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

Understanding the Stigma Experience of Men Living with HIV in Sub-Saharan Africa: A Qualitative Meta-synthesis

Men living with HIV (MLWH) in sub-Saharan Africa experience poor health outcomes and increased AIDS-related deaths due to stigma influencing testing and treatment uptake and adherence. PRISMA 2020 was used to report a meta-synthesis of the stigma experiences of MLWH in SSA. With the help of an expert librarian, a search of six databases was formulated and performed to examine the available qualitative and mixed method studies with qualitative results relevant to the research question. Studies focused on adult men living with HIV, with five studies specifically examining the HIV experience of men who have sex with men. Study themes were synthesized to describe MLWH's perceived, internalized, anticipated, enacted, and intersectional stigma experiences. Most studies included masculinity as a key theme that affected both testing and treatment adherence upon diagnosis. Future research is needed to better understand subpopulations, such as men who have sex with men living with HIV, and what interventions may be beneficial to mitigate the disparities among MLWH in SSA.

Knowledge, and utilization of HIV self-testing, and its associated factors among women in sub-Saharan Africa: evidence from 21 countries demographic and health survey

BACKGROUND

HIV Self-Testing (HIVST) holds great significance in the fight against the HIV epidemic in Sub-Saharan Africa (SSA). It offers a convenient and confidential option for individuals to know their HIV status and seek appropriate care and support. For women in this region, where stigma, discrimination, and lack of access to healthcare services are prevalent, HIVST can empower them to take control of their health and make informed decisions. However, no study in the region has been conducted on this topic. Hence, this study aimed to fill the evidence, and population gaps by identifying women's HIVST knowledge, and utilization, and its associated factors in SSA.

METHODS

The data used were gathered from the most recent demographic and health surveys conducted in SSA nations between 2015 and 2022. We incorporated DHS data from 21 countries into our investigation. For our analysis, we used a weighted sample of 270,241 women overall was utilized. To handle both individual and community level factors, a multilevel logistic regression was used for the analysis. The adjusted odds ratio and its 95% confidence interval were then presented, and variables with univariate multilevel regression p-values of ≤ 0.25 and in multivariable multilevel logistic regression < 0.05 p value were considered significant factors of HIVST.

RESULTS

The overall prevalence of knowledge, and utilization of HIVST among women was about 2.17 (95% CI: 2.12, 2.23) only. Women aged 25-34 years old (AOR = 1.78, 95% CI: 1.65,1.92), and 35-49 years old (AOR = 1.33, 95% CI: 1.22,1.46), primary education(AOR = 1.25, 95%CI: 1.12, 1.38), and secondary/higher education (AOR = 3.08, 95% CI: 2.79, 3.41), poorer (AOR = 1.22, 95% CI: 1.08, 1.38), middle (AOR = 1.19, 95% CI: 1.06, 1.37), richer (AOR = 1.45, 95% CI 1.45, 1.64), and richest (AOR = 1.81, 95% CI: 1.59, 2.05), employed (AOR = 1.73 05% CI: 1.62, 1.85), mass media exposure (AOR = 1.39, 95% CI: 1.31, 1.49), knew modern contraception (AOR = 2.75, 95% CI: 1.84, 4.13), health facility delivery (AOR = 1.17, 95% CI: 1.02, 1.37), being from urban (AOR = 1.53, 95% CI: 1.63, 1.73), divorced or widowed (AOR = 77, 95% CI:1.13, 1.34), have more than one sexual partners (AOR =, 95% CI: 1.24, 1.41), heard about STIs (AOR 7.47 =, 95% CI: 5.16, 10.81), high community ANC coverage (AOR = 1.46, 95% CI: 1.31, 1.63), high community mass media (AOR = 1.37 95% CI: 1.21, 1.56), Central/Southern Africa (AOR = 0.66 95% CI: 0.59,0.74), and East Africa regions (AOR = 0.87 95% CI: 0.81,0.94) were associated with the knowledge and utilization of HIVST.

CONCLUSIONS

The level of knowledge and utilization of HIVST among women in SSA was very low. To improve this situation, maternal health services can be enhanced. This can be achieved by facilitating institutional delivery, promoting access to modern contraception, increasing ANC coverage, empowering women's associations, creating culturally respectful mass media content, and involving rural and economically disadvantaged women. By implementing these measures, we can enhance women's knowledge and improve their use of HIVST.

Self-testing knowledge and beliefs on HIV self-testing use in central Uganda

The government of Uganda and its implementing partners have made significant investments in HIV self-testing (HST) services to reduce clinic-related barriers to HIV testing. However, although HSTs have been around for a reasonable time, their uptake, especially among unskilled working individuals, has remained suboptimal, which threatens the efforts to achieve the 95-95-95 UNAIDS goals to end HIV by 2030. This study set out to examine whether knowledge and individual beliefs about self-testing influence the use of HIV self-tests among causal workers in Kampala. This cross-sectional study was conducted among 453 participants selected via systematic random sampling from Darling Uganda Ltd. in Wakiso district between July and September 2023. Standardized questionnaires were used, and the analysis was performed using Pearson Correlations and Linear Regression in SPSS. The findings indicate that HIV self-testing (HST) knowledge was positively related to HST use (r = .387, p≤.01), perceived susceptibility (r = .212, p≤.01), perceived benefits (r = .152, p≤.01), and perceived barriers (r = .101, p≤.05). Individual beliefs, that is, perceived susceptibility (r = .355, p≤.01), perceived benefits (r = .487, p≤.01), and perceived barriers (r = .148, p≤.01), were significantly related to HST use. Perceived benefits were the best predictor of HST use among this population (β = .442, p = .000). Therefore, (44.2%) of HST use was attributed to the benefits attached to the service. Therefore, increasing awareness regarding the benefits of HST among such populations increases the chances of HIV testing, particularly among men. This can pave the way for the 95-95-95 goal by 2030 of UNAIDS.

