Self-sampling kits to increase HIV testing among black Africans in the UK: the HAUS mixed-methods study

Evaluating the Implementation of Home-Based Sexual Health Care Among Men Who Have Sex with Men: Limburg4zero

Home-based sexual health care (including self-sampling testing) could reduce barriers to clinic-based testing. This study systematically evaluated the implementation of home-based sexual health care ('Limburg4Zero') among men who have sex with men (MSM) in a mixed urban-rural region of the Netherlands. We systematically assessed implementation outcomes (contextual domains, population reached, effectiveness, adoption by health care providers (HCP), implementation fidelity, and maintenance) using the practical, robust implementation and sustainability model. We used a mixed-methods research design that combined survey and in-depth interview data from our priority population (MSM) and implementers with insights from our community advisory board and field notes from monthly meetings with the implementers. Of 1076 requested tests, 906 MSM received a (self-sampling STI/HIV) test kit and sexual health information. Most participants (median age 31) had a university or college degree and had a Western ethnicity. The return rate for laboratory testing was 67%. Home-based care participants more often never tested HIV before (39%) compared to STI clinic attendees (28%). Adoption by HCP was highly acceptable, although perceived pragmatic and technical challenges were experienced. Key elements of the home-based care service were implemented as designed, with co-created adjustments for optimization during the implementation. Maintaining the innovation in the long term was desirable, although future recommendations for efficient continuation should be considered. Implementation of home-based sexual health care has demonstrably increased care accessibility for MSM who had never previously been tested. Therefore, a systematic approach is crucial to foster the impact of home-based sexual health care.

Acceptability of self-sampling and self-testing for infections: a rapid systematic review on public users' views

BACKGROUND

Self-sampling and self-testing have been increasingly used for sexually transmitted infections (STIs) and quickly became widespread during the COVID-19 pandemic. User acceptability, preferences, and experiences are important factors affecting self-sampling/self-testing uptake. Understanding these factors is key to managing infections and planning responses to health emergencies. This review aimed to identify user views and experiences related to the acceptability, usability, motivations and preferences for self-sampling/self-testing for infections.

METHODS

We conducted a rapid systematic review. We searched Medline, EMBASE, PsycINFO, CINAHL, and Web of Science, limiting records to those published in English between 2014 and 2023. We also searched manually for additional peer-reviewed and grey literature. We included reports of public users' views on self-sampling/self-testing for any symptomatic and asymptomatic infections (except human papillomavirus) with qualitative, mixed-methods or survey data relevant to the review aim. Data were extracted into tables and qualitative findings were coded in NVivo. We synthesised data narratively.

RESULTS

We identified 194 eligible reports, including 64 from Europe (which we prioritised for detailed synthesis) and 130 from outside of Europe. In Europe, the studied infections were respiratory (n = 42, including 37 for COVID-19), STIs/HIV/genital infections (n = 20), and hepatitis C (n = 2). Findings indicate that users found self-sampling/self-testing acceptable across infection/sampling types, populations, settings, and countries. Users wanted self-sampling/self-testing to help determine infection status and protect others. The main benefits were privacy and convenience, helping reduce the potential stigma of STIs/HIV/genital infections, and (for COVID-19) informing behaviour (e.g., socialising, self-isolating) and contributing to research. Easier to perform and less invasive sampling approaches were more acceptable. However, some participants reported challenges to self-sampling/self-testing, such as not understanding instructions, pain/discomfort in collecting samples, and lack of confidence in interpreting results.

CONCLUSIONS

This review synthesised evidence on the acceptability of SS/ST and factors affecting it across different infections, sampling approaches, settings, and populations. Evidence shows that most people with experience of self-sampling/self-testing found it acceptable and were willing to accept some discomfort in favour of several perceived benefits. This amenability to self-sampling/self-testing could be leveraged for diagnosing infections and preventing transmission. It can be used to support the viability of new models of clinical care and pandemic preparedness.

TRIAL REGISTRATION

The review was pre-registered on PROSPERO (ref. CRD42024507656 ).

