self-testing (HIVST) is effective in scaling up HIV testing uptake among key populations due to its cost-effective, confidential, and convenient feature. However, lacking linkage to care support remains a key challenge. This scoping synthesised the global evidence regarding implementing strategies to promote linkage to care for key populations after HIVST. Methods This scoping review was conducted according to the Joanna Briggs Institute Manual for Evidence Synthesis. A data search was conducted on September 1, 2021. The searched databases were PubMed, Embase, EBSCOhost, Cochrane Library, Wan Fang Data (Chinese), China National Knowledge Infrastructure (Chinese), and Japan Medical Abstracts Society (Japanese). Results Twenty studies from 2011 records met the eligibility criteria and were included for review. The study populations were MSM (9), mixed high-risk populations (7), female sex workers (3), and transgender youth (1). Implementation strategies to promote linkage to care for key populations after HIVST were classified into seven categories: 1) HIVST kits with linkage-to-care information, 2) web-based or mobile app-guided HIVST, 3) remote HIVST counselling, 4) intensive follow-up, 5) HIVST promotion through social media and key opinion leaders, 6) community engagement in HIVST and 7) financial incentive. The digital-supported intervention mainly targeted MSM in high-income settings, and the community-based approach and financial incentive strategies were mainly implemented in low and middle-income settings. Comparison of linkage outcomes between studies is problematic due to mixed interpretation and measurement of linkage to care after HIVST. Conclusions Implementation strategies to promote linkage to care for key populations are diverse and should be incorporated in different settings and backgrounds. Innovative digital-supported HIVST research for female sex workers and high-risk populations in low and middle-income settings is warranted. A standardised definition of linkage to care following HIVST and a unified measurement of linkage outcomes should be developed and applied in future research.
Collapse
Affiliation(s)
- Panpan Ma
- Department of Global Health Nursing, St. Luke's International University, Tokyo, Japan
- Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan
| | - Rina Shoki
- Department of Global Health Nursing, St. Luke's International University, Tokyo, Japan
| | - Xinyi Su
- Department of Fundamental Nursing, Central South University, Changsha, Hunan, China
| | - Erika Ota
- Department of Global Health Nursing, St. Luke's International University, Tokyo, Japan
- Tokyo Foundation for Policy Research, Tokyo, Japan
| |
Collapse
|
22
|
Mantell JE, Khalifa A, Christian SN, Romo ML, Mwai E, George G, Strauss M, Govender K, Kelvin EA. Preferences, beliefs, and attitudes about oral fluid and blood-based HIV self-testing among truck drivers in Kenya choosing not to test for HIV. Front Public Health 2022; 10:911932. [PMID: 36438254 PMCID: PMC9682285 DOI: 10.3389/fpubh.2022.911932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 10/03/2022] [Indexed: 11/10/2022] Open
Abstract
Introduction Clinical trials in sub-Saharan Africa support that HIV self-testing (HIVST) can increase testing rates in difficult-to-reach populations. However, trials mostly evaluate oral fluid HIVST only. We describe preferences for oral fluid vs. blood-based HIVST to elucidate prior trial results and inform testing programs. Methods Participants were recruited from a HIVST randomized controlled trial in Nakuru County, Kenya, which aimed to test the effect of choice between oral HIVST and facility-based testing compared to standard-of-care on HIV testing among truck drivers. We conducted in-depth interviews (IDIs) with purposively sampled trial participants who declined HIV testing at baseline or who were offered access to oral fluid HIVST and chose not to pick up the kit during follow-up. IDIs were conducted with all consenting participants. We first describe IDI participants compared to the other study participants, assessing the statistical significance of differences in characteristics between the two samples and then describe preferences, beliefs, and attitudes about HIVST biospecimen type expressed in the IDIs. Results The final sample consisted of 16 men who refused HIV testing at baseline and 8 men who did not test during follow-up. All IDI participants had tested prior to study participation; mean number of years since last HIV test was 1.55, vs. 0.98 among non-IDI participants (p = 0.093). Of the 14 participants who answered the question about preferred type of HIVST, nine preferred blood-based HIVST, and five, oral HIVST. Preference varied by study arm with four of five participants who answered this question in the Choice arm and five of nine in the SOC arm preferring blood-based HIVST. Six key themes characterized truckers' views about test type: (1) Rapidity of return of test results. (2) Pain and fear associated with finger prick. (3) Ease of use. (4) Trust in test results; (5) fear of infection by contamination; and (6) Concerns about HIVST kit storage and disposal. Conclusion We found no general pattern in the themes for preference for oral or blood-based HIVST, but if blood-based HIVST had been offered, some participants in the Choice arm might have chosen to self-test. Offering choices for HIVST could increase testing uptake.
Collapse
Affiliation(s)
- Joanne E. Mantell
- Department of Psychiatry, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University Irving Medical Center, New York, NY, United States,*Correspondence: Joanne E. Mantell
| | - Aleya Khalifa
- ICAP at Columbia University, New York, NY, United States,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States
| | - Stephanie N. Christian
- Department of Behavioral and Community Health Sciences, University of Pittsburgh School of Public Health, Pittsburgh, PA, United States
| | - Matthew L. Romo
- Department of Epidemiology and Biostatistics and Institute for Implementation Science in Population Health, CUNY Graduate School of Public Health and Health Policy, City University of New York, New York, NY, United States
| | - Eva Mwai
- The North Star Alliance, Nairobi, Kenya
| | - Gavin George
- Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa,Division of Social Medicine and Global Health, Lund University, Lund, Sweden
| | - Michael Strauss
- Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
| | - Kaymarlin Govender
- Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
| | - Elizabeth A. Kelvin
- Department of Epidemiology and Biostatistics and Institute for Implementation Science in Population Health, CUNY Graduate School of Public Health and Health Policy, City University of New York, New York, NY, United States
| |
Collapse
|
23
|
Simo Fotso A, Johnson C, Vautier A, Kouamé KB, Diop PM, Silhol R, Maheu-Giroux M, Boily MC, Rouveau N, Doumenc-Aïdara C, Baggaley R, Ehui E, Larmarange J. Routine programmatic data show a positive population-level impact of HIV self-testing: the case of Côte d'Ivoire and implications for implementation. AIDS 2022; 36:1871-1879. [PMID: 35848584 PMCID: PMC9594126 DOI: 10.1097/qad.0000000000003328] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/29/2022] [Accepted: 07/04/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVES We estimate the effects of ATLAS's HIV self-testing (HIVST) kit distribution on conventional HIV testing, diagnoses, and antiretroviral treatment (ART) initiations in Côte d'Ivoire. DESIGN Ecological study using routinely collected HIV testing services program data. METHODS We used the ATLAS's programmatic data recorded between the third quarter of 2019 and the first quarter of 2021, in addition to data from the President's Emergency Plan for AIDS Relief dashboard. We performed ecological time series regression using linear mixed models. Results are presented per 1000 HIVST kits distributed through ATLAS. RESULTS We found a negative but nonsignificant effect of the number of ATLAS' distributed HIVST kits on conventional testing uptake (-190 conventional tests; 95% confidence interval [CI]: -427 to 37). The relationship between the number of HIVST kits and HIV diagnoses was significant and positive (+8 diagnosis; 95% CI: 0 to 15). No effect was observed on ART initiation (-2 ART initiations; 95% CI: -8 to 5). CONCLUSIONS ATLAS' HIVST kit distribution had a positive impact on HIV diagnoses. Despite the negative signal on conventional testing, even if only 20% of distributed kits are used, HIVST would increase access to testing. The methodology used in this paper offers a promising way to leverage routinely collected programmatic data to estimate the effects of HIVST kit distribution in real-world programs.
