Ability to use oral fluid and fingerstick HIV self-testing (HIVST) among South African MSM

Comparative acceptability of saliva-based self-testing versus blood-based self-testing for HIV screening among key populations in Kisangani

INTRODUCTION

HIV self-testing represents a convenient and confidential option for HIV testing-the present study aimed to assess the acceptability of blood versus saliva self-tests among key populations in Kisangani.

METHODS

This study was an analytical cross-sectional study. Our sample size was 363 subjects. After obtaining their consent, we administered a questionnaire to participants. We asked participants to choose between blood and saliva self-testing. We defined the acceptability of the self-test (saliva or blood) as the intention to use the self-test using a 5-point Likert scale. Descriptive statistics were described by estimating proportions for categorical variables and means with standard deviations for symmetrically distributed quantitative variables. The variable of interest was the acceptability of self-testing, which was dichotomized (Very Likely/Unlikely). The corresponding endpoint was the proportion of participants accepting the self-test in HIV screening. A bivariate analysis was performed to determine factors related to the acceptability of the self-test, using Pearson's Chi-square (χ2) and ANOVA followed by 2-to-2 multiple comparisons (Bonferroni) for comparison of means and proportions. A progressive stepwise logistic regression model at the 5% threshold included variables with a bi-variate association.

RESULTS

The acceptability of the blood self-test was 71.6% compared to 28.4% for the saliva self-test. Factors associated with acceptability of the self-test were higher level of education aOR CI95%: 1.5(0.4-5.5) p = 0.006; non-use of condoms with casual partners aOR CI95%: 2.8(1.4-5) p = 0.003; knowledge of the type of self-test aOR CI95%:2.4(1.02-5.65) p = 0.043 and the obstacle to acceptability of the self-test was non-availability of the self-test aOR CI 95%: 18.9(6.5-54.9) p < 0.0001.

CONCLUSION

Our study showed that key populations in Kisangani preferred blood self-testing over saliva self-testing. Blood self-tests must be made available to key population groups, as this would improve access to testing for these populations, thus boosting the first UNAIDS target 95.

HIV self-test performance evaluation among priority populations in rural Mozambique: Results from a community-based observational study

BACKGROUND

In 2021, Mozambique initiated community-based oral HIV self-testing (HIVST) to increase testing access and uptake among priority groups, including adult males, adolescents, and young adults. Within an HIVST pilot project, we conducted a performance evaluation assessing participants' ability to successfully conduct HIVST procedures and interpret results.

METHODS

A cross-sectional study was performed between February-March 2021 among employees, students (18-24 years of age), and community members, using convenience sampling, in two rural districts of Zambézia Province, Mozambique. We quantified how well untrained users performed procedures for the oral HIVST (Oraquick®) through direct observation using a structured checklist, from which we calculated an HIVST usability index (scores ranging 0-100%). Additionally, participants interpreted three previously processed anonymous HIVST results. False reactive and false non-reactive interpretation results were presented as proportions. Bivariate analysis was conducted using Chi-square and Fisher exact tests.

RESULTS

A total of 312 persons participated (131[42%] community members, 71[23%] students, 110[35%] employees); 239 (77%) were male; the mean age was 28 years (standard deviation 10). Average usability index scores were 80% among employees, 86% among students, and 77% among community members. Main procedural errors observed included "incorrect tube positioning" (49%), "incorrect specimen collection" (43%), and "improper waiting time for result interpretation" (42%). From the presented anonymous HIVST results, 75% (n = 234) correctly interpreted all three results, while 9 (3%) of study participants failed to correctly interpret any results. Overall, 36 (12%) gave a false non-reactive result interpretation, 21 (7%) a false reactive result interpretation, and 14 (4%) gave both false non-reactive and false reactive result interpretations. Community members generally had lower performance.

CONCLUSIONS

Despite some observed testing procedural errors, most users could successfully perform an HIVST. Educational sessions at strategic places (e.g., schools, workplaces), and support via social media and hotlines, may improve HIVST performance quality, reducing the risk of incorrect interpretation.

Full title- acceptability and feasibility of HIV self-testing (HIVST) among MSM and transgender women (hijra) in Bangladesh: A mixed-method study

Background

HIV testing coverage among males having sex with males (MSM) and transgender women (locally known as hijra) is low in Bangladesh. Oral fluid-based HIV self-testing (HIVST) may improve coverage due to its convenience and privacy but is yet to be tested in Bangladesh. Therefore, the acceptability and feasibility of supervised HIVST was examined.

Methods

A cross-sectional study was conducted among 379 MSM and hijra selected from five geographical regions from February-October 2020. Semi-structured questionnaire was used to examine socio-demographics, risk behaviors, and perception to acceptability and feasibility (correct completion) of HIVST. Both bivariate and multivariable logistic regression analyses were performed. Qualitative data collection encompassed in-depth interviews (N = 19), key informant interviews (N = 10), and two focus group discussions (N = 12). Line-by-line content, contextual and thematic analysis were done and triangulated to explore facilitators and challenges of HIVST among MSM and hijra.

Results

Among 379 participants, the acceptability of HIVST was 99.5 % (n = 377). Reasons for acceptability included interest in independent testing (84.3 %), peer influence (57.3 %), quicker-easier procedure (54.9 %), and painless procedure (52.5 %). Qualitative findings revealed participant's risk perceptions, empowering feelings, social stigma, complementing working hours, and convenience during COVID-19 lockdowns. Around 92 % of the participants correctly completed HIVST. In multivariable analysis, the likelihood of correct test conduction was found higher among metropolitan, younger, married, educated, and participants who felt confident during HIVST process. Qualitative findings underscored the importance of supervising the use of HIVST for first-time users. Participants, particularly the less educated groups, highlighted the video demonstration as a useful tool in the context of difficulties in reading the textual instructions. However, most participants pointed out the result interpretation as the trickiest part of HIVST. All participants demonstrated willingness for future HIVST, were interested in social media-based approaches (84 %), were willing to purchase subsidized kits, and preferred conducting future tests alone at home (83.2 %).