Men's perceptions of HIV self-testing in Eswatini: a qualitative study

Men in Eswatini test for HIV at lower rates compared to women despite the widespread availability of HIV testing services in the country. HIV self-test kits have been proposed as an HIV testing model to reach more men by bypassing the health facility, which is known to be a barrier for men using HIV testing services. In this study, we sought to understand men's perspectives on HIV self-testing in Eswatini. We conducted semi-structured interviews with 22 men, recruited from a rural community and from an urban men's clinic, to assess their awareness of HIV self-testing and their perceptions of it as an alternative HIV testing option. Findings show that men were aware of HIV self-testing but had concerns that left most feeling hesitant about adopting it. Many men expressed doubts about the accuracy of self-testing and their own technical competence to use the kit without supervision. They also expressed fears about testing, and possibly learning they were HIV positive, without adequate pre - and post-HIV test counseling. To allay men's fears and improve uptake of HIV self-testing, practitioners might consider innovative methods such as virtual counseling services and linking HIV self-testing to other community-based HIV care services.

Effectiveness of Linkage to Care and Prevention Interventions Following HIV Self-Testing: A Global Systematic Review and Meta-analysis

Over 38.4 million people were living with HIV globally in 2021. The HIV continuum includes HIV testing, diagnosis, linkage to combined antiretroviral therapy (cART), and retention in care. An important innovation in the HIV care continuum is HIV self-testing. There is a paucity of evidence regarding the effectiveness of interventions aimed at linking self-testers to care and prevention, including pre-exposure prophylaxis (PrEP). To bridge this gap, we carried out a global systematic review and meta-analysis to ascertain the effectiveness of interventions post-HIV self-testing regarding: (1) linkage to care or ART, (2) linkage to PrEP, and (3) the impact of HIV self-test (HIVST) interventions on sexual behaviors. We searched PubMed, Web of Science, SCOPUS, Cochrane Library, CINAHL Plus (EBSCO), MEDLINE (Ovid), Google Scholar, and ResearchGate. We included only published randomized controlled trials (RCTs) and quasi-experiment that compared HIVST to the standard of care (SoC). Studies with sufficient data were aggregated using meta-analysis on RevMan 5.4 at a 95% confidence interval. Cochrane's Q test was used to assess heterogeneity between the studies, while Higgins and Thompson's I2 was used to quantify heterogeneity. Subgroup analyses were conducted to identify the source of heterogeneity. Of the 2669 articles obtained from the databases, only 15 studies were eligible for this review, and eight were included in the final meta-analysis. Overall, linkage to care was similar between the HIVST arm and SoC (effect size: 0.92 [0.45-1.86]; I2: 51%; p: 0.04). In the population subgroup analysis, female sex workers (FSWs) in the HIVST arm were significantly linked to care compared to the SoC arm (effect size: 0.53 [0.30-0.94]; I2: 0%; p: 0.41). HIVST interventions did not significantly improve ART initiation in the HIVST arm compared to the SoC arm (effect size: 0.90 [0.45-1.79]; I2: 74%; p: < 0.001). We found that more male partners of women living with HIV in the SoC arm initiated PrEP compared to partners in the HIVST arm. The meta-analysis showed no difference between the HIVST and SoC arm regarding the number of clients (effect size: - 0.66 [1.35-0.02]; I2: 64%; p: 0.09) and non-clients FSWs see per night (effect size: - 1.45 [- 1.45 to 1.38]; I2: 93%; p: < 0.001). HIVST did not reduce the use of condoms during insertive or receptive condomless anal intercourse among MSM. HIVST does not improve linkage to care in the general population but does among FSWs. HIVST intervention does not improve linkage to ART nor significantly stimulate healthy sexual behaviors among priority groups. The only RCT that linked HIVST to PrEP found that PrEP uptake was higher among partners of women living with HIV in the SoC arm than in the HIVST arm. More RCTs among priority groups are needed, and the influence of HIVST on PrEP uptake should be further investigated.

Health provider perspectives of Village Health Team-delivered oral HIV self-testing among men in Central Uganda: a qualitative evaluation using RE-AIM framework

Background

HIV self-testing (HIVST) is a practical and effective way to provide HIV testing services to at-risk and underserved populations, particularly men. Utilizing Village Health Teams (VHTs) could enhance community-based delivery of oral HIVST to reach the last un-tested individuals who may be at-risk of infection. However, little is known about what VHTs and facility-based healthcare workers think about facilitating oral HIVST and delivery of subsequent HIV services. We investigated the views of health providers on oral HIVST delivered by VHTs among men in rural communities in Central Uganda.

Methods

We conducted a qualitative study in Mpigi district, interviewing 27 health providers who facilitated oral HIV self-testing among men. The providers consisting of 15 VHTs and 12 facility-based health workers were purposively selected. All interviews were audio-recorded, transcribed verbatim, and translated to English for a hybrid inductive-deductive thematic analysis. We used the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) Implementation Science framework to generate and categorize open codes.

Results

In terms of reaching men with HIV testing services, the providers considered HIVST to be a fast and convenient method, which could boost HIV testing. However, they also had concerns about its accuracy. In terms of effectiveness, HIVST was perceived as a reliable, user-friendly, and efficient approach to HIV testing. However, it depended on the user's preference for testing algorithms. Regarding adoption, HIVST was considered to enhance autonomy, well-suited for use in the community, and offered opportunities for linkage and re-linkage into care. However, at times HIVST faced hesitance. As for Implementation, VHTs had various support roles in HIVST but had concerns about social insecurities and delays in seeking subsequent facility-based services after HIVST. Regarding Maintenance, providers recommended several ways to improve oral HIVST including; optimizing tracking of HIVST distribution and use, improving linkage and retention in care after HIVST, diversifying HIVST for combined HIV prevention packages and including more languages, broadening sensitization among potential HIVST users and health providers, differentiating distribution models, and prioritizing targeted HIVST efforts.

Conclusion

HIVST has the potential to increase testing rates and engagement of men in HIV services. However, for it to be implemented on a population-wide scale, continuous sensitization of potential users and health providers is necessary, along with streamlined structures for tracking kit distribution, use, and reporting of results. Further implementation research may be necessary to optimize the role of health providers in facilitating HIVST.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Feasibility and Acceptability of Human Immunodeficiency Virus Self-Testing for Men of Middle-to-Upper Socioeconomic Status in Botswana: A Pilot Study at 4 Worksites in the Financial Sector

Background

Although Botswana has made great progress in expanding human immunodeficiency virus (HIV) testing, men are less likely to be tested for HIV and test at a later stage compared with women. For Botswana to increase HIV testing coverage among men, HIV self-testing (HIVST) may be a promising supplement to standard, healthcare facility-based HIV testing. We conducted a pilot test of the feasibility and acceptability of HIVST for men of middle-to-upper socioeconomic status in Botswana.