Collapse
Affiliation(s)
- Arlette Simo Fotso
- Centre Population & Développement, Université Paris-Cité, IRD, Inserm, Paris
- French Institute for Demographic Studies, INED, Aubervilliers, France
| | | | - Anthony Vautier
- Solidarité Thérapeutique et Initiatives pour la Santé, Solthis, Dakar, Sénégal
| | | | - Papa Moussa Diop
- Solidarité Thérapeutique et Initiatives pour la Santé, Solthis, Dakar, Sénégal
| | - Romain Silhol
- Medical Research Council Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
| | - Mathieu Maheu-Giroux
- Department of Epidemiology and Biostatistics, School of Population and Global Health, McGill University, Montréal, QC, Canada
| | - Marie-Claude Boily
- Medical Research Council Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
| | - Nicolas Rouveau
- Centre Population & Développement, Université Paris-Cité, IRD, Inserm, Paris
| | | | | | - Eboi Ehui
- Programme National de Lutte contre le Sida, Abidjan, Côte d’Ivoire
| | - Joseph Larmarange
- Centre Population & Développement, Université Paris-Cité, IRD, Inserm, Paris
| |
Collapse
|
24
|
McGowan M, Casmir E, Wairimu N, Mogere P, Jahn A, Ngure K, Ortblad KF, Roche SD. Assessing young Kenyan women's willingness to engage in a peer-delivered HIV self-testing and referral model for PrEP initiation: A qualitative formative research study. Front Public Health 2022; 10:932948. [PMID: 36276357 PMCID: PMC9583529 DOI: 10.3389/fpubh.2022.932948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 09/09/2022] [Indexed: 01/25/2023] Open
Abstract
Background Pre-exposure prophylaxis (PrEP) is highly effective for HIV prevention, but uptake remains low, especially among adolescent girls and young women (AGYW) in Kenya. A model in which trained AGYW using PrEP deliver HIV self-tests to their close friends and refer them to PrEP may help increase PrEP uptake in this population. To understand AGYW's potential willingness to engage in such a model, we conducted a qualitative formative study in Kenya. Method We conducted semi-structured in-depth interviews (IDIs) with AGYW (16 to 24 years) in Kiambu County who were determined at risk of HIV acquisition. We purposively recruited "PrEP-naïve" (no prior PrEP use) and "PrEP-experienced" AGYW who used PrEP for at least 1 month within the previous year. We solicited perspectives on initiating/engaging in conversations about HIV risk and PrEP, distributing/receiving HIV self-test kits, and referring/following through on a referral to clinic-based HIV services. We analyzed verbatim transcripts using rapid qualitative analysis and a combination of inductive and deductive approaches, with the latter informed by the Integrated Behavior Model (IBM). Results From August to December 2020, we conducted 30 IDIs: 15 with PrEP-experienced and 15 with PrEP-naïve AGYW. Participants' median age was 20 [interquartile range (IQR): 20-22]. Overall, most participants anticipated that they would be willing to engage in this model. PrEP-experienced AGYW emphasized the salience of their concerns about friends' HIV risk behaviors, with several noting that they are already in the habit of discussing PrEP with friends. Many additionally expressed positive attitudes toward the proposed target behaviors, perceived these to be normative among AGYW, and expressed confidence in their ability to carry out the behaviors with proper support. Although few participants had HIVST experience, nearly all anticipated they would be able to use an HIV self-test kit correctly if provided instruction. Conclusion The Kenyan AGYW who participated in this study generally anticipated that they would be willing to engage in a formal peer PrEP referral model enhanced with peer-delivered HIV self-tests. Future research is needed to pilot test this model to determine its acceptability, feasibility, and effect on HIVST and PrEP uptake within this population.
Collapse
Affiliation(s)
- Maureen McGowan
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany,*Correspondence: Maureen McGowan
| | | | - Njeri Wairimu
- Partners in Health and Research Development, Thika, Kenya
| | - Peter Mogere
- Partners in Health and Research Development, Thika, Kenya
| | - Albrecht Jahn
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Kenneth Ngure
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Katrina F. Ortblad
- Public Health Science Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States
| | - Stephanie D. Roche
- Public Health Science Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States
| |
Collapse
|
25
|
Zewdie K, Kiptinness C, Ngure K, Kipkurui N, Wairimu N, Ambiyo F, Mugo NR, Baeten JM, Mugwanya KK. Targeted Implementation of HIV Self-Testing Increases Testing Uptake Among Partners of Index Persons Known to Have HIV in Kenya. J Acquir Immune Defic Syndr 2022; 90:524-529. [PMID: 35476826 PMCID: PMC9283250 DOI: 10.1097/qai.0000000000003003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/18/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Partners of persons living with HIV (PLHIV) are at a high risk of HIV acquisition, particularly if PLHIV are newly diagnosed or not virally suppressed. A focused partner HIV testing strategy could stimulate efficient identification of persons for pre-exposure prophylaxis (PrEP) or antiretroviral therapy (ART) programs. METHODS We sequentially implemented 2 partner testing strategies at 2 Kenyan HIV clinics: (1) an invitation for clinic-based testing and (2) HIV self-testing (HIVST) kits distribution to index PLHIV. For each testing strategy, we enrolled approximately 150 consecutive index PLHIV with partners of unknown HIV status, not on ART, <6 months on ART, or who had detectable viral load. We compared partner engagement, testing uptake, and linkage for ART or PrEP between the 2 testing strategies. RESULTS Of 313 index PLHIV enrolled (160 in invitation, 153 in HIVST), the median age was 32 years (interquartile range 26-40) and 76% were women. Overall, 73% of participants (229) discussed HIV testing with their partners: 76% (121) in the invitation strategy vs 71% (108) in the HIVST strategy [adjusted odds ratio (adjOR): 0.54, 95% confidence interval (CI): 0.31 to 0.97]. Overall, 52% (79) partners in the HIVST strategy tested vs 38% (60) in the invitation strategy (adjOR: 1.78, 95% CI: 1.13 to 2.78). Among partners engaged, 73% in the HIVST strategy vs 50% in the invitation tested (adjOR: 2.68, 95% CI: 1.46 to 4.96); 25% (35/139) tested positive for HIV. Eighty-nine percentage (31/35) who tested positive initiated treatment, but only 21% (20/93) who tested negative initiated PrEP. CONCLUSIONS HIVST kit distribution to PLHIV with partners of unknown HIV status effectively increased partner testing. Only one-fifth of partners who tested negative initiated PrEP-thus innovations to link to prevention services are urgently needed.
Collapse
Affiliation(s)
- Kidist Zewdie
- Department of Epidemiology, University of Washington, Seattle, USA
| | | | - Kenneth Ngure
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | | | | | - Faith Ambiyo
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Nelly R. Mugo
- Kenya Medical Research Institute, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, USA
| | - Jared M. Baeten
- Department of Epidemiology, University of Washington, Seattle, USA
- Department of Global Health, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
- Gilead Sciences, Foster City, USA
| | - Kenneth K. Mugwanya
- Department of Epidemiology, University of Washington, Seattle, USA
- Department of Global Health, University of Washington, Seattle, USA
| |
Collapse
|
26
|
Tobin KE, Heidari O, Winiker A, Pollock S, Rothwell MD, Alexander K, Owczarzak J, Latkin C. Peer Approaches to Improve HIV Care Cascade Outcomes: a Scoping Review Focused on Peer Behavioral Mechanisms. Curr HIV/AIDS Rep 2022; 19:251-264. [PMID: 35798989 DOI: 10.1007/s11904-022-00611-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2022] [Indexed: 12/01/2022]
Abstract
PURPOSE OF REVIEW There are three main components of peer-based approaches regardless of type: education, social support, and social norms. The purpose of this scoping review was to examine evidence in the literature among peer-based interventions and programs of components and behavioral mechanisms utilized to improve HIV care cascade outcomes. RECENT FINDINGS Of 522 articles found, 40 studies were included for data abstraction. The study outcomes represented the entire HIV care cascade from HIV testing to viral suppression. Most were patient navigator models and 8 of the studies included all three components. Social support was the most prevalent component. Role modeling of behaviors was less commonly described. This review highlighted the peer behavioral mechanisms that operate in various types of peer approaches to improve HIV care and outcomes in numerous settings and among diverse populations. The peer-based approach is flexible and commonly used, particularly in resource-poor settings.
Collapse
Affiliation(s)
- Karin E Tobin
- Department of Health, Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
| | - Omeid Heidari
- Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Abigail Winiker
- Department of Health, Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Sarah Pollock
- Department of Health, Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Melissa Davey Rothwell
- Department of Health, Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | | | - Jill Owczarzak
- Department of Health, Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Carl Latkin
- Department of Health, Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
27
|
Murray LR, Ferraz D, Zucchi EM, da Silva Sorrentino I, Grangeiro A. Autonomy and Care in Context: The Paradox of Sex Workers' Acceptability of HIV Self-Tests in São Paulo, Brazil. ARCHIVES OF SEXUAL BEHAVIOR 2022; 51:2699-2710. [PMID: 34820782 PMCID: PMC8612389 DOI: 10.1007/s10508-021-02129-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 08/06/2021] [Accepted: 08/07/2021] [Indexed: 06/13/2023]
Abstract
Cisgender female sex workers (CFSW) continue to face structural barriers to HIV prevention. We analyzed the acceptability of the oral HIV self-test (HIV-ST) among CFSW as part of a pragmatic trial on HIV prevention in Brazil. Data from in-depth interviews conducted with 12 women from diverse sex worker contexts and participant observation were analyzed using thematic analysis. CFSW valued autonomy in their workplaces and saw the HIV-ST as a possibility for self-care. Some feared clients' reactions, manager reprimands, and a positive result. HIV and sex work stigma largely drove self-care practices and perceived acceptability of the self-test. We argue that the autonomy offered by the self-test presents a paradox: increasing autonomy on the one hand while risking sidestepping structural dimensions of HIV vulnerability on the other. These nuances must be considered in interventions promoting the HIV-ST by considering the specificities of sex worker contexts, addressing stigma, and effectively involving CFSW and their organizations in intervention development.