Conclusion

Oral fluid-based HIVST was an acceptable and feasible approach for MSM and hijra in Bangladesh who were willing to do future tests independently after the supervised approach. Willingness to purchase kits and interest for social media-based approaches indicate scalability and sustainability potential of HIVST.

Review of HIV Self Testing Technologies and Promising Approaches for the Next Generation

The ability to self-test for HIV is vital to preventing transmission, particularly when used in concert with HIV biomedical prevention modalities, such as pre-exposure prophylaxis (PrEP). In this paper, we review recent developments in HIV self-testing and self-sampling methods, and the potential future impact of novel materials and methods that emerged through efforts to develop more effective point-of-care (POC) SARS-CoV-2 diagnostics. We address the gaps in existing HIV self-testing technologies, where improvements in test sensitivity, sample-to-answer time, simplicity, and cost are needed to enhance diagnostic accuracy and widespread accessibility. We discuss potential paths toward the next generation of HIV self-testing through sample collection materials, biosensing assay techniques, and miniaturized instrumentation. We discuss the implications for other applications, such as self-monitoring of HIV viral load and other infectious diseases.

HIV Testing Strategies, Types of Tests, and Uptake by Men Who have Sex with Men and Transgender Women: A Systematic Review and Meta-analysis

This systematic review and meta-analysis investigated the effectiveness of strategies and types of tests on HIV testing uptake by men who have sex with men (MSM) and transgender women (TGW), and in reaching PLWH. Articles published up to July 2020 were identified from major electronic databases and grey literature. Data were extracted and assessed for risk of bias. Estimates were pooled using random-effect meta-analysis while heterogeneity was evaluated by Cochran's Q test and I². This study is registered with PROSPERO (CRD42020192740). Of 6820 titles, 263 studies (n = 67,288 participants) were included. The testing strategies reported in most studies were community- (71.2%) and facility-based (28.8%). Highest uptake, with facility-based testing, occurred and reached more PLWH while with standard laboratory tests, it occurred with the highest HIV prevalence among MSM. However, urine test showed a highest rate of new HIV infection. Multiple test combinations had the highest uptake and reached more PLWH among TGW. Various testing strategies, considering barriers and regional differences, and different test types, need be considered, to increase uptake among MSM and TGW.

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

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.

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

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

Willingness of health care providers to offer HIV self-testing from specialized HIV care services in the northeast of Brazil

Background

The insufficient knowledge regarding the serological status of people affected with human immunodeficiency virus (HIV) is a concern in Brazil. HIV self-testing (HIVST) has been proved to have great potential for increasing testing, especially among vulnerable populations. The large-scale distribution of HIVST by the Brazilian public health system has increased in recent years. We aimed to investigate the awareness of HIVST among health care providers (HCP) from specialized HIV/AIDS care services in the state of Bahia, Northeast Brazil. Further we investigated HCP acceptability and willingness to offer its use.

Methods

A cross-sectional study on HCP from 29 specialized care services (SCS) located in 21 cities in the state of Bahia. HCP working in the service for at least 6 months were included. Sociodemographic, occupational, and behavioral data were collected using a questionnaire. Descriptive statistics were carried out. Bivariate, and multivariate analyses estimating adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) using logistic regression were conducted.

Results

The awareness and acceptability of HIVST and the willingness to provide it were 79.8, 55.2, and 47.1%, respectively. Few HCP reported that the SCS where they worked dispensed HIVST (3.6%), and 13.5% received some information or training on HIVST. Factors associated with willingness to offer HIVST were: HIVST acceptability (aOR = 9.45; 95% CI: 4.53–19.71), willingness to use HIVST on themselves (aOR = 4.45; 95% CI: 1.62–12.24), confidence in offering HIVST to clients (aOR = 5.73; 95% CI: 2.26–12.72), and considering everyone eligible for HIVST (aOR = 2.88; 95% CI: 1.25–6.59).

Conclusions

Although most HCP were aware of HIVST, acceptability and willingness to provide it to the clients was moderate. The scale up of HIVST as a mean for the HIV prevention and control policy in Brazil, requires further training of HCP and better implementation of this program.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08091-2.

Sensitivity and specificity of OraQuick® HIV self-test compared to a 4th generation laboratory reference standard algorithm in urban and rural Zambia

BACKGROUND

HIV self-testing (HIVST) has the potential to increase coverage of HIV testing, but concerns exist about intended users' ability to correctly perform and interpret tests, especially in poor communities with low literacy rates. We assessed the clinical performance of the 2016 prototype OraQuick® HIV Self-Test in rural and urban communities in Zambia to assess the sensitivity and specificity of the test compared to the national HIV rapid diagnostic test (RDT) algorithm and a laboratory reference standard using 4th generation enzyme immunoassays and HIV RNA detection.

METHODS

Participants were recruited from randomly selected rural and urban households and one urban health facility between May 2016 and June 2017. Participants received a brief demonstration of the self-test, and then self-tested without further assistance. The research team re-read the self-test, repeated the self-test, drew blood for the laboratory reference, and conducted RDTs following the national HIV testing algorithm (Determine™ HIV1/2 (Alere) confirmed using Unigold™ HIV1/2 (Trinity Biotech)). Selected participants (N = 85) were videotaped whilst conducting the testing to observe common errors.

RESULTS

Initial piloting showed that written instructions alone were inadequate, and a demonstration of self-test use was required. Of 2,566 self-test users, 2,557 (99.6%) were able to interpret their result. Of participants who were videoed 75/84 (89.3%) completed all steps of the procedure correctly. Agreement between the user-read result and the researcher-read result was 99.1%. Compared to the RDT algorithm, user-conducted HIVST was 94.1% sensitive (95%CI: 90.2-96.7) and 99.7% specific (95%CI: 99.3-99.9). Compared to the laboratory reference, both user-conducted HIVST (sensitivity 87.5%, 95%CI: 82.70-91.3; specificity 99.7%, 95%CI: 99.4-99.9) and the national RDT algorithm (sensitivity 93.4%, 95%CI: 89.7-96.1%; specificity 100% (95%CI: 99.8-100%) had considerably lower sensitivity.