Methods

Thirty-five men were recruited through 4 workplaces (banking sector). Wellness officers emailed all potentially eligible male employees about the opportunity to participate. Men were surveyed at baseline and follow-up on basic sociodemographic characteristics, HIV testing history, HIV stigma, use of the HIVST kit (at follow-up), and confirmatory testing and linkage to care if a preliminary positive result is obtained (at follow-up).

Results

All 35 men used the kit. The proportion who agreed with the statement that getting tested for HIV helps people feel better increased significantly from 80.7% at baseline to 100% at follow-up. In open-ended questions, men described the advantages of HIVST, including improved privacy and convenience, lowered HIV stigma, and enhanced control over testing. Concerns about HIVST included potential negative mental health consequences owing to not receiving pretest and posttest counseling, and not linking to care after a reactive result.

Conclusions

Results suggest that an intervention in which HIVST is discrete, private, and under men's control can help overcome stigma around HIV testing, resulting in a greater number of men tested.

HIV self-testing acceptability among injured persons seeking emergency care in Nairobi, Kenya

BACKGROUND

Emergency department-based HIV self-testing (ED-HIVST) could increase HIV-testing services to high-risk, under-reached populations.

OBJECTIVES

This study sought to understand the injury patient acceptability of ED-HIVST.

METHODS

Injury patients presenting to the Kenyatta National Hospital Accident and Emergency Department were enrolled from March to May 2021. Likert item data on HIVST assessing domains of general acceptability, personal acceptability, and acceptability to distribute to social and/or sexual networks were collected. Ordinal regression was performed yielding adjusted odds ratios (aOR) to identify characteristics associated with high HIVST acceptability across domains.

RESULTS

Of 600 participants, 88.7% were male, and the median age was 29. Half reported having primary care providers (PCPs) and 86.2% reported prior HIV testing. For each Likert item, an average of 63.5% of the participants reported they 'Agree Completely' with positive statements about ED-HIVST in general, for themselves, and for others. In adjusted analysis for general acceptability, those <25 (aOR = 1.67, 95%CI:1.36-2.08) and with prior HIV testing (aOR = 1.68, 95%CI:1.27-2.21) had greater odds of agreeing completely. For personal acceptability, those with a PCP (aOR = 3.31, 95%CI:2.72-4.03) and prior HIV testing (aOR = 1.83, 95%CI:1.41-2.38) had greater odds of agreeing completely. For distribution acceptability, participants with a PCP (aOR = 2.42, 95%CI:2.01-2.92) and prior HIV testing (aOR = 1.79, 95%CI: 1.38-2.33) had greater odds of agreeing completely.

CONCLUSIONS

ED-HIVST is perceived as highly acceptable, and young people with prior testing and PCPs had significantly greater favourability. These data provide a foundation for ED-HIVST programme development in Kenya.

Interventions to improve young men's utilisation of HIV-testing services in KwaZulu-Natal, South Africa: perspectives of young men and health care providers

Introduction: HIV-testing services (HTS) are an important point of entry to prevention and treatment of HIV in South Africa. Despite the availability of HTS across the region and in SA, the uptake among men remains low, especially young men residing in rural and peri-urban communities. This study aimed to explore interventions that could improve the uptake of HTS among young men in KwaZulu-Natal.Methods: A descriptive exploratory qualitative study was conducted in which 17 young men and two health care providers in Ladysmith were purposively and conveniently sampled. Data were collected through semi-structured interviews using WhatsApp and landline audio calls between September and December 2021 and thematically analysed.Results: An improvement in the health care provider attitudes and service delivery, establishment of adherence clubs for young people living with HIV, ensuring a diverse and balanced health care provider staff composition at primary health care facilities, and increased demand creation in spaces frequented by men are vital for enhancing access and utilisation of HTS among young men. Additionally, health care providers believe that the presence of male health care providers, investment in health education, prioritising men in the morning at the primary health care facilities, and the establishment of male clinics within communities as key factors in improving the uptake of HTS among young men.Conclusion: To attract and retain young men in HTS and in HIV treatment and care, several improvements at primary health care facilities need to be implemented. These should focus on addressing the specific needs and preferences of young men, ensuring their comfort and engagement in health care.

The Use of HIV Pre-exposure Prophylaxis Among Men Accessing Routine Sexual and Reproductive Health Services in South Africa

PURPOSE

This study describes a cohort of men seeking oral pre-exposure prophylaxis (PrEP) services and explores their patterns of PrEP use within an implementation project seeking to integrate PrEP provision within sexual and reproductive health services in public health clinics in South Africa.

METHODS

Routine program and survey data from 364 males initiated on oral PrEP between July 2020 and May 2022 were analyzed. PrEP use was examined, including time to first discontinuation and restart patterns. Factors associated with early PrEP discontinuation and PrEP restart were analyzed.

RESULTS

Despite primarily focusing on access for adolescent girls and young women, PrEP services reached males with HIV prevention needs. PrEP use for ≤1 month (early discontinuation) was high at 58%; however, 18% restarted on PrEP, with 4% restarting repeatedly. Having depression symptoms was associated with early PrEP discontinuation (adjusted odds ratio [AOR]: 1.71, 95% CI [confidence interval]: 1.06-2.78). Those ≥25 years were less likely to discontinue early, as were those with a partner treated for a sexually transmitted infection in the preceding three months (AOR: 0.33, 95% CI: 0.13-0.84) and those who had been circumcised (AOR: 0.59, 95% CI: 0.36-0.96). Those 18-20 years old were less likely to restart PrEP than those ≥25 years (AOR: 0.43, 95% CI: 0.19-0.97), as were those whose partner's HIV status was unknown (AOR: 0.33, 95% CI: 0.12-0.88).

DISCUSSION

This study identified interest and uptake of oral PrEP among an underrepresented population of predominantly heterosexual males seeking sexual and reproductive health services. It found high rates of early PrEP discontinuation, with a subset returning to restart PrEP. Further research is needed to determine whether these periods of PrEP use are associated with periods of HIV risk.