Collapse
Affiliation(s)
- Laura Rebecca Murray
- Núcleo de Estudos de Políticas Públicas em Direitos Humanos, Universidade Federal do Rio de Janeiro, Anexo do CFCH, 3º Andar, Av. Pasteur 250 Urca, Rio de Janeiro, RJ, 22290-140, Brazil.
| | - Dulce Ferraz
- Escola FIOCRUZ de Governo, Diretoria Regional de Brasília, Fundação Oswaldo Cruz, Brasília, DF, Brazil
| | - Eliana Miura Zucchi
- Programa de Pós-Graduação em Saúde Coletiva, Mestrado Profissional em Psicologia, Desenvolvimento e Políticas Públicas, Universidade Católica de Santos, Santos, SP, Brazil
| | - Isa da Silva Sorrentino
- Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Alexandre Grangeiro
- Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| |
Collapse
|
28
|
Agot K, Cain M, Medley A, Kimani J, Gichangi P, Kiio C, Mukiri E, Odonde P, Toroitich-Ruto C, Bingham T, Downer M, Chesang K. 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. AIDS Care 2022; 34:717-724. [PMID: 33657929 PMCID: PMC10962321 DOI: 10.1080/09540121.2021.1894318] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 02/16/2021] [Indexed: 10/22/2022]
Abstract
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.
Collapse
Affiliation(s)
- Kawango Agot
- Impact Research and Development Organization, Kisumu, Kenya
| | - Meagan Cain
- U.S. Centers for Disease Control and Prevention, Division of Global HIV and TB, Atlanta, GA, USA
| | - Amy Medley
- U.S. Centers for Disease Control and Prevention, Division of Global HIV and TB, Atlanta, GA, USA
| | - Joshua Kimani
- University of Nairobi/University of Manitoba, Nairobi, Kenya
| | - Peter Gichangi
- International Center for Reproductive Health-Kenya, Mombasa, Kenya
| | - Caroline Kiio
- International Center for Reproductive Health-Kenya, Mombasa, Kenya
| | - Elosy Mukiri
- University of Nairobi/University of Manitoba, Nairobi, Kenya
| | | | | | - Trista Bingham
- U.S. Centers for Disease Control and Prevention, Division of Global HIV and TB, Atlanta, GA, USA
| | - Marie Downer
- Centers for Disease Control and Prevention, Nairobi, Kenya
| | | |
Collapse
|
29
|
Ssemata AS, Bwalya C, Muhumuza R, Ndekezi D, Mbewe M, Simwinga M, Bond V, Seeley J. Assessing knowledge, acceptability and social implications of a peer-to-peer HIV self-testing kit distribution model among adolescents aged 15-24 in Zambia and Uganda-HISTAZU: a mixed-method study protocol. BMJ Open 2022; 12:e059340. [PMID: 35623747 PMCID: PMC9150152 DOI: 10.1136/bmjopen-2021-059340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION HIV self-testing (HIVST) across sub-Saharan African countries may be acceptable as it overcomes significant barriers to clinic-based HIV testing services such as privacy and confidentiality. There are a number of suggested HIVST distribution models. However, they may not be responsive to the testing service needs of adolescents and young people (AYP). We will investigate the knowledge, acceptability and social implications of a peer-to-peer distribution model of HIVST kits on uptake of HIV prevention including pre-exposure prophylaxis, condoms, and voluntary medical male circumcision and testing services and linkage to anti-retroviral therapy among AYP aged 15-24 in Zambia and Uganda. METHODS AND ANALYSIS We will conduct an exploratory mixed methods study among AYP aged 15-24 in Uganda and Zambia. Qualitative data will be collected using audio-recorded in-depth interviews (IDIs), focus group discussions (FGDs), and participant observations. All IDIs and FGDs will be transcribed verbatim, coded and analysed through a thematic-content analysis. The quantitative data will be collected through a structured survey questionnaire derived from the preliminary findings of the qualitative work and programme evaluation quantitative data collected on uptake of services from a Zambian trial. The quantitative phase will evaluate the number of AYP reached and interested in HIVST and the implication of this on household social relations and social harms. The quantitative data will be analysed through bivariate analyses. The study will explore any social-cultural and study design barriers or facilitators to uptake of HIVST. ETHICS AND DISSEMINATION This study is approved by the Uganda Virus Research Institute Research and Ethics committee, Uganda National Council for Science and Technology, University of Zambia Biomedical Ethics Committee, Zambia National Health Research Authority and the London School of Hygiene and Tropical Medicine. Dissemination activities will involve publications in peer-reviewed journals, presentations at conferences and stakeholder meetings in the communities.
Collapse
Affiliation(s)
- Andrew Sentoogo Ssemata
- Social Aspects of Health Across the Life Course, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Wakiso, Uganda
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
| | - Chiti Bwalya
- Zambart, University of Zambia-Ridgeway Campus, Lusaka, Zambia
| | - Richard Muhumuza
- Social Aspects of Health Across the Life Course, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Wakiso, Uganda
| | - Denis Ndekezi
- Social Aspects of Health Across the Life Course, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Wakiso, Uganda
| | - Madalitso Mbewe
- Zambart, University of Zambia-Ridgeway Campus, Lusaka, Zambia
| | | | - Virginia Bond
- Zambart, University of Zambia, Lusaka, Zambia
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Janet Seeley
- Social Aspects of Health Across the Life Course, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Wakiso, Uganda
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| |
Collapse
|
30
|
Mannoh I, Amundsen D, Turpin G, Lyons CE, Viswasam N, Hahn E, Ryan S, Baral S, Hansoti B. A Systematic Review of HIV Testing Implementation Strategies in Sub-Saharan African Countries. AIDS Behav 2022; 26:1660-1671. [PMID: 34797449 PMCID: PMC9426653 DOI: 10.1007/s10461-021-03518-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2021] [Indexed: 11/25/2022]
Abstract
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.
Collapse
Affiliation(s)
- Ivy Mannoh
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Gnilane Turpin
- Department of Epidemiology, Center for Public Health and Human Rights, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Carrie E Lyons
- Department of Epidemiology, Center for Public Health and Human Rights, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Nikita Viswasam
- Department of Epidemiology, Center for Public Health and Human Rights, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Elizabeth Hahn
- Department of Epidemiology, Center for Public Health and Human Rights, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Sofia Ryan
- Department of Epidemiology, Center for Public Health and Human Rights, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Stefan Baral
- Department of Epidemiology, Center for Public Health and Human Rights, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Bhakti Hansoti
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Medicine Suite 200, 5801 Smith Avenue, Baltimore, MD, 21209, USA.
- Department of International Health, Bloomberg School of Public Health, Baltimore, MD, USA.
| |
Collapse
|
31
|
Sundararajan R, Ponticiello M, Nansera D, Jeremiah K, Muyindike W. Interventions to Increase HIV Testing Uptake in Global Settings. Curr HIV/AIDS Rep 2022; 19:184-193. [PMID: 35441985 PMCID: PMC9110462 DOI: 10.1007/s11904-022-00602-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2022] [Indexed: 12/16/2022]
Abstract
Purpose of Review HIV testing is the critical first step to direct people living with HIV (PLWH) to treatment. However, progress is still being made towards the UNAIDS benchmark of 95% of PLWH knowing their status by 2030. Here, we discuss recent interventions to improve HIV testing uptake in global settings. Recent Findings Successful facility-based HIV testing interventions involve couples and index testing, partner notification, and offering of incentives. Community-based interventions such as home-based self-testing, mobile outreach, and hybrid approaches have improved HIV testing in low-resource settings and among priority populations. Partnerships with trusted community leaders have also increased testing among populations disproportionally impacted by HIV. Summary Recent HIV testing interventions span a breadth of facility- and community-based approaches. Continued research is needed to engage men in sub-Saharan Africa, people who inject drugs, and people who avoid biomedical care. Interventions should consider supporting linkage to care for newly diagnosed PLWH.
Collapse
Affiliation(s)
- Radhika Sundararajan
- Department of Emergency Medicine, Weill Cornell Medicine, 525 East 68th Street, M-130, New York, NY, 10065, USA. .,Weill Cornell Center for Global Health, New York, NY, USA.