CONCLUSIONS

Self-testers in Zambia who used OraQuick® HIV Self-Test achieved reasonable clinical performance compared to the national RDT algorithm. However, sensitivity of the self-test was reduced compared to a laboratory reference standard, as was the national RDT algorithm. In-person demonstration, along with the written manufacturer instructions, was needed to obtain accurate results. Programmes introducing self-care diagnostics should pilot and optimise support materials to ensure they are appropriately adapted to context.

Negotiating Use of a Blood-Based, Dual HIV and Syphilis Test with Potential Sexual Partners Among a Sample of Cisgender Men and Transgender Women Who Have Sex with Men in New York City

Cisgender men who have sex with men (cMSM) and transgender women (TGW) are disproportionally burdened by HIV. Among these populations, HIV partner-testing is a highly acceptable harm reduction tool. Particularly, cMSM and TGW report a stronger preference for blood-based tests that include assays for multiple STIs. However, no existing research has explored how these populations negotiate blood-based testing with sexual partners. In the SMARTtest study, 48 sexually active cMSM and TGW took home dual, blood-based HIV/Syphilis kits for self- and partner-testing. After 3 months, they completed a follow-up assessment and in-depth interviews about their experiences initiating testing. Of the 42 responding participants, 27 (64%) reported that it had been "fairly" or "very easy" to raise the idea of testing with partners. Participants predominantly employed partner-conscious communication strategies, including framing the testing proposal as a mandatory, non-personal component of their participation in a research study, gradually incorporating testing mentions into discussions about sexual health, and using the kits to facilitate joint testing. Yet, 21 (44%) participants reported having sex with at least one partner they did not ask to test. Concern regarding partner reactions emerged as a significant barrier to discussing test use; similarly, many partners were averse to taking a blood-based test in the context of a casual sexual encounter. Nonetheless, these findings suggest that dual, blood-based HIV/STI rapid tests may represent acceptable harm reduction tools among similar populations of cMSM and TGW, particularly if future partner-testing research is broadened to consider key couples' dynamics that may impact test usage.

Using a Virtual Platform for Conducting Grandfamily Research

BACKGROUND

Due to the COVID-19 pandemic, our research team quickly pivoted from planned face-to-face interaction with participants to virtual interactions. During this transition we discovered invaluable new practices for conducting research remotely, including the collection of physiological data.

OBJECTIVE

Our objective was to describe the methodological challenges we encountered when conducting this research virtually with grandparent-grandchild dyads, as well as to describe the strategies we developed to overcome those challenges. Of primary focus were procedures for finger-stick blood sample collection. Of secondary focus were procedures for conducting virtual-based research with older adults and across multiple generations.

METHODS

During an observational study utilizing a virtual platform with 11 grandparent-grandchild dyads (mean age 64.2 ± 5.0 years for grandparents; 9.3 ± 1.9 years for grandchildren), we documented lessons learned (based on the discussion within our team and feedback we have received from participants) that could be applicable for other, similar research endeavors.

RESULTS

We found several challenges in collecting blood samples, including: staff were unfamiliar with providing online instruction; participants needed to develop familiarity with the blood sample collection process (without having in-person assistance); we had to develop methods for delivering blood sample collection kits to participants safely. We also found that it took longer than expected to run procedures, a challenge that might be found when conducting any type of dyadic research utilizing a virtual platform, particularly involving older adults and across multiple-generations. Additionally, it was difficult to keep child participants engaged in the virtual interactions. We document how we employed targeted strategies to overcome those obstacles. Recommendations for strategies from our team include: Provide comprehensive and clear instruction/materials on blood sampling procedure; Offer warm support throughout the blood collection process; be prepared to divide study visits into more than one session as needed; proactively anticipate potential roadblocks; consider carefully the participants' developmental stages and attention span.

DISCUSSION

The insights we gained will be useful for informing future research with grandparent-grandchild dyads in remote or rural populations utilizing virtual platforms.

Implementation of HIV Self-Testing to Reach Men in Rural uMkhanyakude, KwaZulu-Natal, South Africa. a DO-ART Trial Sub Study

Background: KwaZulu-Natal, South Africa has one of the highest HIV prevalence rates globally. Persons <35 years and men have lower rates of HIV testing. HIV self-testing (HIVST) may overcome many barriers of facility-based HIV testing in order to identify HIV positive young persons and men and link them to care. We investigated whether HIVST distribution was a feasible approach to reach men and assessed the proportion of participants who reported their HIVST results, tested positive and linked to care. Methods: Teams comprised of a nurse, clinic research assistant, and recruiters distributed HIVST kits in rural uMkhanyakude, KwaZulu-Natal from August-November 2018 with a focus on testing men. Workplaces (farms), social venues, taxi ranks, and homesteads were used as HIVST kit distribution points following community sensitisation through community advisory boards and community leaders. HIVST kits, demonstration of use, and small incentives to report testing outcomes were provided. The Department of Health provided confirmatory testing and HIV care at clinics. Results: Over 11 weeks in late 2018, we distributed 2,634 HIVST kits of which 2,113 (80%) were distributed to persons aged <35 years, 2,591 (98%) to men and 356 (14%) to first time testers. Of the HIVST distributed, 2,107 (80%) reported their results to the study team, and 157 (7%) tested positive. Of persons who tested positive, 107/130 (82%) reported having a confirmatory test of which 102/107 (95%) were positive and initiated on ART. No emergencies or social harms were reported. Conclusion: Large scale distribution of HIVST kits targeting men in rural KwaZulu-Natal is feasible and highly effective in reaching men, including those who had not previously tested for HIV. While two-thirds of persons who tested HIV positive initiated ART, additional linkage strategies are needed for those who do not link after HIVST. HIVST should be used as a tool to reach men in order to achieve 95% coverage in the UNAIDS testing and care cascade in KwaZulu-Natal.