How much does HIV self-testing cost in low and middle income countries? A systematic review of evidence from economic studies

Objectives

HIV self-testing (HIVST) has been proposed as an innovative strategy to diagnose human immunodeficiency virus (HIV). While HIVST offers the potential to broaden accessibility of early HIV diagnosis and treatment initiation, this testing strategy incurs additional cost and requires confirmatory testing and treatment. We have conducted the first systematic review to summarize the current economic literature for HIVST in low- and middle-income countries (LMICs).

Design

A search strategy was developed including key terms for HIV, self-testing and cost-effectiveness and was conducted in Medline and Embase databases. Studies were included that reported costs per outcome and included both cost-effectiveness and cost-utility outcome measures. The search strategy identified publications up until August 15, 2023 were included. Abstract and full text screening was conducted and a standardized data abstraction form was used for included studies. Costs are reported in USD, 2020.

Results

Our search strategy identified 536 total titles from the search strategy, which were screened down to 25 relevant studies that provided both cost and outcome data on HIVST. There was significant heterogeneity in the HIVST intervention, study population, costs and outcomes reported among included studies. Cost per person tested ranged from $1.09-155. Cost per case diagnosed ranged from $20-1,277. Cost-utility estimates ranged from cost-saving to $1846 per DALY averted. Higher cost-effectiveness estimates were associated with more expensive testing algorithms with increased support for linkage to care and post-test counseling.

Conclusion

All studies considered HIVST cost-effective although major drivers were identified included underlying HIV prevalence, testing cost and linkage to care. HIVST is likely to be cost-effective in a LMIC context, however policy makers should be aware of the drivers of cost-effectiveness when implementing HIVST programs as these underlying factors can impact the overall cost-effectiveness of HIVST.

Peer PrEP referral + HIV self-test delivery for PrEP initiation among young Kenyan women: study protocol for a hybrid cluster-randomized controlled trial

BACKGROUND

Oral HIV pre-exposure prophylaxis (PrEP) for HIV prevention is highly effective, but uptake remains low in Africa, especially among young women who are a priority population for HIV prevention services. HIV self-testing (HIVST) has been proven to increase HIV testing in diverse populations but has been underutilized to support linkage to HIV prevention services. Most young women who initiate PrEP in Africa do so through informal peer referral. We wanted to test a model of formalized peer referral enhanced with HIVST delivery among young Kenyan women.

METHODS

The Peer PrEP Trial is a two-arm hybrid effectiveness-implementation cluster-randomized controlled trial being conducted in central Kenya. Eligible participants (i.e., peer providers, n = 80) are women (≥ 16-24 years) refilling or initiating PrEP at public healthcare clinics who can identify at least four peers who could benefit from PrEP and not enrolled in another HIV study. Peer providers will be 1:1 randomized to (1) formal peer PrEP referral + HIVST delivery, where they will be encouraged to refer four peers (i.e., peer clients, ≥ 16-24 years) using educational materials and HIVST kits (two per peer client), or (2) informal peer PrEP referral, where they are encouraged to refer four peer clients using informal word-of-mouth referral. In both arms, peer providers will deliver a standard PrEP referral card with information on nearby public clinics delivering PrEP services. Peer providers will complete surveys at baseline and 3 months; peer clients will complete surveys at 3 months. Our primary outcome is PrEP initiation among peer clients, as reported by peer providers at 3 months. Secondary outcomes include PrEP continuation (any refilling), HIV testing (past 3 months), sexual behaviors (past month), and PrEP adherence (past month) among peer clients, as reported by both peer providers and clients at 3 months. Implementation outcomes will include participants' perceived acceptability, appropriateness, and feasibility of the intervention as well assessments of the intervention's fidelity and cost.

DISCUSSION

Evidence from this trial will help us understand how HIVST could support health systems by facilitating linkage to PrEP services among young women who could benefit in Kenya and similar settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04982250. Registered on July 29, 2021.

Partner testing with HIV self-test distribution by Ugandan pregnant women living with HIV: a randomized trial

INTRODUCTION

Secondary distribution of HIV self-tests (HIVST) by HIV-negative pregnant women to male partners increases men's testing rates. We examined whether this strategy promotes male partner testing for pregnant women living with HIV (PWLHIV).

METHODS

We conducted an open-label individually randomized trial in Kampala, Uganda, in which PWLHIV ≥18 years who reported a partner of unknown HIV status were randomized 2:1 to secondary distribution of HIVST for male partner(s) or standard-of-care (SOC; invitation letter to male partner for fast-track testing). Women were followed until 12 months post-partum. Male partners were offered confirmatory HIV testing and facilitated linkage to antiretroviral treatment (ART) or oral pre-exposure prophylaxis (PrEP). Using intention-to-treat analysis, primary outcomes were male partner testing at the clinic and initiation on PrEP or ART evaluated through 12 months post-partum (ClinicalTrials.gov, NCT03484533).

RESULTS

From November 2018 to March 2020, 500 PWLHIV were enrolled with a median age of 27 years (interquartile range [IQR] 23-30); 332 were randomized to HIVST and 168 to SOC with 437 PWLHIV (87.4%) completing 12 months follow-up post-partum. Of 236 male partners who tested at the clinic and enrolled (47.2%), their median age was 31 years (IQR 27-36), 45 (88.3%) men with HIV started ART and 113 (61.1%) HIV-negative men started PrEP. There was no intervention effect on male partner testing (hazard ratio [HR] 1.04; 95% confidence interval [CI]: 0.79-1.37) or time to ART or PrEP initiation (HR 0.96; 95% CI: 0.69-1.33). Two male partners and two infants acquired HIV for an incidence of 0.99 per 100 person-years (95% CI: 0.12-3.58) and 1.46 per 100 person-years (95% CI: 0.18%-5.28%), respectively. Social harms related to study participation were experienced by six women (HIVST = 5, SOC = 1).

CONCLUSIONS

Almost half of the partners of Ugandan PWLHIV tested for HIV with similar HIV testing rates and linkage to ART or PrEP among the secondary distribution of HIVST and SOC arms. Although half of men became aware of their HIV serostatus and linked to services, additional strategies to reach male partners of women in antenatal care are needed to increase HIV testing and linkage to services among men.