Understanding Practical, Robust Implementation and Sustainability of Home-based Comprehensive Sexual Health Care: A Realist Review

This review identifies which elements of home-based comprehensive sexual health care (home-based CSH) impacted which key populations, under which circumstances. A realist review of studies focused on home-based CSH with at least self-sampling or self-testing HIV and additional sexual health care (e.g., treatment, counseling). Peer-reviewed quantitative and qualitative literature from PubMed, Embase, Cochrane Register of Controlled Trials, and PsycINFO published between February 2012 and February 2023 was examined. The PRISM framework was used to systematically assess the reach of key populations, effectiveness of the intervention, and effects on the adoption, implementation, and maintenance within routine sexual health care. Of 730 uniquely identified records, 93 were selected for extraction. Of these studies, 60% reported actual interventions and 40% described the acceptability and feasibility. Studies were mainly based in Europe or North America and were mostly targeted to MSM (59%; 55/93) (R). Overall, self-sampling or self-testing was highly acceptable across key populations. The effectiveness of most studies was (expected) increased HIV testing. Adoption of the home-based CSH was acceptable for care providers if linkage to care was available, even though a minority of studies reported adoption by care providers and implementation fidelity of the intervention. Most studies suggested maintenance of home-based CSH complementary to clinic-based care. Context and mechanisms were identified which may enhance implementation and maintenance of home-based CSH. When providing the individual with a choice of testing, clear instructions, and tailored dissemination successful uptake of STI and HIV testing may increase. For implementers perceived care and treatment benefits for clients may increase their willingness to implement home-based CSH. Therefore, home-based CSH may determine more accessible sexual health care and increased uptake of STI and HIV testing among key populations.

Interventions supporting engagement with sexual healthcare among people of Black ethnicity: a systematic review of behaviour change techniques

BACKGROUND

Black ethnic groups are disproportionately affected by sexually transmitted infections (STIs). This review aimed to identify interventions designed to increase engagement with sexual healthcare among people of Black ethnicity as determined by rates of STI testing, adherence to sexual health treatment, and attendance at sexual healthcare consultations. The behaviour change techniques (BCTs) used within identified interventions were evaluated.

METHOD

Four electronic databases (Web of science; ProQuest; Scopus; PubMed) were systematically searched to identify eligible articles published between 2000 and 2022. Studies were critically appraised using the Mixed Methods Appraisal Tool. Findings were narratively synthesised.

RESULTS

Twenty one studies across two countries were included. Studies included randomised controlled trials and non-randomised designs. Behavioural interventions had the potential to increase STI/HIV testing, sexual healthcare consultation attendance and adherence to sexual health treatment. Behavioural theory underpinned 16 interventions which addressed barriers to engaging with sexual healthcare. Intervention facilitators' demographics and lived experience were frequently matched to those of recipients. The most frequently identified novel BCTs in effective interventions included information about health consequences, instruction on how to perform behaviour, information about social and environmental consequences, framing/reframing, problem solving, and review behavioural goal(s).

DISCUSSION

Our findings highlight the importance of considering sociocultural, structural and socio-economic barriers to increasing engagement with sexual healthcare. Matching the intervention facilitators' demographics and lived experience to intervention recipients may further increase engagement. Examination of different BCT combinations would benefit future sexual health interventions in Black ethnic groups.

Health Consumer Engagement, Enablement, and Empowerment in Smartphone-Enabled Home-Based Diagnostic Testing for Viral Infections: Mixed Methods Study

Background

Health consumers are increasingly taking a more substantial role in decision-making and self-care regarding their health. A range of digital technologies is available for laypeople to find, share, and generate health-related information that supports their health care processes. There is also innovation and interest in home testing enabled by smartphone technology (smartphone-supported home testing [smart HT]). However, few studies have focused on the process from initial engagement to acting on the test results, which involves multiple decisions.

Objective

This study aimed to identify and model the key factors leading to health consumers’ engagement and enablement associated with smart HT. We also explored multiple levels of health care choices resulting from health consumer empowerment and activation from smart HT use. Understanding the factors and choices associated with engagement, enablement, empowerment, and activation helps both research and practice to support the intended and optimal use of smart HT.

Methods

This study reports the findings from 2 phases of a more extensive pilot study of smart HT for viral infection. In these 2 phases, we used mixed methods (semistructured interviews and surveys) to shed light on the situated complexities of health consumers making autonomous decisions to engage with, perform, and act on smart HT, supporting the diagnostic aspects of their health care. Interview (n=31) and survey (n=282) participants underwent smart HT testing for influenza in earlier pilot phases. The survey also extended the viral infection context to include questions related to potential smart HT use for SARS-CoV-2 diagnosis.

Results

Our resulting model revealed the smart HT engagement and enablement factors, as well as choices resulting from empowerment and activation. The model included factors leading to engagement, specifically various intrinsic and extrinsic influences. Moreover, the model included various enablement factors, including the quality of smart HT and the personal capacity to perform smart HT. The model also explores various choices resulting from empowerment and activation from the perspectives of various stakeholders (public vs private) and concerning different levels of impact (personal vs distant).