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

INTRODUCTION

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

METHODS

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

RESULTS AND DISCUSSION

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

CONCLUSIONS

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

Self-testing for HIV, HBV, and HCV using finger-stick whole-blood multiplex immunochromatographic rapid test: A pilot feasibility study in sub-Saharan Africa

Background

The burden of HIV, HBV, and HCV infections remains disproportionately high in sub-Saharan Africa, with high rates of co-infections. Multiplex rapid diagnostic tests for HIV, HBV and HCV serological testing with high analytical performances may improve the “cascade of screening” and quite possibly the linkage-to-care with reduced cost. Based on our previous field experience of HIV self-testing, we herein aimed at evaluating the practicability and acceptability of a prototype finger-stick whole-blood Triplex HIV/HCV/HBsAg self-test as a simultaneous serological screening tool for HIV, HBV, and HCV in the Democratic Republic of the Congo (DRC).

Methods

A cross-sectional multicentric study consisting of face-to-face, paper-based, and semi-structured questionnaires with a home-based and facility-based recruitment of untrained adult volunteers at risk of HIV, HBV, and HCV infections recruited from the general public was conducted in 2020 in urban and rural areas in the DRC. The practicability of the Triplex self-test was assessed by 3 substudies on the observation of self-test manipulation including the understanding of the instructions for use (IFU), on the interpretation of Triplex self-test results and on its acceptability.

Results

A total of 251 volunteers (mean age, 28 years; range, 18–49; 154 males) were included, from urban [160 (63.7%)] and rural [91 (36.3%)] areas. Overall, 242 (96.4%) participants performed the Triplex self-test and succeeded in obtaining a valid test result with an overall usability index of 89.2%. The correct use of the Triplex self-test was higher in urban areas than rural areas (51.2% versus 16.5%; aOR: 6.9). The use of video IFU in addition to paper-based IFU increased the correct manipulation and interpretation of the Triplex self-test. A total of 197 (78.5%) participants correctly interpreted the Triplex self-test results, whereas 54 (21.5%) misinterpreted their results, mainly the positive test results harboring low-intensity band (30/251; 12.0%), and preferentially the HBsAg band (12/44; 27.3%). The rates of acceptability of reuse, distribution of the Triplex self-test to third parties (partner, friend, or family member), linkage to the health care facility for confirmation of results and treatment, and confidence in the self-test results were very high, especially among participants from urban areas.

Conclusions

This pilot study shows evidence for the first time in sub-Saharan Africa on good practicability and high acceptability of a prototype Triplex HIV/HCV/HBsAg self-test for simultaneous diagnosis of three highly prevalent chronic viral infections, providing the rational basis of using self-test harboring four bands of interest, i.e. the control, HIV, HCV, and HBsAg bands. The relatively frequent misinterpretation of the Triplex self-test points however the necessity to improve the delivery of this prototype Triplex self-test probably in a supervised setting. Finally, these observations lay the foundations for the potential large-scale use of the Triplex self-test in populations living in sub-Saharan Africa at high risk for HIV, HBV, and HCV infections.

HIV Self-Testing Uptake and Intervention Strategies Among Men in Sub-Saharan Africa: A Systematic Review

Background: HIV testing is an essential gateway to HIV prevention and treatment services. However, HIV testing uptake remains low among men due to stigma, discrimination, and confidentiality concerns. HIV self-testing (HIVST) is an alternative HIV testing method that can address many of these barriers for men. We conducted a systematic review to examine HIVST uptake and intervention strategies among Men in Sub-Saharan Africa.

Methods: We used a systematic approach to survey literature published from January 2010 to June 2020 using five electronic databases (PubMed-Medline, CINAHL Complete, PsychINFO, Google Scholar, and Web of Science) and a manual search. Studies were included if they were peer-reviewed, published in English, and examined HIVST willingness, uptake, and/or linkage to care and included men in Sub-Saharan Africa.

Results: Sixty-three articles related to HIVST were reviewed. Of the included articles, 37 discussed HIVST uptake/acceptability and 24 discussed intervention strategies. Both oral swab and finger-prick methods had high acceptability with ease of access and availability of the test cited as important by men. Free HIVST kits were preferred by men. Secondary distribution of kits via peers, sexual partners, and female sex workers were successful.

Conclusion: HIV self-testing is highly acceptable to men. More efforts are needed to develop policies to implement HIVST programs targeting men in Sub-Saharan Africa, including a focus on linkage to care in sub-Saharan Africa. Future interventions should directly target men independently in tandem with using peers and their romantic partners to promote self-testing among men in sub-Saharan Africa. HIVST kit distribution strategies should be combined with services that can offer confirmatory tests and counseling for men as well as linkage to care.

Young people's preferences for HIV self-testing services in Nigeria: a qualitative analysis

BACKGROUND

HIV self-testing (HIVST) provides young people with a convenient, discreet, and empowering way to know their HIV status. However, there is limited knowledge of young people's preferences for HIVST services and potential factors that may influence the uptake of HIVST among this population. The purpose of this research was to use qualitative methods to examine HIVST preferences among Nigerian youth.

METHODS

Semi-structured in-depth interviews with a purposive sample of young people 14-24 years old were conducted in Lagos, Nigeria. Data were analyzed thematically to identify themes and domains related to preferences and factors influencing the use of HIV self-testing.

RESULTS

A total of 65 youth with mean age of 21 years, were interviewed, and the majority were females (56%). Four themes emerged as the most important characteristics that may influence young people's preferences for HIV self-testing: 1) Cost (i.e. majority of participants noted that they would pay between NGN500 to NGN1,500 naira (USD1.38-USD4.16) for oral HIV self-testing kits); 2) Testing method (i.e. although blood-based sample kits were more popular than oral-based self-testing kits, most preferred the oral-based option due to its perceived benefits and for some, phobia of needles); 3) Access location (i.e. participants suggested they preferred to obtain the HIVST kits from youth-friendly centers, pharmacies, private health facilities, and online stores); and 4) Continuing care and support (i.e. participants highlighted the importance of linkage to care with trained youth health workers for positive or negative test results or toll-free helpline).