| | - Matthew Ponticiello
- Department of Emergency Medicine, Weill Cornell Medicine, 525 East 68th Street, M-130, New York, NY, 10065, USA
| | - Denis Nansera
- Mbarara Regional Referral Hospital, Mbarara, Uganda.,Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Winnie Muyindike
- Mbarara Regional Referral Hospital, Mbarara, Uganda.,Mbarara University of Science and Technology, Mbarara, Uganda
| |
Collapse
|
32
|
Mujugira A, Nakyanzi A, Nabaggala MS, Muwonge TR, Ssebuliba T, Bagaya M, Nampewo O, Sapiri O, Nyanzi KR, Bambia F, Nsubuga R, Serwadda DM, Ware NC, Baeten JM, Haberer JE. Effect of HIV Self-Testing on PrEP Adherence Among Gender-Diverse Sex Workers in Uganda: A Randomized Trial. J Acquir Immune Defic Syndr 2022; 89:381-389. [PMID: 34954718 PMCID: PMC8860206 DOI: 10.1097/qai.0000000000002895] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 12/06/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND HIV self-testing (HIVST) and pre-exposure prophylaxis (PrEP) are complementary tools that could empower sex workers to control their HIV protection, but few studies have jointly evaluated PrEP and HIVST in any setting. METHODS The Empower Study was an open-label randomized trial in Uganda. Sex workers were offered F/tenofovir disoproxil fumarate and randomized 1:1 to monthly HIVST and quarterly in-clinic testing (intervention) or quarterly in-clinic HIV testing alone (standard of care) and followed up for 12 months. PrEP adherence was measured using electronic adherence monitoring and tenofovir diphosphate (TFV-DP) levels in dried blood spots. Adherence outcomes and sexual behaviors were compared by arm using generalized estimating equation models. RESULTS We enrolled 110 sex workers: 84 cisgender women, 14 transgender women, 10 men who have sex with men, and 2 transgender men. The median age was 23 years. The 12-month retention was 75%. Nearly all (99.4%) used ≥1 HIVST kit. The proportion with TFV-DP levels ≥700 fmol/punch in the HIVST and standard of care arms at the 3-, 6-, 9-, and 12-month visits was 2.4%, 2.3%, 0%, and 0% and 7.9%, 0%, 0%, and 0%, respectively, with no differences by randomization arm (P > 0.2). Self-reported condomless sex acts with paying partners was similar by arm [adjusted incidence rate ratio 0.70; 95% confidence interval (CI): 0.42 to 1.17; P = 0.18]. One seroconversion occurred (HIV incidence, 0.9/100 person-years); TFV-DP was not detected at any visit. CONCLUSIONS A gender-diverse sample of sex workers in Uganda used HIVST but not daily oral PrEP for HIV protection. Alternate approaches to promote PrEP use, including long-acting formulations, should be considered in this population.
Collapse
Affiliation(s)
- Andrew Mujugira
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Global Health, University of Washington, Seattle, WA
| | - Agnes Nakyanzi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Maria S. Nabaggala
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Timothy R. Muwonge
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Timothy Ssebuliba
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Monica Bagaya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Olivia Nampewo
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Oliver Sapiri
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Kikulwe R. Nyanzi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Felix Bambia
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Rogers Nsubuga
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - David M. Serwadda
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Norma C Ware
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA; and
| | - Jared M. Baeten
- Department of Global Health, University of Washington, Seattle, WA
| | | |
Collapse
|
33
|
McGowan M, Roche SD, Nakitende A, Wachinger J, Nanyiri E, Amongin J, Nakabuye A, Musoke DK, McMahon SA, Bӓrnighausen T, Ortblad KF. Understanding how social support influences peer-delivered HIV prevention interventions among Ugandan female sex workers: a case study from HIV self-testing. BMC Public Health 2022; 22:427. [PMID: 35241042 PMCID: PMC8895611 DOI: 10.1186/s12889-022-12836-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 02/21/2022] [Indexed: 03/25/2023] Open
Abstract
BACKGROUND Female sex workers (FSWs) have tightly connected peer networks and remain at high risk of HIV acquisition. Peer delivery of HIV prevention interventions, such as HIV self-testing (HIVST), is a recommended implementation strategy for increasing intervention uptake and continuation among FSWs. We analyzed qualitative data from a peer-delivered HIVST intervention among FSWs in urban Uganda to understand the ways social support within this peer network can motivate or discourage the uptake of peer-delivered HIVST. METHODS Between February and April 2017, we conducted in-depth interviews (IDIs) with FSWs (n = 30) and focus group discussions (FGDs) with FSW peer educators (PEs, n = 5) finishing participation in a four-month randomized implementation trial testing models of peer-delivered HIVST in Kampala. FSW participants were ≥ 18 years old, self-reported exchanging sex for money or goods (past month) and had not recently tested for HIV (past 3 months). FSW PEs either directly distributed HIVST kits to participants or provided coupons exchangeable for HIVST kits from specified healthcare facilities. In the IDIs and FGDs, we asked participants to share their experiences receiving or delivering peer-delivered HIVST, respectively. Using a hybrid deductive and inductive coding approach, we arranged findings along the dimensions of an established social support theory: informational, instrumental, and emotional support. RESULTS The median age of participants was 30 years (IQR: 27-33) and PEs was 33 years (IQR: 29-37). We found that social support within FSW peer networks both motivated and discouraged uptake of peer-delivered HIVST. For example, sharing positive HIVST experiences (informational support), directly delivering HIVST kits (instrumental support), and encouraging linkage to care (emotional support) motivated HIVST uptake among FSWs. Conversely, the spread of misinformation (informational support), limited HIVST kit availability fostering mistrust of PEs (instrumental support), and fear of social exclusion following HIV status disclosure (emotional support) discouraged HIVST uptake among FSWs. CONCLUSIONS In Uganda, social support (e.g., informational, instrumental, and emotional support) among FSW peers can work in ways that both motivate and discourage peer-delivered intervention uptake. Future FSW peer-delivered HIV prevention interventions should be designed around the dimensions of social support within FSW peer networks to maximize initial and repeat intervention delivery and uptake.
Collapse
Affiliation(s)
- Maureen McGowan
- Heidelberg Institute of Global Health, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany.
| | - Stephanie D Roche
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, USA
| | | | - Jonas Wachinger
- Heidelberg Institute of Global Health, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | | | | | | | | | - Shannon A McMahon
- Heidelberg Institute of Global Health, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
- Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Till Bӓrnighausen
- Heidelberg Institute of Global Health, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA
- Africa Health Research Institute, Somkhele and Durban, South Africa
| | - Katrina F Ortblad
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, USA
| |
Collapse
|
34
|
Horvath KJ, Bwanika JM, Lammert S, Banonya J, Atuhaire J, Banturaki G, Kamulegeya LH, Musinguzi D, Kiragga AN. HiSTEP: A Single-Arm Pilot Study of a Technology-Assisted HIV Self-testing Intervention in Kampala, Uganda. AIDS Behav 2022; 26:935-946. [PMID: 34453646 DOI: 10.1007/s10461-021-03449-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2021] [Indexed: 11/29/2022]
Abstract
We developed and pilot tested a 3-month HIV self-testing intervention called HiSTEP ("HIV Self-testing Engagement Project") among 95 adult (18+ years) at-risk (condomless sex < 3 months) adults in Kampala, Uganda. HiSTEP leverages theoretically-grounded (in the Information-Motivation-Behavioral Skills model) text messages, a telehealth centre with live support, and "last-mile" HIV self-testing kit delivery to a location chosen by the participant. Nearly 94% of participants were retained at month 3. HIV self-testing was highly acceptable across age and gender groups (94% very satisfied), although older women had slightly lower acceptability ratings (92% very satisfied). Only 13% of participants used HIV self-testing prior to enrollment. Over the 3-month study period, 86% of participants ordered a total of 169 HIV self-testing kits (69% for participant use; 31% for use by others). Findings show that the intervention approach taken in HiSTEP may be particularly valuable for engaging at-risk Ugandan adults in HIV self-testing using a novel technology-assisted promotion and delivery method.
Collapse
Affiliation(s)
- Keith J Horvath
- Department of Psychology, San Diego State University, San Diego, CA, USA.
- School of Public Health, University of Minnesota, Minneapolis, MN, USA.
| | - John Mark Bwanika
- The Medical Concierge Group Limited, Kampala, Uganda
- Infectious Diseases Institute Limited, Kampala, Uganda
| | - Sara Lammert
- School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Joy Banonya
- The Medical Concierge Group Limited, Kampala, Uganda
| | - Joan Atuhaire
- The Medical Concierge Group Limited, Kampala, Uganda
| | | | | | | | | |
Collapse
|
35
|
Wilson KS, Mugo C, Katz DA, Manyeki V, Mungwala C, Otiso L, Bukusi D, McClelland RS, Simoni JM, Driver M, Masyuko S, Inwani I, Kohler PK. High Acceptance and Completion of HIV Self-testing Among Diverse Populations of Young People in Kenya Using a Community-Based Distribution Strategy. AIDS Behav 2022; 26:964-974. [PMID: 34468968 PMCID: PMC8409270 DOI: 10.1007/s10461-021-03451-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2021] [Indexed: 02/01/2023]
Abstract
Oral HIV self-testing (HIVST) may expand access to testing among hard-to-reach reach adolescents and young adults (AYA). We evaluated community-based HIVST services for AYA in an urban settlement in Kenya. Peer-mobilizers recruited AYA ages 15-24 through homes, bars/clubs, and pharmacies. Participants were offered oral HIVST, optional assistance and post-test counseling. Outcomes were HIVST acceptance and completion (self-report and returned kits). Surveys were given at enrollment, post-testing, and 4 months. Log-binomial regression evaluated HIVST preferences by venue. Among 315 reached, 87% enrolled. HIVST acceptance was higher in bars/clubs (94%) than homes (86%) or pharmacies (75%). HIVST completion was 97%, with one confirmed positive result. Participants wanted future HIVST at multiple locations, include PrEP, and cost ≤ $5USD. Participants from bars/clubs and pharmacies were more likely to prefer unassisted testing and peer-distributers compared to participants from homes. This differentiated community-based HIVST strategy could facilitate engagement in HIV testing and prevention among AYA.