Conclusions

The findings provide insight into the nuanced and complex ways health consumers make decisions to engage with and perform smart HT and how they may react to positive results in terms of public-private and personal-distant dimensions. Moreover, the study illuminates the role that providers and smart HT sources can play to better support digitally engaged health consumers in the smart HT decision process.

Process Evaluation of a Randomised Controlled Trial for TeleClinical Care, a Smartphone-App Based Model of Care

Background

A novel smartphone app-based model of care (TeleClinical Care – TCC) for patients with acute coronary syndrome (ACS) and heart failure (HF) was evaluated in a two-site, pilot randomised control trial of 164 participants in Sydney, Australia. The program included a telemonitoring system whereby abnormal blood pressure, weight and heart rate readings were monitored by a central clinical team, who subsequently referred clinically significant alerts to the patients' usual general practitioner (GP, also known as primary care physician in the United States), HF nurse or cardiologist. While the primary endpoint, 30-day readmissions, was neutral, intervention arm participants demonstrated improvements in readmission rates over 6 months, cardiac rehabilitation (CR) completion and medication compliance. A process evaluation was designed to identify contextual factors and mechanisms that influenced the results, as well as strategies of improving site and participant recruitment and the delivery of the intervention, for a planned larger effectiveness trial of over 1,000 patients across the state of New South Wales, Australia (TCC-Cardiac).

Methods

Multiple data sources were used in this mixed-methods process evaluation, including interviews with four TCC team members, three GPs and three cardiologists. CR completion rates, HF outreach service (HFOS) referrals and cardiologist follow-up appointments were audited. A patient questionnaire was also analysed for evidence of improved self-care as a hypothesised mechanism of the TCC app. An implementation research logic model was used to synthesise our findings.

Results

Rates of HFOS referral (83 vs. 72%) and cardiologist follow-up (96 vs. 93%) were similarly high in the intervention and control arms, respectively. Team members were largely positive towards their orientation and training, but highlighted several implementation strategies that could be optimised for TCC-Cardiac: streamlining of the enrolment process, improving the reach of the trial by screening patients in non-cardiac wards, and ensuring team members had adequate time to recruit (>15 h per week). GPs and cardiologists viewed the intervention acceptably regarding potential benefit of closely monitoring, and responding to abnormalities for their patients, though there were concerns of the potential additional workload generated by alerts that did not merit clinical intervention. Clear delineation of which clinician (GP or cardiologist) was primarily responsible for alert management was also recommended, as well as a preference to receive regular summary data. Several patients commented on the mechanisms of improved self-management because of TCC, which could have led to the outcome of improved medication compliance.

Discussion

Use of TCC was associated with several benefits, including higher patient engagement and completion rates with CR. The conduct and delivery of TCC-Cardiac will be improved by the findings of this process evaluation to optimise recruitment, and establishing the roles of GPs and cardiologists as part of the model.

How has implementation been incorporated in health technology assessments in the United Kingdom? A systematic rapid review

OBJECTIVES

Health interventions in a clinical setting may be complex. This is particularly true of clinical interventions which require systems reorganization or behavioural change, and/or when implementation involves additional challenges not captured within a clinical trial setting. Medical Research Council guidance on complex interventions highlights the need to consider economic evaluation alongside implementation. However, the extent to which this guidance has been adhered to, and how, is unclear. The failure to incorporate implementation within the evaluation of an intervention may hinder the translation of research findings into routine practice. This will have consequences for patient care. This study examined the methods used to address implementation within health research conducted through funding from the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme.

METHODS

We conducted a rapid review using a systematic approach. We included all NIHR HTA monographs which contained the word "implementation" within the title or abstract published between 2014 and 2020. We assessed the studies according to existing recommendations for specifying and reporting implementation approaches in research. Additional themes which were not included in the recommendation, but were of particular relevance to our research question, were also identified and summarized in a narrative synthesis.

RESULTS

The extent to which implementation was formally incorporated, and defined, varied among studies. Methods for examining implementation ranged from single stakeholder engagement events to the more comprehensive process evaluation. There was no obvious pattern as to whether approaches to implementation had evolved over recent years. Approximately 50% (22/42) of studies included an economic evaluation. Of these, two studies included the use of qualitative data obtained within the study to quantitatively inform aspects relating to implementation and economic evaluation in their study.