CONCLUSION

HIV self-testing preferences among Nigerian youth appear to be influenced by several factors including lower cost, less invasive testing method, location of testing, and linkage to care and support post testing. Findings underscore the need to address young people's HIV self-testing preferences as a foundation for implementing programs and research to increase the uptake of HIVST.

Using individual stated-preferences to optimize HIV self-testing service delivery among men who have sex with men (MSM) in Malaysia: results from a conjoint-based analysis

BACKGROUND

HIV self-testing (HIVST) has the potential to improve HIV testing uptake and frequency for key populations like MSM who experience multiple barriers accessing clinic-based HIV testing. In the absence of HIVST in Malaysia, there is no guidance to inform HIVST delivery. This study investigated the acceptability of HIVST and preferences about the HIVST service delivery approaches using a standardized stated preference method.

METHODS

A cross-sectional online survey conducted between January and April 2019 assessed the interest in HIVST in 544 MSM in Malaysia. Participants ranked eight hypothetical HIVST service delivery program elements with varied combinations of six, two-level HIVST service delivery program attributes (cost, privacy, accuracy, kit collection site, kit type, and testing support). SPSS conjoint procedure was used to estimate the relative importance of each attribute and preference across eight possible HIVST service delivery programs.

RESULTS

Overall, 70.4% had previously tested for HIV, and of those, 64.0% had done so in the past 6 months (45.0% of all participants). Of all the participants, 25.2% reported having used HIVST previously. The acceptability for HIVST service delivery models ranged from 44.9 to 77.1%, with mean acceptability of 56.2% across the eight hypothetical HIVST distribution scenarios. The HIVST service delivery scenario with the highest acceptability had the following attributes: no cost (free), anonymity (name not required), 99-100% accuracy, home-delivered, fingerstick, and testing support using telephone hotline or texting. HIVST cost was the most important attribute (relative importance score: RIS = 19.30) associated with acceptability, followed by anonymity (RIS = 18.41), accuracy (RIS = 17.33), kit delivery (RIS = 16.99), fingerstick kit (RIS = 15.86), and support (RIS = 12.08).

CONCLUSIONS

Acceptability for HIVST in Malaysian MSM was high but differed markedly by a number of HIVST delivery scenarios and attributes. These findings could be relevant as the Malaysian Ministry of Health is in the process of developing a regulatory framework for ensuring the quality of kits, as well as policies supporting safe use while broader implementation under national AIDS programs.

Increases in HIV status disclosure and sexual communication between South African men who have sex with men and their partners following use of HIV self-testing kits

Availability of HIV self-testing may increase HIV testing frequency among men who have sex with men (MSM). It is unclear, however, if self-testing may impact HIV-related sexual behaviors among MSM, including HIV status disclosure and condom use. We conducted a mixed methods analysis of changes in HIV-related behaviors after HIV self-testing introduction, using data from 110 MSM participating in a feasibility and acceptability study of HIV self-testing in Mpumalanga Province, South Africa. We found increased HIV status disclosure from study participants to sexual partners after HIV self-testing introduction, from 61.8% at baseline to 75.5% at 6-month follow-up (p = 0.04), but decreased condom use with female partners (p = 0.03). Qualitative interviews reveal that some participants used test results to inform condom use. Distribution of self-testing kits can improve mutual disclosure, but should be accompanied by information stressing that the tests may not detect early HIV infections or other sexually transmitted infections.

Field evaluation of capillary blood and oral-fluid HIV self-tests in the Democratic Republic of the Congo

Background

HIV self-testing (HIVST) is an additional approach to increasing uptake of HIV testing services. The practicability and accuracy of and the preference for the capillary blood self-test (Exacto Test HIV) versus the oral fluid self-test (OraQuick HIV self-test) were compared among untrained individuals in the Democratic Republic of the Congo (DRC).

Methods

This multicenter cross-sectional study (2019) used face-to-face, tablet-based, structured questionnaires in a facility-based HIVST approach. Volunteers from the general public who were at high risk of HIV infection, who were between 18 and 49 years of age, and who had signed an informed consent form were eligible for the study. The successful performance and correct interpretation of the self-test results were the main outcomes of the practicability evaluation. The successful performance of the HIV self-test was conditioned by the presence of the control band. The sensitivity and specificity of the participant-interpreted results compared to the laboratory results were estimated for accuracy. Preference for either type of self-test was assessed. Logistic regression models were used to examine factors associated with participants’ preference.

Results

A total of 528 participants were included in this survey. The rate of successful performance of the HIV self-tests was high, with the blood test (99.6%) and the oral-fluid test (99.4%) yielding an absolute difference of 0.2% (95% CI: -1.8 to 1.1; P = 0.568). The rate of correct interpretation of the HIV self-test results was 84.4% with the blood test versus 83.8% with the oral-fluid test (difference = 0.6; 95% CI: -0.2 to 1.7; P = 0.425). Misinterpretation (25.4% for the blood test and 25.6% for the oral-fluid test) and inability to interpret (20.4% for the blood test and 21.1% for the oral-fluid test) test results were significantly more prevalent with invalid tests. The Exacto Test HIV self-test and the OraQuick HIV self-test showed 100% and 99.2% sensitivity, and 98.9% and 98.1% specificity, respectively. Preference for oral-fluid-based HIVST was greater than that for blood-based HIVST (85.6% versus 78.6%; P = 0.008). Preference for the blood test was greater among participants with a university education (86.1%; aOR = 2.4 [95% CI: 1.1 to 4.9]; P = 0.016), a higher risk of HIV infection (88.1%; aOR = 2.3 [95% CI: 1.0 to 5.3]; P = 0.047), and knowledge about the existence of HIVST (89.3%; aOR = 2.2 [95% CI: 1.0 to 5.0]; P = 0.05).