Collapse
Affiliation(s)
- Kate S Wilson
- Department of Global Health, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359931, Seattle, WA, 98104, USA.
| | - Cyrus Mugo
- University of Nairobi/Kenyatta National Hospital, Nairobi, Kenya
| | - David A Katz
- Department of Global Health, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359931, Seattle, WA, 98104, USA
| | - Vivianne Manyeki
- University of Nairobi/Kenyatta National Hospital, Nairobi, Kenya
| | - Carol Mungwala
- University of Nairobi/Kenyatta National Hospital, Nairobi, Kenya
| | | | | | - R Scott McClelland
- Department of Global Health, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359931, Seattle, WA, 98104, USA
- Department of Epidemiology, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
| | - Jane M Simoni
- Department of Global Health, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359931, Seattle, WA, 98104, USA
- Department of Psychology, University of Washington, Seattle, USA
| | - Matt Driver
- Department of Cardiology, Cedar Sinai Medical Center, Los Angeles, USA
| | - Sarah Masyuko
- National AIDS and STI Control Program (NASCOP), Nairobi, Kenya
| | - Irene Inwani
- University of Nairobi/Kenyatta National Hospital, Nairobi, Kenya
| | - Pamela K Kohler
- Department of Global Health, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359931, Seattle, WA, 98104, USA
- Department of Child, Family, and Population Health, Nursing, University of Washington, Seattle, USA
| |
Collapse
|
36
|
Chen S, Forster S, Yang J, Yu F, Jiao L, Gates J, Wang Z, Liu H, Chen Q, Geldsetzer P, Wu P, Wang C, McMahon S, Bärnighausen T, Adam M. Animated, video entertainment-education to improve vaccine confidence globally during the COVID-19 pandemic: an online randomized controlled experiment with 24,000 participants. Trials 2022; 23:161. [PMID: 35183238 PMCID: PMC8857749 DOI: 10.1186/s13063-022-06067-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 01/29/2022] [Indexed: 12/31/2022] Open
Abstract
Background Science-driven storytelling and entertainment-education (E-E) media demonstrate potential for promoting improved attitudes and behavioral intent towards health-related practices. Months after the outbreak of coronavirus disease 2019 (COVID-19), emerging research highlights the essential role of interventions to improve public confidence in the COVID-19 vaccine. To improve vaccine confidence, we designed three short, animated videos employing three research-informed pedagogical strategies. These can be distributed globally through social media platforms, because of their wordless and culturally accessible design. However, the effectiveness of short, animated storytelling videos, deploying various pedagogic strategies, needs to be explored across different global regions. Methods/design The present study is a multi-site, parallel group, randomized controlled trial (RCT) comparing the effectiveness of (i) a storytelling-instructional-humor approach, (ii) a storytelling-analogy approach, (iii) a storytelling-emotion-focused approach, and (iv) no video. For our primary outcomes, we will measure vaccine hesitancy, and for secondary outcomes, we will measure behavioral intent to seek vaccination and hope. Using online platforms, we will recruit 12,000 participants (aged 18–59 years) from the USA and China, respectively, yielding a total sample size of 24,000. Discussion This trial uses innovative online technology, reliable randomization algorithms, validated survey instruments, and list experiments to establish the effectiveness of three short, animated videos employing various research-informed pedagogical strategies. Results will be used to scientifically support the broader distribution of these short, animated video as well as informing the design of future videos for rapid, global public health communication. Trial registration German Clinical Trials Register DRKS #00023650. Date of registration: 2021/02/09. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06067-5.
Collapse
|
37
|
GLICK JL, RUSSO RG, HUANG AKH, JIVAPONG B, RAMASAMY V, ROSMAN LM, PELAEZ DL, SHERMAN SG. ART uptake and adherence among female sex workers (FSW) globally: A scoping review. Glob Public Health 2022; 17:254-284. [PMID: 33301704 PMCID: PMC8190161 DOI: 10.1080/17441692.2020.1858137] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We conducted the first scoping literature review on ART uptake and adherence among Female Sex Workers (FSW), following PRISMA-ScR guidelines. Searches were conducted in PubMed, Embase, CINAHL, PsycInfo, and Sociological Abstracts. Eligibility criteria included: reporting an ART uptake or adherence result among FSW aged 18 or older; peer-reviewed; published in English between 1996 and 2018. Our search identified 6,735 studies; 30 met eligibility requirements. ART uptake ranges from 0 to 100% and adherence ranges from 50-90%, depending on measurement methods. Uptake and adherence influencing factors are mapped onto a social ecological model (SEM). Knowledge and beliefs, substance use, food insecurity and sex-work engagement were negatively associated, while older age, relationships and social support were positively associated with ART uptake and adherence. Standardised methods to measure uptake and adherence prevalence must be established for data comparison. Evidence regarding ART uptake and adherence barriers and facilitators span multiple SEM levels, although more research is needed regarding structural and occupational level influencers. Results suggest that the multi-level ART uptake and adherence barriers faced by FSW require complex multi-level evidence-based interventions. Study findings can inform ART interventions, future research, and offer guidance to other support services with FSW, such as PrEP interventions.
Collapse
Affiliation(s)
- Jennifer L. GLICK
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore MD, USA,Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Bloomberg School of Public Health, Baltimore MD, USA
| | - Rienna G. RUSSO
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore MD, USA
| | - Aimee Kao-Hsuan HUANG
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Bloomberg School of Public Health, Baltimore MD, USA
| | - Belinda JIVAPONG
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore MD, USA
| | | | - Lori M. ROSMAN
- Welch Medical Library, Johns Hopkins University, Baltimore MD, USA
| | - Danielle L PELAEZ
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Bloomberg School of Public Health, Baltimore MD, USA
| | - Susan G. SHERMAN
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Bloomberg School of Public Health, Baltimore MD, USA
| |
Collapse
|
38
|
Nasuuna E, Namimbi F, Muwanguzi PA, Kabatesi D, Apolot M, Muganzi A, Kigozi J. Early observations from the HIV self-testing program among key populations and sexual partners of pregnant mothers in Kampala, Uganda: A cross sectional study. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000120. [PMID: 36962171 PMCID: PMC10021783 DOI: 10.1371/journal.pgph.0000120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 11/22/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND HIV self-testing (HIVST) was adopted for key populations (KPs) and sexual partners of pregnant and lactating women (mothers) in Uganda in October 2018. We report early observations during HIVST implementation in Kampala, Uganda. METHODS HIVST was rolled out to reach those with unknown HIV status at 38 public health facilities, using peer-to-peer community-based distribution for female sex workers (FSW) and men who have sex with men (MSM) and secondary distribution for mothers, who gave HIVST kits to their partners. Self-testers were asked to report results within 2 days; those who did not report received a follow-up phone call from a trained health worker. Those with HIV-positive results were offered confirmatory testing at the facility using the standard HIV-testing algorithm. Data on kits distributed, testing yield, and linkage to care were analysed. RESULTS We distributed 9,378 HIVST kits. Mothers received 5,212 (56%) for their sexual partners while KPs received 4,166 (44%) (MSM, 2192 [53%]; FSW1, 974, [47%]). Of all kits distributed, 252 (3%) individuals had HIV-positive results; 126 (6.5%) FSW, 52 (2.3%) MSM and 74 (1.4%) partners of mothers. Out of 252 individuals who had HIV-positive results, 170 (67%) were confirmed HIV-positive; 36 (2%) were partners of mothers, 99 (58%) were FSW, and 35 (21%) were MSM. Linkage to treatment (126) was 74%. CONCLUSIONS HIVST efficiently reached, tested, identified and modestly linked to care HIV positive FSW, MSM, and partners of mothers. However, further barriers to confirmatory testing and linkage to care for HIV-positive self-testers remain unexplored.
Collapse
Affiliation(s)
- Esther Nasuuna
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Florence Namimbi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Patience A Muwanguzi
- Department of Nursing, School of Health Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Donna Kabatesi
- Division of Global HIV and TB, Centres for Disease Control and Prevention, Kampala, Uganda
| | - Madina Apolot
- Division of Global HIV and TB, Centres for Disease Control and Prevention, Kampala, Uganda
| | - Alex Muganzi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joanita Kigozi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| |
Collapse
|
39
|
Mphande M, Campbell P, Hoffman RM, Phiri K, Nyirenda M, Gupta SK, Wong V, Dovel K. Barriers and facilitators to facility HIV self-testing in outpatient settings in Malawi: a qualitative study. BMC Public Health 2021; 21:2200. [PMID: 34856958 PMCID: PMC8638200 DOI: 10.1186/s12889-021-12213-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 08/29/2021] [Indexed: 11/18/2022] Open
Abstract
Background Facility HIV self-testing (HIVST) within outpatient departments can increase HIV testing coverage by facilitating HIVST use in outpatient waiting spaces while clients wait for routine care. Facility HIVST allows for the majority of outpatients to test with minimal health care worker time requirements. However, barriers and facilitators to outpatients’ use of facility HIVST are still unknown. Methods As part of a cluster randomized trial on facility HIVST in Malawi, we conducted in-depth interviews with 57 adult outpatients (> 15 years) who were exposed to the HIVST intervention and collected observational journals that documented study staff observations from facility waiting spaces where HIVST was implemented. Translated and transcribed data were analyzed using constant comparison analysis in Atlas.ti. Results Facility HIVST was convenient, fast, and provided autonomy to outpatients. The strategy also had novel facilitators for testing, such as increased motivation to test due to seeing others test, immediate support for HIVST use, and easy access to additional HIV services in the health facility. Barriers to facility HIVST included fear of judgment from others and unwanted status disclosure due to lack of privacy. Desired changes to the intervention included private, separate spaces for kit use and interpretation and increased opportunity for disclosure and post-test counseling. Conclusions Facility HIVST was largely acceptable to outpatients in Malawi with novel facilitators that are unique to facility HIVST in OPD waiting spaces. Trial registration The parent trial is registered with ClinicalTrials.gov, NCT03271307, and Pan African Clinical Trials, PACTR201711002697316.