DISCUSSION

A variety of approaches were identified for incorporating implementation within an HTA. However, they did not go far enough in terms of incorporating implementation into the actual design and evaluation. To ensure the implementation of clinically effective and cost-effective interventions, we propose that further guidance on how to incorporate implementation within complex interventions is required. Incorporating implementation into economic evaluation provides a step in this direction.

Characteristics of newly diagnosed HIV-positive service users using a pan-London e-sexually transmitted infection screening service

Maximising opportunities and removing barriers to HIV testing can help reduce the undiagnosed HIV population. Digital STI/HIV screening services have increased in availability and can improve access and testing coverage. We identified the characteristics of individuals who tested HIV positive using a regional, integrated, self-sampling STI service. The e-notes of service users with reactive HIV screening results were reviewed. Between 8 January 2018 and 31 December 2019, 0.097% (144/148,257) users received a reactive HIV result, 30/144 (20.8%) of whom had previously diagnosed HIV infection. All of the remaining 114 users were notified of their screening result, an estimated 109/114 (95.6%) received confirmatory testing (CT) at a sexual health clinic (SHC) and the confirmatory outcome was documented in 102/114 (89.5%) of cases: 34/114 (29.8%)were HIV positive, 68/114 (59.6%) HIV were negative and the result was unknown in 12/114 (10.5%). All new diagnoses transitioned to HIV outpatient care. These individuals were median age 28 years; 94.1% (32/34) male; 88.2% (30/34) men who have sex with men and 11.8% (4/34) heterosexual; 58.8% (20/34) of white/'white other' ethnicity and 42.2% of Black, Asian and minority ethnic group; 50%(17/34) had a concurrent STI; 9% and 21% had never tested for HIV or attended a SHC before. n HIV test reactivity rate of 0.1%(95% CI) was observed. Confirmed new HIV diagnoses comprised 0.023% of all HIV tests performed. All individuals where CT confirmed a new HIV diagnosis transitioned to HIV specialist care.

Potential of HIV Self-Sampling to Increase Testing Frequency Among Gay, Bisexual, and Other Men Who Have Sex With Men, and the Role of Online Result Communication: Online Cross-Sectional Study

Background

Late HIV diagnosis remains frequent among the gay, bisexual, and other men who have sex with men (GBMSM) population across Europe. HIV self-sampling could help remove barriers and facilitate access to testing for this high-risk population.

Objective

We assessed the capacity of HIV self-sampling to increase the testing frequency among GBMSM living in Denmark, Germany, Greece, Portugal, Romania, and Spain, and evaluated the role of new technologies in the result communication phase.

Methods

We analyzed a convenience sample of 5019 GBMSM with prior HIV testing experience who were recruited during 2016 through gay dating websites. We estimated the proportion of GBMSM who reported that the availability of self-sampling would result in an increase of their current testing frequency. We constructed a Poisson regression model for each country to calculate prevalence ratios and 95% CIs of factors associated with an increase of testing frequency as a result of self-sampling availability.

Results

Overall, 59% (between country range 54.2%-77.2%) of the participants considered that they would test more frequently for HIV if self-sampling was available in their country. In the multivariate analysis, the increase of testing frequency as a result of self-sampling availability was independently associated with reporting a higher number of unprotected anal intercourse events in all countries except for Greece. Independent associations were also observed among GBMSM who were not open about their sex life in Germany, Greece, Portugal, and Spain; those with a lower number of previous HIV tests in Denmark, Greece, Portugal, and Spain; and for those that took their last test more than 3 months previously in Germany, Portugal, Romania, and Spain. In addition, 58.4% (range 40.5%-73.6%) of the participants indicated a preference for learning their result through one-way interaction methods, mainly via email (25.6%, range 16.8%-35.2%) and through a secure website (20.3%, range 7.3%-23.7%). Almost two thirds (65%) of GBMSM indicated preferring one of these methods even if the result was reactive.

Conclusions

Availability of HIV self-sampling kits as an additional testing methodology would lead to a much-needed increase of testing frequency, especially for the hidden, high-risk, and undertested GBMSM population. Online-based technologies without any personal interaction were preferred for the communication of the results, even for reactive results.