Conclusion

Our field observations demonstrate that blood-based and oral-fluid-based HIVST are both practicable approaches with a high and comparable rate of accuracy in the study setting. Although preference for the oral-fluid test was generally greater, preference for the blood test was greater among participants with a university education, a high risk of HIV infection, and knowledge about the existence of HIVST. Both approaches seem complementary in the sense that users can choose the type of self-test that best suits them for a similar result. Taken together, our observations support the use of the two HIV self-test kits in the DRC.

Then We Looked at His Results: Men Who Have Sex With Men from New York City and Puerto Rico Report Their Sexual Partner's Reactions to Receiving Reactive HIV Self-Test Results

Secondary distribution of HIV self-tests to sexual partners is acceptable but concerns remain about reactions if a partner tests HIV-positive. We report on 14 participants whose sexual partners tested HIV-positive during the "I'll Show You Mine" Study, a randomized controlled trial (N = 272) of HIV self- and partner-testing among men who have sex with men (MSM) and transgender women (TGW). All 14 were MSM and racial/ethnic minorities, mean age was 36.6 years; 86% were gay-identified. Twenty-four partners tested positive; about half were new partners. Six participants had multiple partners test positive. During in-depth interviews with 10 of these participants, they reported their partners' reactions ranged from tearful and worried among those whose result was unexpected, to resignation among those who suspected a positive result, to nonchalance among partners who participants concluded knew of their HIV infection. After testing, some HIV-positive partners disclosed prior knowledge of their status. No partner reacted violently. Participants typically comforted their partners and encouraged confirmatory testing. Four participants had anal intercourse with partners who tested positive. Participants and partners were able to effectively handle situations in which the partner tested HIV-positive.

Strategies to improve access for MSM in low-income and middle-income countries

PURPOSE OF REVIEW

HIV prevention and treatment interventions for MSM are not well studied or reported from low-income and middle-income countries (LMIC) in comparison to those targeting gender-conforming populations. Some evidence-based strategies to engage MSM in appropriate healthcare have recently reported on their experiences and impact. Novel recruitment strategies have been developed for treatment and preexposure prophylaxis (PrEP) for MSM, leveraging new community engagement strategies and social media technologies.

RECENT FINDINGS

Despite publication of several new guidelines, there is little recent evidence available to guide MSM health programs in LMIC, highlighting the need for ongoing research and publication. Some important PrEP pilot study results have recently been published, such as the PrEP Brazil and Princess PrEP programmes, which could guide the scale-up of MSM PrEP. The novel use of technology and online platforms to strengthen MSM health delivery and support is particularly important.

SUMMARY

Providing healthcare to MSM requires consideration of context, broad stakeholder engagement, implementation of best practice guidelines and ongoing situational assessment and integration of novel community engagement methods that are evidence-based. Implementation of improved antiretroviral programmes and the access to PrEP for MSM are vital.

Female sex workers perspectives and concerns regarding HIV self-testing: an exploratory study in Tanzania

BACKGROUND

HIV testing is a gateway to HIV care and treatment for people diagnosed with HIV and can link those with negative results to HIV preventive services. Despite the importance of HIV testing services (HTS) in HIV control, uptake of HTS among female sex workers (FSWs) across sub-Saharan Africa (SSA) remains sub-optimal. Concerns about stigma associated with sex work and fear of loss of livelihood if HIV status becomes known, are some of the restrictions for FSWs to utilize HTS offered through health care facilities. Introduction of HIV self-testing (HIVST) may mitigate some of the barriers for the uptake of HTS. This study explored the acceptability of FSWs towards the introduction of HIVST in Tanzania.

METHODS

We conducted an exploratory study employing in-depth interviews (IDI) and participatory group discussions (PGD) with FSWs in selected regions of Tanzania. Study participants were recruited through snowball sampling. Data were thematically analysed by two analysts using NVivo software. The analysis was informed by the social-ecological model and focused on factors associated with the acceptability of HIVST.

RESULTS

We conducted 21 PGD sessions involving 227 FSWs. Twenty three IDIs were conducted to complement data collected through PGD. Our study has demonstrated that FSWs are enthusiastic toward HIVST. Convenience (time and cost saved), and belief that HIVST will increase privacy and confidentiality motivated participants' support for the self-testing approach. Participants did express concerns about their ability to interpret and trust the results of the test. Participants also expressed concern that HIVST could cause personal harm, including severe distress and self-harm for individuals with a reactive test. Very likely, concern about adverse effects of HIVST was linked to the study participants' lay perception that HIVST would be provided only through unassisted modality.

CONCLUSIONS

FSWs demonstrated high enthusiasm to use the HIVST once it becomes available. Expectations for increased confidentiality, autonomy, and reduced opportunity costs were among the leading factors that attracted FSWs to HIVST. The major obstacles to the acceptability of HIVST included fear of HIV reactive test and not trusting self-diagnoses. Our findings underscore the importance of providing adequate access to counselling and referral services in conjunction with HIVST.

An implementation study of oral and blood-based HIV self-testing and linkage to care among men in rural and peri-urban KwaZulu-Natal, South Africa

INTRODUCTION

In South Africa, HIV-infected men are less likely than women to test and know their status (the first UNAIDS "90-90-90" target), and men have worse outcomes across the HIV care cascade. HIV self-testing (HIVST) may address this testing disparity but questions remain over the most effective distribution strategy and linkage following a positive test result. We implemented a men-focused HIVST distribution programme to evaluate components contributing to participation and retention.

METHODS

We conducted an implementation study of multi-venue HIVST kit distribution in rural and peri-urban KwaZulu-Natal (KZN), South Africa. We distributed HIVST kits at community points, workplaces and social venues for on site or take-home use. Clients could choose blood-based or oral-fluid-based HIVST kits and elect to watch an in-person or video demonstration. We provided a USD2 incentive to facilitate reporting test results by phone or SMS. Persons with reactive HIVST results were provided immediate confirmatory tests (if used HIVST on site) or were referred for confirmatory testing (if took HIVST off site) and linkage to care for ART initiation. We describe the testing and linkage cascade in this sample and describe predictors of reactive HIVST results and linkage.