Peer-based Promotion and Nurse-led Distribution of HIV Self-Testing Among Networks of Men in Dar es Salaam, Tanzania: Development and Feasibility Results of the STEP Intervention

Background

According to the 2016-2017 Tanzania HIV Impact Survey, only 45% of men living with HIV (MLWH) were aware of their HIV status. In an effort to increase HIV testing in Tanzania, including among men, the Government of Tanzania passed a law in December 2019 to allowing HIV self-testing (HIVST) to be included in the national testing strategies. The objective of this paper is to describe the development and pilot feasibility assessment of the Self-Testing Education and Promotion (STEP) intervention, which was one of the projects conducted in Tanzania focusing on men to inform policy change.

Methods

The development and piloting processes were guided by the ADAPT-ITT model and informed by a national PEPFAR/USAID-funded HIV implementation science project called Sauti.The adapted STEP intervention included the following two components: 1) peer-based HIVST promotion; and 2) nurse-led HIVST distribution. For the feasibility assessment, 25 men were selected and trained to promote HIVST among their peers before helping to recruit 253 men to receive instructions and collect an HIVST kit from a nurse at a community-based study tent site.

Results

Of the 236 participants who completed the 1-month follow-up survey, 98.3% reported using the kit. The majority (92.4%) of participants reported a negative HIVST result while 4.2% (n=10) received a positive result. Most (70%, n=7) of the participants with a positive result sought follow-up services at a healthcare facility while 40.3% (n=95) of the participants with a negative self-test result visited the community-based project site. Most of the men (53%, n =129) did not visit a healthcare facility or the study site. The majority of participants reported having a mobile phone and forty-seven of them called someone to share their results while twenty-seven sent a text message about their results.

Conclusion

The findings demonstrate that the combined peer-based promotion and nurse-led distribution of HIVST intervention in the community for men was acceptable and feasible. However, the high proportion of men who visited the tent site in the community after self-testing indicated that future research should evaluate the potential for nurses to provide community-based linkage to HIV care and prevention services for self-testers.

Effect of index HIV self-testing for sexual partners of clients enrolled in antiretroviral therapy (ART) programs in Malawi: A randomized controlled trial

BACKGROUND

HIV testing among the sexual partners of HIV-positive clients is critical for case identification and reduced transmission in southern and eastern Africa. HIV self-testing (HIVST) may improve uptake of HIV services among sexual partners of antiretroviral therapy (ART) clients, but the impact of HIVST on partner testing and subsequent ART initiation remains unclear.

METHODS AND FINDINGS

We conducted an individually randomized, unblinded trial to assess if an index HIVST intervention targeting the partners of ART clients improves uptake of testing and treatment services in Malawi. The trial was conducted at 3 high-burden facilities in central and southern Malawi. ART clients attending HIV treatment clinics were randomized using simple randomization 1:2·5 to: (1) standard partner referral slip (PRS) whereby ART clients were given facility referral slips to distribute to their primary sexual partners; or (2) index HIVST whereby ART clients were given HIVST kits + HIVST instructions and facility referral slips to distribute to their primary sexual partners. Inclusion criteria for ART clients were: ≥15 years of age, primary partner with unknown HIV status, no history of interpersonal violence (IPV) with partner, and partner lives in facility catchment area. The primary outcome was partner testing 4-weeks after enrollment, reported by ART clients using endline surveys. Medical chart reviews and tracing activities with partners with a reactive HIV test measured ART initiation at 12 months. Analyses were conducted based on modified intention-to-treat principles, whereby we excluded individuals who did not have complete endline data (i.e., were loss to follow up from the study). Adjusted models controlled for the effects of age and marital status. A total of 4,237 ART clients were screened and 484 were eligible and enrolled (77% female) between March 28, 2018 and January 5, 2020. A total of 365 participants completed an endline survey (257/34 index HIVST arm; 107/13 PRS arm) and were included in the final analysis (78% female). Testing coverage among sexual partners was 71% (183/257) in the index HIVST arm and 25% (27/107) in the PRS arm (aRR: 2·77, 95% CI [2·56 to 3·00], p ≤ 0.001). Reported HIV positivity rates did not significantly differ by arm (16% (30/183) in HIVST versus 15% (4/27) in PRS; p = 0.99). ART initiation at 12 months was 47% (14/30) in HIVST versus 75% (3/4) in PRS arms; however, index HIVST still resulted in a 94% increase in the proportion of all partners initiating ART due to higher HIV testing rates in the HIVST arm (5% partners initiated ART in HVIST versus 3% in PRS). Adverse events including IPV and termination of the relationship did not vary by arm (IPV: 3/257 index HIVST versus 4/10 PRS; p = 0.57). Limitations include reliance on secondary report by ART clients, potential social desirability bias, and not powered for sex disaggregated analyses.

CONCLUSIONS

Index HIVST significantly increased HIV testing and the absolute number of partners initiating ART in Malawi, without increased risk of adverse events. Additional research is needed to improve linkage to HIV treatment services after HIVST use.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03271307, and Pan African Clinical Trials, PACTR201711002697316.

Knowledge of HIV and/or AIDS and HIV testing services among young men in South Africa

BACKGROUND

The youth is at a heightened risk of immunodeficiency virus and/or acquired immunodeficiency syndrome (HIV and/or AIDS) infection because of risk-taking behaviour. There remains a gap in understanding young men's knowledge of HIV and/or AIDS and HIV testing services (HTS) in hard-to-reach communities in South Africa.

AIM

This article aimed to explore young men's knowledge of HIV and/or AIDS, including HTS in Ladysmith, KwaZulu-Natal (KZN).

SETTING

Rural and peri-urban areas around the town of Ladysmith.

METHODS

Employing a qualitative descriptive research design, 17 young men aged between 18 and 30 years were purposively and conveniently sampled and interviewed using WhatsApp and landline audio calls to collect their data, which was thematically analysed.

RESULTS

Young men had good knowledge of HIV and/or AIDS but lacked knowledge about HTS and HIV self-testing (HIVST). They obtained their information about HIV and/or AIDS and HTS from various sources and were aware of where to access HTS. They were generally unaware and supportive of HIVST.