Collapse
Affiliation(s)
| | - Paula Campbell
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Risa M Hoffman
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | | | | | - Sundeep K Gupta
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Vincent Wong
- Office of HIV/AIDS, United States Agency for International Development, Washington D.C, USA
| | - Kathryn Dovel
- Partners in Hope, Box, 302, Lilongwe, Malawi.,Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| |
Collapse
|
40
|
Shava E, Bogart LM, Manyake K, Mdluli C, Maribe K, Monnapula N, Nkomo B, Mosepele M, Moyo S, Mmalane M, Bärnighausen T, Makhema J, Lockman S. Feasibility of oral HIV self-testing in female sex workers in Gaborone, Botswana. PLoS One 2021; 16:e0259508. [PMID: 34748576 PMCID: PMC8575243 DOI: 10.1371/journal.pone.0259508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 10/20/2021] [Indexed: 11/17/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Emily Shava
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Laura M. Bogart
- RAND Corporation, Santa Monica, California, United States of America
| | - Kutlo Manyake
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | | | | | | | - Mosepele Mosepele
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- University of Botswana, Gaborone, Botswana
| | - Sikhulile Moyo
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Mompati Mmalane
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Till Bärnighausen
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- University of Heidelberg, Heidelberg, Germany
- Wellcome Trust Africa Centre for Health and Population Studies, Mtubatuba, South Africa
| | - Joseph Makhema
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Shahin Lockman
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| |
Collapse
|
41
|
Kelvin EA, George G, Romo ML, Mantell JE, Mwai E, Nyaga EN, Odhiambo JO, Govender K. The Impact on HIV Testing Over 6 Months When Free Oral HIV Self-Test Kits Were Available to Truck Drivers in Kenya: A Randomized Controlled Trial. Front Public Health 2021; 9:635907. [PMID: 34660501 PMCID: PMC8514766 DOI: 10.3389/fpubh.2021.635907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 07/30/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Studies suggest that offering HIV self-testing (HIVST) increases short-term HIV testing rates, but few have looked at long-term outcomes. Methods: We conducted a randomized controlled trial (RIDIE 55847d64a454f) on the impact of offering free oral HIVST to 305 truck drivers recruited from two clinics in Kenya. We previously reported that those offered HIVST were more likely to accept testing. Here we report on the 6-month follow-up during which intervention participants could pick-up HIVST kits from eight clinics. Results: There was no difference in HIV testing during 6-month follow-up between participants in the intervention and the standard of care (SOC) arms (OR = 1.0, p = 0.877). The most common reasons given for not testing were lack of time (69.6%), low risk (27.2%), fear of knowing HIV status (20.8%), and had tested recently (8.0%). The null association was not modified by having tested at baseline (interaction p = 0.613), baseline risk behaviors (number of partners in past 6 months, interaction p = 0.881, had transactional sex in past 6 months, interaction p = 0.599), nor having spent at least half of the past 30 nights away from home for work (interaction p = 0.304). Most participants indicated a preference for the characteristics associated with the SOC [preference for blood-based tests (69.4%), provider-administered testing (74.6%) testing in a clinic (70.1%)]. However, those in the intervention arm were more likely to prefer an oral swab test than those in the SOC (36.6 vs. 24.6%, p = 0.029). Conclusions: Offering HIVST kits to truck drivers through a clinic network had little impact on testing rates over the 6-month follow-up when participants had to return to the clinic to access HIVST. Clinic-based distribution of HIVST kits may not address some major barriers to testing, such as lack of time to go to a clinic, fear of knowing one's status and low risk perception. Preferred HIV testing attributes were consistent with the SOC for most participants, but oral swab preference was higher among those in the intervention arm, who had seen the oral HIVST and had the opportunity to try it. This suggests that preferences may change with exposure to different testing modalities.
Collapse
Affiliation(s)
- Elizabeth A. Kelvin
- Department of Epidemiology and Biostatistics, CUNY Graduate School of Public Health and Health Policy, City University of New York, New York, NY, United States
- CUNY Institute for Implementation Science in Population Health, City University of New York, New York, NY, United States
| | - Gavin George
- Health Economics and HIV and AIDS Research Division, University of KwaZulu-Natal, Durban, South Africa
| | - Matthew L. Romo
- Department of Epidemiology and Biostatistics, CUNY Graduate School of Public Health and Health Policy, City University of New York, New York, NY, United States
- CUNY Institute for Implementation Science in Population Health, City University of New York, New York, NY, United States
| | - Joanne E. Mantell
- Gender, Sexuality and Health Area, Department of Psychiatry, HIV Center for Clinical and Behavioral Studies, Columbia University Irving Medical Center, New York, NY, United States
| | - Eva Mwai
- North Star Alliance, Nairobi, Kenya
| | | | | | - Kaymarlin Govender
- Health Economics and HIV and AIDS Research Division, University of KwaZulu-Natal, Durban, South Africa
| |
Collapse
|
42
|
Mujugira A, Nakyanzi A, Kasiita V, Kamusiime B, Nalukwago GK, Nalumansi A, Twesigye CC, Muwonge TR, Baeten JM, Wyatt MA, Haberer JE, Ware NC. HIV self-testing and oral pre-exposure prophylaxis are empowering for sex workers and their intimate partners: a qualitative study in Uganda. J Int AIDS Soc 2021; 24:e25782. [PMID: 34473405 PMCID: PMC8412089 DOI: 10.1002/jia2.25782] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 07/19/2021] [Indexed: 11/11/2022] Open
Abstract
Introduction HIV self‐testing (HIVST) and oral pre‐exposure prophylaxis (PrEP) are complementary, evidence‐based, self‐controlled HIV prevention tools that may be particularly appealing to sex workers. Understanding how HIVST and PrEP are perceived and used by sex workers and their intimate partners could inform prevention delivery for this population. We conducted qualitative interviews to examine ways in which HIVST and PrEP use influence prevention choices among sex workers in Uganda. Methods Within a randomized trial of HIVST and PrEP among 110 HIV‐negative cisgender women, cisgender men and transgender women sex workers (NCT03426670), we conducted 40 qualitative interviews with 30 sex workers and 10 intimate partners (June 2018 to January 2020). Sex worker interviews explored (a) experiences of using HIVST kits; (b) how HIVST was performed with sexual partners; (c) impact of HIVST on PrEP pill taking; and (d) sexual risk behaviours after HIVST. Partner interviews covered (i) introduction of HIVST; (ii) experiences of using HIVST; (iii) HIV status disclosure; and (iv) HIVST's effect on sexual behaviours. Data were analysed using an inductive content analytic approach centering on descriptive category development. Together, these categories detail the meaning of HIVST and PrEP for these qualitative participants. Results Using HIVST and PrEP was empowering for this group of sex workers and their partners. Three types of empowerment were observed: (a) economic; (b) relational; and (c) sexual health. (i) Using HIVST and PrEP made sex without condoms safer. Sex workers could charge more for condomless sex, which was empowering economically. (ii) Self‐testing restored trust in partners’ fidelity upon being reunited after a separation. This trust, in combination with condomless sex made possible by PrEP use, restored intimacy, empowering partnered relationships. (iii) HIVST and PrEP enabled sex workers to take control of their HIV prevention efforts and avoid the stigma of public clinic visits. In this way they were empowered to protect their sexual health. Conclusions In this sample, sex workers’ use of HIVST and PrEP benefitted not only prevention efforts, but also economic and relational empowerment. Understanding these larger benefits and communicating them to stakeholders could strengthen uptake and use of combination prevention interventions in this marginalized population.