RESULTS

Between July and November 2018, we distributed 4496 HIVST kits in two regions of KZN (96% to men, median age 28 (IQR 23 to 35). Most participants (58%) chose blood-based HIVST and 42% chose oral-swab kits. 11% of men were testing for the first time. A total of 3902 (83%) of testers reported their test result to the study team, with 314 (8%) screening positive for HIV. Among 274 men with reactive HIVST results, 68% linked to ART; no significant predictors of linkage were identified. 10% of kit users reported they would prefer a different type (oral vs. blood) of kit for repeat testing than the type they used.

CONCLUSIONS

HIVST is acceptable to men and rapid distribution with optional testing support is feasible in rural and peri-urban settings. HIVST kits successfully reached younger men and identified undetected infections. Both oral and blood-based HIVST were selected. Scaling up HIVST distribution and guidance may increase the number of first-time testers among men and help achieve the first UNAIDS "90" for men in South Africa.

Sexual network distribution of HIV self-testing kits: Findings from the process evaluation of an intervention for men who have sex with men in China

BACKGROUND

The World Health Organization has recommended HIV self-testing (HIVST) as an alternative testing strategy given the limitations of facility-based testing. While the benefits of HIV self-testing have been demonstrated at the individual level among men who have sex with men (MSM), limited data exist on if this testing approach can be effectively diffused through individuals' social or sexual networks. The objectives of this study were to examine patterns and correlates of HIVST distribution within Chinese MSM's sexual networks.

METHODS

Data used for this analysis was a part of the process evaluation of an HIVST intervention trial among MSM in Nanjing, China. Between May and October 2017, we enrolled 400 men into the trial. Participants assigned to the intervention group (N = 200) were given three HIVST kits at baseline and could request more during the follow-up periods. We incorporated measures for process evaluation in the self-administered online follow-up surveys. This analysis reported findings from the three-month follow-up survey in the intervention group. Frequencies and percentages were used to describe characteristics of participants who distributed kits to their sexual partners as well as patterns of distribution. Multivariable logistic regression was conducted to identify independent correlates of participants who distributed the kits.

RESULTS

Of the 177 participants retained (88.5%) at the three-month follow-up, 72 (40.7%) distributed one or more kits to either primary or casual partners. About half of distributors (51.4%) gave one HIVST kit to their sexual partners while 15.3% distributed 3 or more. Over half gave these kits (58.3%) to primary sexual partners while 27.8% reported giving the kits to both primary and casual partners. About half (54.2%) of distributors used the kits together with their partners. Compared to participants who had an HIV test in the past six months, those who tested over six months ago or never tested had significantly lower odds of distributing the kits (AOR = 0.484, 95% CI: 0.250-0.983, p = 0.032). Compared to those who had not used the kits themselves, participants who did had significantly higher odds of distributing the kits (AOR = 3.345, 95% CI: 1.488-7.517, p = 0.003). Participants who reported higher HIV testing efficacy had 2.051 fold greater odds (95% CI: 1.062-3.961, p = 0.033) of distributing the kits compared to those who had lower efficacy.

CONCLUSION

Our study demonstrated that a sexual network-based approach to distributing HIVST among Chinese MSM is feasible and can be a promising strategy to improve the effectiveness of HIVST programs including its reach to untested men. Such approach should be complimented by intervention components that enhance HIV testing efficacy and improve experiences of HIVST.

HIV self-testing: The key to unlock the first 90 in West and Central Africa

The West and Central African region (WCAR) still registers some of the highest rates of new HIV infections worldwide (16%) despite a low prevalence of HIV (1.9%). In this region, only 48% of people living with HIV are aware of their HIV status. To fill this gap, HIV Self testing (HIVST) could potentially be an additional approach to overcome the barriers to diagnose HIV infected patients, therefore being one of the keys to unlock the first 90 as recommended by the World Health Organization (WHO) since 2016. However, many challenges remain for the adoption of HIVST in routine clinical practice in low prevalence settings and need to be contextualized to WCAR settings. We report in this paper some of the challenges and discuss opportunities for a successful implementation of HIVST in the WCAR.

Usability assessment of seven HIV self-test devices conducted with lay-users in Johannesburg, South Africa

Introduction

The first 90 of the 90-90-90 initiative introduced by the World Health Organization(WHO) in 2015 requires 90% of people with HIV be aware of their status by 2020. In South Africa, conventional facility-based testing had reached 84.9% in 2018; innovative new methods, like HIV self-testing(HIVST) may close the testing gap. This study aimed to determine the usability of seven HIVST kits among untrained South Africans.

Methods

This cross-sectional study of 1400 adults in Johannesburg evaluated the usability of five blood fingerstick and two oral fluid HIVSTs, using WHO prequalification criteria, from June 2016 to June 2018. Participants were handed one kit, with no further information about the device or test procedure, and asked to perform the test in front of an observer. The observer used product-specific semi-structured questionnaires organized into a composite usability index(UI) using a HIVST process checklist, a contrived results interpretation and a post-test interview that expanded on participant experiences with the device and instructions-of-use(IFU). Participants were not tested themselves, but provided with contrived results to interpret.

Results

The average UI was 92.8%(84.2%-97.6%); the major difficulty was obtaining and transferring the specimen. Participants correctly interpreted 96.1% of the non-reactive/negative, 97.0% of the reactive/positive, 98.0% of the invalid and 79.9% of the weak positive results. Almost all participants(97.0%) stated they would visit a clinic or seek treatment for positive results; with negative results, half(50.6%) stated they should re-test in the next three months while one-third(36.1%) said they should condomize. Nearly all found the devices easy to use(96.6%), the IFUSs easy to understand(97.9%) and felt confident using the test unassisted(95.9%) but suggested improvements to packaging/IFUs to further increase usability; 19.9% preferred clinic-based testing to HIVST.