CONCLUSION

Male-targeted HIV and/or AIDS knowledge and testing interventions are needed to encourage and support young men to test for HIV. Human immunodeficiency virus self-testing should be explored as an alternative to clinic-based service to encourage young men to know their status, specifically those with limited access to or are reluctant to attend clinics. Strengthening HIV and/or AIDS education could facilitate better decision-making towards HIV testing among young men.Contribution: This study contributes to an understanding of young adult men's knowledge of HIV and/or AIDS and HTS in underserved settings in South Africa.

Evaluating an Innovative HIV Self-Testing Service With Web-Based, Real-Time Counseling Provided by an Artificial Intelligence Chatbot (HIVST-Chatbot) in Increasing HIV Self-Testing Use Among Chinese Men Who Have Sex With Men: Protocol for a Noninferiority Randomized Controlled Trial

BACKGROUND

Counseling support for HIV self-testing (HIVST) users is essential to ensure support and linkage to care among men who have sex with men (MSM). An HIVST service with web-based real-time instruction, pretest, and posttest counseling provided by trained administrators (HIVST-OIC) was developed by previous projects. Although the HIVST-OIC was highly effective in increasing HIVST uptake and the proportion of HIVST users receiving counseling along with testing, it required intensive resources to implement and sustain. The service capacity of HIVST-OIC cannot meet the increasing demands of HIVST.

OBJECTIVE

This randomized controlled trial primarily aims to establish whether HIVST-chatbot, an innovative HIVST service with web-based real-time instruction and counseling provided by a fully automated chatbot, would produce effects that are similar to HIVST-OIC in increasing HIVST uptake and the proportion of HIVST users receiving counseling alongside testing among MSM within a 6-month follow-up period.

METHODS

A parallel-group, noninferiority randomized controlled trial will be conducted with Chinese-speaking MSM aged ≥18 years with access to live-chat applications. A total of 528 participants will be recruited through multiple sources, including outreach in gay venues, web-based advertisement, and peer referral. After completing the baseline telephone survey, participants will be randomized evenly into the intervention or control groups. Intervention group participants will watch a web-based video promoting HIVST-chatbot and receive a free HIVST kit. The chatbot will contact the participant to implement HIVST and provide standard-of-care, real-time pretest and posttest counseling and instructions on how to use the HIVST kit through WhatsApp. Control group participants will watch a web-based video promoting HIVST-OIC and receive a free HIVST kit in the same manner. Upon appointment, a trained testing administrator will implement HIVST and provide standard-of-care, real-time pretest and posttest counseling and instructions on how to use the HIVST kit through live-chat applications. All participants will complete a telephone follow-up survey 6 months after the baseline. The primary outcomes are HIVST uptake and the proportion of HIVST users receiving counseling support along with testing in the past 6 months, measured at month 6. Secondary outcomes include sexual risk behaviors and uptake of HIV testing other than HIVST during the follow-up period. Intention-to-treat analysis will be used.

RESULTS

Recruitment and enrollment of participants started in April 2023.

CONCLUSIONS

This study will generate important research and policy implications regarding chatbot use in HIVST services. If HIVST-chatbot is proven noninferior to HIVST-OIC, it can be easily integrated into existing HIVST services in Hong Kong, given its relatively low resource requirements for implementation and maintenance. HIVST-chatbot can potentially overcome the barriers to using HIVST. Therefore, the coverage of HIV testing, the level of support, and the linkage to care for MSM HIVST users will be increased.

TRIAL REGISTRATION

ClinicalTrial.gov NCT05796622; https://clinicaltrials.gov/ct2/show/NCT05796622.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/48447.

Secondary distribution of HIV self-test kits by HIV index and antenatal care clients: implementation and costing results from the STAR Initiative in South Africa

BACKGROUND

Partner-delivered HIV self-testing kits has previously been highlighted as a safe, acceptable and effective approach to reach men. However, less is known about its real-world implementation in reaching partners of people living with HIV. We evaluated programmatic implementation of partner-delivered self-testing through antenatal care (ANC) attendees and people newly diagnosed with HIV by assessing use, positivity, linkage and cost per kit distributed.

METHODS

Between April 2018 and December 2019, antenatal care (ANC) clinic attendees and people or those newly diagnosed with HIV clients across twelve clinics in three cities in South Africa were given HIVST kits (OraQuick Rapid HIV-1/2 Antibody Test, OraSure Technologies) to distribute to their sexual partners. A follow-up telephonic survey was administered to all prior consenting clients who were successfully reached by telephone to assess primary outcomes. Incremental economic costs of the implementation were estimated from the provider's perspective.

RESULTS

Fourteen thousand four hundred seventy-three HIVST kits were distributed - 10,319 (71%) to ANC clients for their male partner and 29% to people newly diagnosed with HIV for their partners. Of the 4,235 ANC clients successfully followed-up, 82.1% (3,475) reportedly offered HIVST kits to their male partner with 98.1% (3,409) accepting and 97.6% (3,328) using the kit. Among ANC partners self-testing, 159 (4.8%) reported reactive HIVST results, of which 127 (79.9%) received further testing; 116 (91.3%) were diagnosed with HIV and 114 (98.3%) initiated antiretroviral therapy (ART). Of the 1,649 people newly diagnosed with HIV successfully followed-up; 1,312 (79.6%) reportedly offered HIVST kits to their partners with 95.8% (1,257) of the partners accepting and 95.9% (1,206) reported that their partners used the kit. Among these index partners, 297 (24.6%) reported reactive HIVST results of which 261 (87.9%) received further testing; 260 (99.6%) were diagnosed with HIV and 258 (99.2%) initiated ART. The average cost per HIVST distributed in the three cities was US$7.90, US$11.98, and US$14.81, respectively.

CONCLUSIONS

Partner-delivered HIVST in real world implementation was able to affordably reach many male partners of ANC attendees and index partners of people newly diagnosed with HIV in South Africa. Given recent COVID-19 related restrictions, partner-delivered HIVST provides an important strategy to maintain essential testing services.

The association between HIV self-test awareness and recent HIV testing uptake in the male population in Gambia: data analysis from 2019-2020 demographic and health survey

BACKGROUND

The Gambian Ministry of Health is supportive of HIV self-testing (HIVST) and HIVST initiatives are being piloted as an additional strategy to increase HIV testing for individuals not currently reached by existing services, particularly men. This study aimed to determine awareness of HIVST among Gambian men, and whether prior awareness of HIVST is associated with recent HIV testing uptake.