Surveying testing preferences in Black, Latin American, and other minorities for the co-design of digital vending machines for HIV self-testing

The use of digital vending machines (VMs) to delivery HIV self-testing (HIVST) could expand HIV testing in priority populations. We surveyed primarily Black African (BA) participants and other minority ethnicities, to identify acceptability, preferences, and concerns of using VMs for HIVST dispensing. A structured survey was developed with Black African and Caribbean, Latin American and other Minorities (BLAM) communities, and distributed between September 2018 and January 2019. Participants were recruited using mobile tablet surveys distributed by outreach volunteers, and online through BLAM communities’ websites, workshops, and language-specific messages on social media. Descriptive analyses were undertaken stratified by ethnic groups. One hundred and twenty-eight (67.0%) participants identified as BAs, 31 (16.2%) Black Caribbeans (BCs), 22 (11.5%) Latin Americans (LAs), and 10 (5.2%) other non-white ethnicities (ONWEs). Rates of willingness to use the HIVST were high in all groups except BCs (BAs 77.9%, BCs 53.6%, LAs 81.8%, ONWEs 80.0%). Most participants favoured healthcare-associated venues for VM placement, but there were differences in community venues favoured by different ethnic groups and concerns reported. HIVST is acceptable in many BLAM communities and increases understanding of the concerns and how to address them in the design of VMs for HIVST, to expand HIV testing in these priority communities.

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

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

HCV and HBV prevalence based on home blood self-sampling and screening history in the general population in 2016: contribution to the new French screening strategy

Background

The advent of effective direct-acting antivirals (DAAs), has prompted an assessment of the French Hepatitis C virus (HCV) screening strategy, which historically targeted high-risk groups. One of the options put forward is the implementation of combined (i.e., simultaneous) HCV, Hepatitis B virus (HBV) and HIV screening for all adults at least once during their lifetime (“universal combined screening”). However, recent national survey-based data are lacking to guide decision-making regarding which new strategy to implement. Accordingly, we aimed to provide updated data for both chronic hepatitis C (CHC) and B (CHB) prevalence and for HCV and HBV screening history, using data from the BaroTest and 2016 Health Barometer (2016-HB) studies, respectively.

Methods

2016-HB was a national cross-sectional phone based health survey conducted in 2016 among 20,032 randomly selected individuals from the general population in mainland France. BaroTest was a virological sub-study nested in 2016-HB. Data collected for BaroTest were based on home blood self-sampling on dried blood spots (DBS).

Results

From 6945 analyzed DBS, chronic hepatitis C (CHC) and B (CHB) prevalence was estimated at 0.30% (95% Confidence Interval (CI): 0.13-0.70) and 0.30% (95% CI: 0.13-0.70), respectively. The proportion of individuals aware of their status was estimated at 80.6% (95% CI: 44.2-95.6) for CHC and 17.5% (95% CI: 4.9-46.4) for CHB. Universal combined screening would involve testing between 32.6 and 85.3% of 15-75 year olds according to whether we consider only individuals not previously tested for any of the three viruses, or also those already tested for one or two of the viruses.

Conclusions

Our data are essential to guide decision-making regarding which new HCV screening recommendation to implement in France. They also highlight that efforts are still needed to achieve the WHO’s targets for eliminating these diseases. Home blood self-sampling may prove to be a useful tool for screening and epidemiological studies.

Pilot phase of an internet-based RCT of HIVST targeting MSM and transgender people in England and Wales: advertising strategies and acceptability of the intervention

BACKGROUND

The SELPHI study (An HIV Self-Testing Public Health Intervention) is an online randomised controlled trial (RCT) of HIV self-testing (HIVST). The aim of this study was to assess the feasibility of recruiting UK men who have sex with men (cis and trans) and trans women who have sex with men to the SELPHI pilot, and the acceptability of the HIVST intervention used among those randomised to receive a kit.

METHODS

A mixed-methods approach to assessing trial feasibility and intervention acceptability was taken, using quantitative data from advertising sources and RCT surveys alongside qualitative data from a nested sub-study.

RESULTS

Online recruitment and intervention delivery was feasible. The recruitment strategy led to the registration of 1370 participants of whom 76% (1035) successfully enrolled and were randomised 60/40 to baseline testing vs no baseline testing. Advertising platforms performed variably. Reported HIVST kit use increased from 83% at two weeks to 96% at three months. Acceptability was very high across all quantitative measures. Participants described the instructions as easy to use, and the testing process as simple. The support structures in SELPHI were felt to be adequate. Described emotional responses to HIVST varied.

CONCLUSIONS

Recruiting to a modest sized HIVST pilot RCT is feasible, and the recruitment, intervention and HIVST kit were acceptable. Research on support needs of individuals with reactive results is warranted.