Conclusion

The UI and interpretation of results was high and in-line with previous usability studies, suggesting that these kits are appropriate for use in the general, untrained and unsupervised public.

HIV self-screening distribution preferences and experiences among men who have sex with men in Mpumalanga Province: Informing policy for South Africa

Current research suggests that HIV self-screening (HIVSS) is a feasible and acceptable approach to increase HIV testing among men who have sex with men (MSM). However, few data are available to shape policy around dissemination and implementation. Gaps in knowledge include preferences for distribution of HIVSS kits, potential social harms and benefits of their use, and how much test users would be willing to pay for the kits. The aim was to inform policy recommendations to optimise distribution of HIVSS kits to MSM in South Africa (SA), where there is a high HIV incidence and unmet testing needs. MSM in the high-HIV-prevalence Gert Sibande and Ehlanzeni districts of Mpumalanga Province, SA, were enrolled between October 2015 and May 2017. Participants were provided with their choice of blood or oral fluid HIVSS test kits, receiving 5 kits at enrolment and 4 additional kits at the 3-month follow-up visit. Questionnaires were administered at enrolment, 3 months and 6 months. We analysed participants' reported social benefits and harms, and their preferences for kit distribution and pricing. Among 127 MSM screened and enrolled, 114 responded to follow-up questionnaires regarding distribution preferences, 49.3% preferred to acquire HIVSS kits at a community-based organisation (CBO) and 42.7% at a clinic, with 8% preferring a pharmacy. Participants with higher education preferred CBO sites for distribution; in other respects preferences were similar by demographic characteristics. Reported social benefits were common, including knowing one's status, prevention knowledge gained and improved communication with partners. Despite ubiquitous interest in using the kits, the majority of MSM could not afford to purchase test kits. SA guidelines have integrated HIVSS into HIV and testing policy, but little has been published regarding distribution channels of the kits for MSM and other key populations. There is a partnership between the National Department of Health and CBOs that specialise in key population programming to ensure MSM and other populations with unmet testing needs can access affordable test kits. We observed no social harms, and there were multiple social benefits. Consequently, we recommend immediate free or low-cost distribution of HIVSS kits to MSM through community-based initiatives. Future research should continue to assess optimised linkage to care.

Ability to understand and correctly follow HIV self-test kit instructions for use: applying the cognitive interview technique in Malawi and Zambia

INTRODUCTION

The ability to achieve an accurate test result and interpret it correctly is critical to the impact and effectiveness of HIV self-testing (HIVST). Simple and easy-to-use devices, instructions for use (IFU) and other support tools have been shown to be key to good performance in sub-Saharan Africa and may be highly contextual. The objective of this study was to explore the utility of cognitive interviewing in optimizing the local understanding of manufacturers' IFUs to achieve an accurate HIVST result.

METHODS

Functionally literate and antiretroviral therapy-naive participants were purposefully selected between May 2016 and June 2017 to represent intended users of HIV self-tests from urban and rural areas in Malawi and Zambia. Participants were asked to follow IFUs for HIVST. We then conducted cognitive interviews and observed participants while they attempted to complete the HIVST steps using a structured guide, which mirrored the steps in the IFU. Qualitative data were analysed using a thematic approach.

RESULTS

Of a total of 61 participants, many successfully performed most steps in the IFU. Some had difficulties in understanding these and made errors, which could have led to incorrect test results, such as incorrect use of buffer and reading the results prematurely. Participants with lower levels of literacy and inexperience with standard pictorial images were more likely to struggle with IFUs. Difficulties tended to be more pronounced among those in rural settings. Ambiguous terms and translations in the IFU, unfamiliar images and symbols, and unclear order of the steps to be followed were most commonly linked to errors and lower comprehension among participants. Feedback was provided to the manufacturer on the findings, which resulted in further optimization of IFUs.

CONCLUSIONS

Cognitive interviewing identifies local difficulties in conducting HIVST from manufacturer-translated IFUs. It is a useful and practical methodology to optimize IFUs and make them more understandable.

HIV self-testing: South African young adults' recommendations for ease of use, test kit contents, accessibility, and supportive resources

BACKGROUND

The uptake of HIV self-testing (HIVST) could address socio-structural barriers that prevent South African youth from utilizing the testing resources available in their communities. However, to facilitate this, we must tailor components of the HIVST kit and process to ensure that we reach and encourage youth to test. The purpose of this study to elucidate concerns and issues regarding HIVST rollout among South African youth.

METHODS

This study was conducted in two phases: 1) focus group discussions with rural, South African youth aged 18-24 and 2) direct observations of participants completing with an oral HIVST kit and/or a blood based HIVST kit. In phase 2a participants were invited to try both an oral and blood-based HIVST kit. In phase 2b, participants selected the HIVST kit of their choice.

RESULTS

We enrolled 35 unique participants in phase 1, 20 participants in phase 2a, and 40 participants in phase 2b. While the focus group discussions highlighted hypothetical HIVST use only, participants appreciated the privacy that the HIVST could afford them. However, they expressed concerns about whether HIVST could be trusted due to false positives and negatives, as well as whether a person would be able to emotionally handle the results if they tested alone. They suggested that the kits be used alongside someone who could provide support. In phases 2a and 2b, participants were overwhelmingly positive about both kits regarding ease of use and whether their results could be trusted. The participants, however, experienced more challenges with the blood-based versus oral test. When given the choice in phase 2b, most participants (80%) chose the oral HIVST over the blood-based HIVST.

CONCLUSIONS

During the focus group discussions, participants raised concerns about the validity of HIVST, lack of emotional support when testing alone, and the cost of HIVST kits, all of which could be addressed through current testing campaigns. Most of those who actually tested had positive experiences with HIVST and would recommend it to their friends. When offered a choice, most preferred the oral test.

TRIAL REGISTRATION

NCT03162965 , registered 19th May 2017.