Collapse
Affiliation(s)
- Andrew Mujugira
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda.,Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Kampala, Uganda.,Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Agnes Nakyanzi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Vicent Kasiita
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Brenda Kamusiime
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Grace K Nalukwago
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Alisaati Nalumansi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Chris C Twesigye
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Timothy R Muwonge
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Monique A Wyatt
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Harvard Global, Cambridge, Massachusetts, USA
| | - Jessica E Haberer
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Norma C Ware
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
43
|
Rivera AS, Hernandez R, Mag-Usara R, Sy KN, Ulitin AR, O'Dwyer LC, McHugh MC, Jordan N, Hirschhorn LR. Implementation outcomes of HIV self-testing in low- and middle- income countries: A scoping review. PLoS One 2021; 16:e0250434. [PMID: 33939722 PMCID: PMC8092786 DOI: 10.1371/journal.pone.0250434] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/07/2021] [Indexed: 01/04/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Adovich S Rivera
- Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
| | - Ralph Hernandez
- College of Medicine, University of the Philippines Manila, Manila, Philippines
| | - Regiel Mag-Usara
- College of Medicine, University of the Philippines Manila, Manila, Philippines
| | - Karen Nicole Sy
- College of Medicine, University of the Philippines Manila, Manila, Philippines
| | - Allan R Ulitin
- Institute of Health Policy and Development Studies, National Institutes for Health, Manila, Philippines
| | - Linda C O'Dwyer
- Galter Health Sciences Library & Learning Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
| | - Megan C McHugh
- Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
| | - Neil Jordan
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, Illinois, United States of America
| | - Lisa R Hirschhorn
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
- Institute of Global Health, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
| |
Collapse
|
44
|
Bond KT, Chandler R, Chapman-Lambert C, Jemmott LS, Lanier Y, Cao J, Nikpour J, Randolph SD. Applying a Nursing Perspective to Address the Challenges Experienced by Cisgender Women in the HIV Status Neutral Care Continuum: A Review of the Literature. J Assoc Nurses AIDS Care 2021; 32:283-305. [PMID: 33929979 PMCID: PMC10688540 DOI: 10.1097/jnc.0000000000000243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT The field of HIV research has grown over the past 40 years, but there remains an urgent need to address challenges that cisgender women living in the United States experience in the HIV neutral status care continuum, particularly among women such as Black women, who continue to be disproportionately burdened by HIV due to multiple levels of systemic oppression. We used a social ecological framework to provide a detailed review of the risk factors that drive the women's HIV epidemic. By presenting examples of effective approaches, best clinical practices, and identifying existing research gaps in three major categories (behavioral, biomedical, and structural), we provide an overview of the current state of research on HIV prevention among women. To illustrate a nursing viewpoint and take into account the diverse life experiences of women, we provide guidance to strengthen current HIV prevention programs. Future research should examine combined approaches for HIV prevention, and policies should be tailored to ensure that women receive effective services that are evidence-based and which they perceive as important to their lives.
Collapse
Affiliation(s)
- Keosha T Bond
- Keosha T. Bond, EdD, MPH, CHES, is an Assistant Medical Professor, Department of Community Health and Social Medicine, City University of New York School of Medicine, New York, New York, USA. Rasheeta Chandler, PhD, RN, FNP-BC, FAANP, FAAN, is an Assistant Professor, School of Nursing, Emory University, Atlanta, Georgia, USA. Crystal Chapman-Lambert, PhD, CRNP, is an Associate Professor, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA. Loretta Sweet Jemmott, PhD, RN, is Vice President, Health and Health Equity, and Professor, College of Nursing and Health Professions, Drexel University, Philadelphia, Pennsylvania, USA. Yzette Lanier, PhD, is an Assistant Professor, School of Nursing, New York University, New York, New York, USA. Jiepin Cao, MS, RN, is a Graduate Student, School of Nursing, Duke University, Durham, North Carolina, USA. Jacqueline Nikpour, BSN, RN, is a Graduate Student, School of Nursing, Duke University, Durham, North Carolina, USA. Schenita D. Randolph, PhD, MPH, RN, CNE, is an Assistant Professor, School of Nursing, and Co-director, Community Engagement Core, Duke Center for Research to Advance Healthcare Equity (REACH Equity), Duke University, Durham, North Carolina, USA
| | | | | | | | | | | | | | | |
Collapse
|
45
|
Financial incentives and deposit contracts to promote HIV retesting in Uganda: A randomized trial. PLoS Med 2021; 18:e1003630. [PMID: 33945526 PMCID: PMC8131095 DOI: 10.1371/journal.pmed.1003630] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 05/18/2021] [Accepted: 04/15/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Frequent retesting for HIV among persons at increased risk of HIV infection is critical to early HIV diagnosis of persons and delivery of combination HIV prevention services. There are few evidence-based interventions for promoting frequent retesting for HIV. We sought to determine the effectiveness of financial incentives and deposit contracts in promoting quarterly HIV retesting among adults at increased risk of HIV. METHODS AND FINDINGS In peri-urban Ugandan communities from October to December 2018, we randomized HIV-negative adults with self-reported risk to 1 of 3 strategies to promote HIV retesting: (1) no incentive; (2) cash incentives (US$7) for retesting at 3 and 6 months (total US$14); or (3) deposit contracts: participants could voluntarily deposit US$6 at baseline and at 3 months that would be returned with interest (total US$7) upon retesting at 3 and 6 months (total US$14) or lost if participants failed to retest. The primary outcome was retesting for HIV at both 3 and 6 months. Of 1,482 persons screened for study eligibility following community-based recruitment, 524 participants were randomized to either no incentive (N = 180), incentives (N = 172), or deposit contracts (N = 172): median age was 25 years (IQR: 22 to 30), 44% were women, and median weekly income was US$13.60 (IQR: US$8.16 to US$21.76). Among participants randomized to deposit contracts, 24/172 (14%) made a baseline deposit, and 2/172 (1%) made a 3-month deposit. In intent-to-treat analyses, HIV retesting at both 3 and 6 months was significantly higher in the incentive arm (89/172 [52%]) than either the control arm (33/180 [18%], odds ratio (OR) 4.8, 95% CI: 3.0 to 7.7, p < 0.001) or the deposit contract arm (28/172 [16%], OR 5.5, 95% CI: 3.3 to 9.1, p < 0.001). Among those in the deposit contract arm who made a baseline deposit, 20/24 (83%) retested at 3 months; 11/24 (46%) retested at both 3 and 6 months. Among 282 participants who retested for HIV during the trial, three (1%; 95%CI: 0.2 to 3%) seroconverted: one in the incentive group and two in the control group. Study limitations include measurement of retesting at the clinic where baseline enrollment occurred, only offering clinic-based (rather than community-based) HIV retesting and lack of measurement of retesting after completion of the trial to evaluate sustained retesting behavior. CONCLUSIONS Offering financial incentives to high-risk adults in Uganda resulted in significantly higher HIV retesting. Deposit contracts had low uptake and overall did not increase retesting. As part of efforts to increase early diagnosis of HIV among high-risk populations, strategic use of incentives to promote retesting should receive greater consideration by HIV programs. TRIAL REGISTRATION clinicaltrials.gov: NCT02890459.
Collapse
|
46
|
Chamie G, Napierala S, Agot K, Thirumurthy H. HIV testing approaches to reach the first UNAIDS 95% target in sub-Saharan Africa. Lancet HIV 2021; 8:e225-e236. [PMID: 33794183 DOI: 10.1016/s2352-3018(21)00023-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 01/20/2021] [Accepted: 01/26/2021] [Indexed: 02/06/2023]
Abstract
HIV testing is a crucial first step to accessing HIV prevention and treatment services and to achieving the UNAIDS target of 95% of people living with HIV being aware of their status by 2030. Combined implementation of facility-based and community-based approaches has helped to achieve high levels of HIV testing coverage in many countries including those in sub-Saharan Africa. Approaches such as index testing and self-testing help to reach individuals at higher risk of acquiring HIV, men, and those less likely to use health facilities or community-based services. However, as the proportion of people living with HIV who are aware of their HIV status has risen, the challenge of reaching those who remain undiagnosed or those who are at high risk of acquiring HIV has grown. Demand generation and novel testing approaches will be necessary to reach undiagnosed people living with HIV and to promote frequent retesting among key and priority populations.