METHODS

We used men's cross-sectional data from the 2019-2020 Gambian Demographic and Health Survey. We employed design-adjusted multivariable logistic regression to examine the association between HIVST awareness and recent HIV testing. Propensity-score weighting was conducted as sensitivity analyses.

RESULTS

Of 3,308 Gambian men included in the study, 11% (372) were aware of HIVST and 16% (450) received HIV testing in the last 12 months. In the design-adjusted multivariable analysis, men who were aware of HIVST had 1.76 times (95% confidence interval: 1.26-2.45) the odds of having an HIV test in the last 12 months, compared to those who were not aware of HIVST. Sensitivity analyses revealed similar findings.

CONCLUSION

Awareness of HIVST may help increase the uptake of HIV testing among men in Gambia. This finding highlights HIVST awareness-raising activities to be an important intervention for nationwide HIVST program planning and implementation in Gambia.

The Implementation of HIV Self-Testing in Resource-Limited Settings Where the HIV Disease Burden is High

In resource-limited settings, there is growing evidence that HIV testing is lacking among high-risk key populations such as men having sex with men, injection drug users, and transgenders largely due to stigma, discrimination, and lack of confidentiality. Findings from recent studies among high-risk key populations and the general population from various regions including resource-limited settings support the need for wider accessibility of HIV self-testing (HIV-ST) to reach those who may not otherwise have access to testing. Therefore, HIV-ST has untapped potential as a strategy to improve access to HIV testing and to increase testing frequency among key high-risk populations and their partners. Though HIV-ST has emerged as a safe, acceptable, and effective way to reach people, there are several roadblocks to implementing the HIV-ST policy, and fast-track policy implementation needs to be necessitated with newer or modified strategic plans.

Changing attitudes towards HIV testing and treatment among three generations of men in Cameroon: a qualitative analysis using the Fogg Behavior Model

INTRODUCTION

Men are less likely than women to test for HIV and promptly initiate antiretroviral treatment, resulting in advanced HIV disease and increased mortality rates among them.

METHODS

In-depth interviews were conducted with men and leaders in the west and central regions of Cameroon. Men were recruited from existing community groups and stratified by age: 21-30 years, 31-40 years, and 41 years and older. Community leaders were recommended by the community dialogue structure chairman. Interviews were conducted using a semi-structured guide in English or French, depending on the participant's preference. Transcripts were coded in the MAXQDA v.12 software and analyzed using thematic analysis and by age group. The Fogg Behavior Model was used to gain a deeper understanding of the different perceptions across all age groups.

RESULTS

Younger men (21-30 years) were generally more accepting of HIV testing, as it had become normative behavior. Although financial barriers could limit access, free testing was mentioned as a prompt to initiate HIV testing. The middle age men (31-40 years) had the most concerns about HIV testing interrupting their work day and recommended increasing testing locations and hours. The older men (41 + years) were the least motivated to get tested, citing worries about the impact on their social standing within the community. All age groups reported being motivated to begin treatment if they were found to be HIV-positive. Participants also provided insights regarding community HIV testing and treatment messaging. Younger and older men preferred to hear directly from qualified health professionals, but younger men noted that social media, radio, and TV could be utilized. Middle age men also identified TV and radio as effective mediums, if door-to-door messaging was not an option.

CONCLUSIONS

The study highlights important considerations when planning future information-sharing activities for HIV testing and treatment. Since lived experiences differ across generations and societal roles continue to change, not only should the content of messages differ among the generations, but the means of communication must also be considered to ensure the messages are conveyed through a trusted source.

Men's Endorsement of Intimate Partner Violence and HIV Testing Behavior Across Sub-Saharan Africa

Despite an upward trend in HIV testing across sub-Saharan Africa, men continue to lag women in the use of HIV testing services. Inequitable gender attitudes held by some men may be implicated in their suboptimal HIV testing behaviors. We sought to ascertain the relationship between men?s endorsement of intimate partner violence (IPV), which is one manifestation of inequitable gender attitudes, and their lifetime and recent HIV testing, using nationally representative Demographic and Health Survey data from 23 sub-Saharan African countries. In a pooled analysis, we found that a unit increase in the IPV index scale is associated with 8% lower odds of lifetime HIV testing, and 6% lower odds of recent HIV testing. The strength of this relationship, however, varied across countries and regions. Our findings suggest that efforts to increase men?s HIV testing in the region should address the inequitable gender attitudes underpinning men?s endorsement of IPV, but that it is important to consider contextual variation.

COVID-19 self-testing in Nigeria: Stakeholders' opinions and perspectives on its value for case detection

BACKGROUND

COVID-19 testing coverage is limited in Nigeria. Access to rapid SARS-CoV-2 antigen-detection self-testing kits may help improve the detection of asymptomatic and mildly symptomatic cases and increase the country's low rate of SARS-CoV-2 testing. Before implementing self-testing in Nigeria, assessing the population's perceptions regarding this approach is imperative. In mid-2021, an exploratory cross-sectional qualitative research was conducted to investigate stakeholders' values and preferences for SARS-CoV-2 self-testing in Nigeria.

METHODS

In-person and online semi-structured interviews and focus group discussions with healthcare workers, representatives of civil society, and potential implementors of self-testing delivery programs were used to explore values and perceptions around access to conventional provider-initiated COVID-19 testing. Topics included the public's values in relation to SARS-CoV-2 self-testing, the safe and effective use of SARS-CoV-2 self-testing, and likely actions upon receiving a positive SARS-CoV-2 self-test result. A thematic analysis approach was applied.

RESULTS

The 58 informants (29 female) reported that Nigeria has limited availability of conventional provider-delivered SARS-CoV-2 testing. While just a few informants were familiar with SARS-CoV-2 self-testing, they generally supported using self-testing as an approach that they felt could assist with early case detection and improve access to testing. Concerns relating to the use of self-testing mainly related to the ability of low-literate individuals to use and interpret the self-tests, the affordability of self-tests, equity of access, and the availability of healthcare system support for those who self-test positive.