Collapse
Affiliation(s)
- Gabriel Chamie
- Division of HIV, Infectious Diseases & Global Medicine, University of California San Francisco, San Francisco, CA, USA.
| | - Sue Napierala
- RTI International, Women's Global Health Imperative, Berkeley, CA, USA
| | - Kawango Agot
- Impact Research and Development Organization, Kisumu, Kenya
| | - Harsha Thirumurthy
- Perelman School of Medicine and Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
47
|
Matovu JKB, Nambuusi A, Wanyenze RK, Serwadda D. Peer-leaders' experiences and challenges in distributing HIV self-test kits in a rural fishing community, Rakai, Uganda. BMC Public Health 2021; 21:708. [PMID: 33845811 PMCID: PMC8042983 DOI: 10.1186/s12889-021-10804-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 04/08/2021] [Indexed: 11/30/2022] Open
Abstract
Background Distribution of HIV self-test kits by trained lay people in the community has resulted in increased uptake of HIV testing services among the targeted populations. However, little data exists on the experiences and challenges faced by trained lay people while distributing the kits. Methods This qualitative study was conducted in Kasensero fishing community, Rakai, Uganda, in September 2019. We purposely selected 18 out of 34 peer-leaders that participated in a peer-led HIV self-testing intervention to participate in a post-intervention qualitative evaluation. The main intervention included identification and training of lay people in the community (‘peer-leaders’) to distribute HIV self-test kits to pre-selected members of their social network. Data for this study were collected at the end of the intervention. Data were collected on peer-leaders’ experiences in distributing the kits, challenges experienced during distribution and suggestions on how to improve peer-led HIV self-testing in typical fishing communities in the future. Data were analyzed manually following a thematic framework approach. Results Of the 18 peer-leaders, eleven (61.1%) were aged 20–24 years while thirteen (72.2%) had secondary education. Most (n = 15) of the peer-leaders reported that they found it easier to distribute the kits to their social network members, with most of them distributing the kits at the social network members’ homes or at their own homes. HIV self-test kits were distributed at varying times (e.g. in the afternoon) depending on the agreement reached between the peer-leader and their social network member. A few peer-leaders reported that some of their social network members initially hesitated to accept the kits while other peer-leaders reported that they spent a ‘lot of time’ explaining the HIV self-testing procedures to some of their illiterate members. Peer-leaders argued for supervised HIV self-testing for illiterate people and the need to continuously follow-up social network members to check if they tested for HIV. Conclusion A majority of the peer-leaders successfully distributed the kits to their social network members save for a few who experienced challenges. These findings suggest that lay people can be trained as effective HIV self-test kits distributors to improve the distribution of kits in the community. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-10804-x.
Collapse
Affiliation(s)
- Joseph K B Matovu
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, P.O. Box 7072, Kampala, Uganda. .,Busitema University Faculty of Health Sciences, Mbale, Uganda.
| | - Aminah Nambuusi
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, P.O. Box 7072, Kampala, Uganda
| | - Rhoda K Wanyenze
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, P.O. Box 7072, Kampala, Uganda
| | - David Serwadda
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, P.O. Box 7072, Kampala, Uganda
| |
Collapse
|
48
|
Jopling R, Nyamayaro P, Andersen LS, Kagee A, Haberer JE, Abas MA. A Cascade of Interventions to Promote Adherence to Antiretroviral Therapy in African Countries. Curr HIV/AIDS Rep 2021; 17:529-546. [PMID: 32776179 PMCID: PMC7497365 DOI: 10.1007/s11904-020-00511-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Purpose of Review We reviewed interventions to improve uptake and adherence to antiretroviral therapy (ART) in African countries in the Treat All era. Recent Findings ART initiation can be improved by facilitated rapid receipt of first prescription, including community-based linkage and point-of-care strategies, integration of HIV care into antenatal care and peer support for adolescents. For people living with HIV (PLHIV) on ART, scheduled SMS reminders, ongoing intensive counselling for those with viral non-suppression and economic incentives for the most deprived show promise. Adherence clubs should be promoted, being no less effective than facility-based care for stable patients. Tracing those lost to follow-up should be targeted to those who can be seen face-to-face by a peer worker. Summary Investment is needed to promote linkage to initiating ART and for differentiated approaches to counselling for youth and for those with identified suboptimal adherence. More evidence from within Africa is needed on cost-effective strategies to identify and support PLHIV at an increased risk of non-adherence across the treatment cascade. Electronic supplementary material The online version of this article (10.1007/s11904-020-00511-4) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Rebecca Jopling
- Health Service & Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Primrose Nyamayaro
- Department of Psychiatry, University of Zimbabwe College of Health Sciences, Mazowe Street, Avondale, Harare, Zimbabwe
| | - Lena S Andersen
- HIV Mental Health Research Unit, Division of Neuropsychiatry, Department of Psychiatry and Mental Health, University of Cape Town, Groote Schuur Hospital Anzio Road, Observatory, Cape Town, South Africa
| | - Ashraf Kagee
- Department of Psychology, Stellenbosch University, Stellenbosch, 7602, South Africa
| | - Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Melanie Amna Abas
- Health Service & Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.
| |
Collapse
|
49
|
Wachinger J, Kibuuka Musoke D, Oldenburg CE, Bärnighausen T, Ortblad KF, McMahon SA. "But I Gathered My Courage": HIV Self-Testing as a Pathway of Empowerment Among Ugandan Female Sex Workers. QUALITATIVE HEALTH RESEARCH 2021; 31:443-457. [PMID: 33427073 PMCID: PMC7887607 DOI: 10.1177/1049732320978392] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
HIV self-testing (HIVST) increases HIV testing in diverse populations, but little is known about the experiences of individuals who self-test. We used a five-step framework approach to analyze 62 qualitative interviews with 33 female sex workers (FSWs) participating in an HIVST trial in urban Uganda. Notions of empowerment emerged from the data, and findings were interpreted based on Kabeer's empowerment framework of resources, agency, and achievements. We found that access to HIVST bolstered empowerment because it increased participant's time and money (resources), control of testing circumstances and status disclosure (agency), and sense of competency (achievements). In addition, we found that knowledge of HIV status empowered participants to better control HIV-related behaviors (agency) and recognize a new sense of self (achievements). This suggests that the availability of HIVST can facilitate feelings of empowerment, meriting a higher awareness for benefits outside of linkage to HIV treatment and prevention services.
Collapse
Affiliation(s)
- Jonas Wachinger
- Heidelberg University, Heidelberg, Germany
- Jonas Wachinger, Heidelberg Institute of Global Health, Heidelberg University, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany.
| | | | | | - Till Bärnighausen
- Heidelberg University, Heidelberg, Germany
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Africa Health Research Institute, Durban, South Africa
| | | | - Shannon A. McMahon
- Heidelberg University, Heidelberg, Germany
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| |
Collapse
|
50
|
Njau B, Damian DJ, Abdullahi L, Boulle A, Mathews C. The effects of HIV self-testing on the uptake of HIV testing, linkage to antiretroviral treatment and social harms among adults in Africa: A systematic review and meta-analysis. PLoS One 2021; 16:e0245498. [PMID: 33503050 PMCID: PMC7840047 DOI: 10.1371/journal.pone.0245498] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 12/31/2020] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION HIV infection is still a global public health problem. More than 75% of HIV-infected people are in Africa, and up to 54% are unaware of their HIV status, limiting access to antiretroviral treatment. CONTEXT AND PURPOSE OF THE STUDY This review aimed to determine whether HIV self-testing (HIVST) increases the uptake of testing, the yield of new HIV-positive diagnoses, and the linkage to antiretroviral treatment, and social harms among adults in Africa. METHODS PubMed, The Cochrane Central Register of Controlled Trials (CENTRAL), Pan African Clinical Trials Registry, The Cochrane Database of Systematic Reviews (CDSR), Databases of Abstracts of Reviews of Effectiveness (DARE), Social Sciences Citation Index, Web of Science and African Index Medicus databases were searched from 1998 to 2019 (updated in December 2019). Eligible trials employed randomized controlled trials (RCTs), before/after studies, and interrupted time series design comparing HIVST to standard HIV testing services or comparing different approaches to HIVST among adults living in Africa were systematically sought. RESULTS After searching 2,617 citations eleven trials were identified including 59,119 participants from four (4) African countries. Meta-analysis of seven trials showed a significant increase in the uptake of HIVST compared to standard HIV testing services: Both fixed-effects (Rate Ratio (RR) = 2.64, 95% CI: 2.51 to 2.79), and random-effects (RR) = 3.10, 95% CI: 1.80 to 5.37, and a significant increase in the uptake of couples' HIVST (RR = 2.50, 95% CI: 2.29 to 2.73 in fixed-effects models; and RR = 2.64, 95% CI: 2.01 to 3.49 in random-effects model). A decrease in linkage to care and ART was observed in HIVST compared to standard HIV testing services (RR = 0.88, 95% CI: 0.88 to 0.95 in fixed-effects models; and RR = 0.78, 95% CI: 0. 56 to 1.08 in random-effects models). Six RCTs measured social harms, with a total of ten reported cases related to HIVST. One RCT comparing two approaches to HIVST showed that offering home-based HIVST with optional home-initiation of antiretroviral treatment increased the reporting of a positive HIV test result (RR: 1.86; 95% CI: 1.16 to 2.98), and linkage to antiretroviral treatment (RR: 2.94; 95% CI: 2.10 to 4.12), compared with facility-based linkage to antiretroviral treatment. CONCLUSIONS HIVST has the potential to increase the uptake of HIV testing compared to standard HIV testing services. Offering HIVST with optional home initiation of HIV care compared to HIVST with facility-based HIV care increases HIV positivity and linkage to antiretroviral treatment. Reported incidences of intimate partner violence related to HIVST were rare. Future research should focus on the potential of HIVST to reach first-time testers, the effect of using different approaches to HIVST, and strategies for linkage to HIV services. SYSTEMATIC REVIEW REGISTRATION This systematic review was prospectively registered on the Prospero International Prospective Register of Systematic Review (CRD42015023935).
Collapse
Affiliation(s)
- Bernard Njau
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Damian J. Damian
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Leila Abdullahi
- Save the Children International SCI, Somalia/Somaliland Country Office, Nairobi, Kenya
| | - Andrew Boulle
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Catherine Mathews
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| |
Collapse
|