CONCLUSION

Although the Nigerian public perceive multiple benefits associated with access to SARS-CoV-2 self-testing, the perceived inefficiency of the national health service delivery system may limit the access of users of the kits to psychosocial and clinical support. Nevertheless, in Nigeria, where COVID-19 vaccine coverage is low and the risk of further waves of COVID-19 is high, self-testing may assist in the prompt detection of cases and contribute to halting the spread of the virus.

Linkage to HIV Care Following HIV Self-testing Among Men: Systematic Review of Quantitative and Qualitative Studies from Six Countries in Sub-Saharan Africa

Gender disparities are pervasive throughout the HIV care continuum in sub-Saharan Africa, with men testing, receiving treatment, and achieving viral suppression at lower rates, and experiencing mortality at higher rates, compared with women. HIV self-testing (HIVST) has been shown to be highly acceptable among men in sub-Saharan Africa. However, evidence on linkage to HIV care following a reactive HIVST result is limited. In this systematic review, we aimed to synthesize the quantitative and qualitative literature from sub-Saharan Africa on men's rates of linkage to HIV care after receiving a reactive HIVST result. We systematically searched 14 bibliometric databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flow diagram was used to document the screening results. The Mixed Methods Appraisal Tool (MMAT) was used to assess the methodological quality of the included studies. Of 22,446 references screened, 15 articles were eligible for inclusion in this review. Linkage to HIV care following a reactive HIVST result was subject to several barriers: financial constraints due to travelling costs, potential long waiting hours at the clinics, stigma, discrimination, and privacy concerns. Men's rates of seeking confirmatory testing and linking to HIV care following a reactive HIVST result were inconsistent across studies. Combining financial incentives with HIVST was found to increase the likelihood of linking to HIV care following a reactive HIVST result. The variable rates of linkage to HIV care following a reactive HIVST result suggest a need for further research and development into strategies to increase linkage to HIV care.

Association of anticipated HIV testing stigma and provider mistrust on preference for HIV self-testing among cisgender men who have sex with men in the Philippines

BACKGROUND

New HIV infections in the Philippines are increasing at an alarming rate. However, over three quarters of men who have sex with men (MSM) have never been tested for HIV. HIV self-testing (HIVST) may increase overall testing rates by removing barriers, particularly fear of stigmatization and mistrust of providers. This study aimed to determine if these factors are associated with preference for HIVST among Filipino cisgender MSM (cis-MSM), and whether there is an interaction between anticipated HIV testing stigma and provider mistrust on preference for HIVST.

METHODS

We conducted secondary analysis of a one-time survey of 803 cis-MSM who were recruited using purposive sampling from online MSM dating sites and MSM-themed bar locations in Metro Manila, Philippines. Summary statistics were computed to describe participant characteristics. Multivariable modified Poisson regression analyses were conducted to determine if anticipated HIV testing stigma and provider mistrust were associated with preference for HIVST among cis-MSM. Other variables such as age, education, monthly income, relationship status, HIV serostatus, and knowing where to get HIV testing were the minimal sufficient adjustment set in the analyses.

RESULTS

Average age of participants was 28.6 years (SD = 8.0); most had received college degrees (73%) and were employed (80%). Most respondents (81%) preferred facility-based testing, while 19% preferred HIVST. A high percentage of participants reported anticipated HIV testing stigma (66%) and provider mistrust (44%). Anticipated HIV testing stigma (aPR = 1.51; 95% CI = 1.01-2.25, p = 0.046) and provider mistrust (aPR = 1.49; 95% CI = 1.07-2.09, p = 0.020) were independently associated with a preference for HIVST. There was a positive, additive interaction between provider mistrust and anticipated HIV testing stigma on preference for HIVST (RERI = 1.13, 95% CI: 0.20-2.06; p = 0.017), indicating that the association between anticipated HIV testing stigma and preference for HIVST is greater among those with provider mistrust compared to those without provider mistrust.

CONCLUSIONS

HIVST should be offered as a supplement to traditional facility-based HIV testing services in the Philippines to expand testing and reach individuals who may not undergo testing due to anticipated HIV testing stigma and provider mistrust.

The Feasibility and Acceptability of an mHealth Conversational Agent Designed to Support HIV Self-testing in South Africa: Cross-sectional Study

BACKGROUND

HIV testing rates in sub-Saharan Africa remain below the targeted threshold, and primary care facilities struggle to provide adequate services. Innovative approaches that leverage digital technologies could improve HIV testing and access to treatment.

OBJECTIVE

This study aimed to examine the feasibility and acceptability of Nolwazi_bot. It is an isiZulu-speaking conversational agent designed to support HIV self-testing (HIVST) in KwaZulu-Natal, South Africa.

METHODS

Nolwazi_bot was designed with 4 different personalities that users could choose when selecting a counselor for their HIVST session. We recruited a convenience sample of 120 consenting adults and invited them to undertake an HIV self-test facilitated by the Nolwazi_bot. After testing, participants completed an interviewer-led posttest structured survey to assess their experience with the chatbot-supported HIVST.

RESULTS

Participants (N=120) ranged in age from 18 to 47 years, with half of them being men (61/120, 50.8%). Of the 120 participants, 111 (92.5%) had tested with a human counselor more than once. Of the 120 participants, 45 (37.5%) chose to be counseled by the female Nolwazi_bot personality aged between 18 and 25 years. Approximately one-fifth (21/120, 17.5%) of the participants who underwent an HIV self-test guided by the chatbot tested positive. Most participants (95/120, 79.2%) indicated that their HIV testing experience with a chatbot was much better than that with a human counselor. Many participants (93/120, 77.5%) reported that they felt as if they were talking to a real person, stating that the response tone and word choice of Nolwazi_bot reminded them of how they speak in daily conversations.

CONCLUSIONS

The study provides insights into the potential of digital technology interventions to support HIVST in low-income and middle-income countries. Although we wait to see the full benefits of mobile health, technological interventions including conversational agents or chatbots provide us with an excellent opportunity to improve HIVST by addressing the barriers associated with clinic-based HIV testing.

Accessibility of HIV Services in Philadelphia: Location-Allocation Analysis

INTRODUCTION

As the first step in the HIV care continuum, timely diagnosis is central to reducing transmission of the virus and ending the HIV epidemic. Studies have shown that distance from a testing site is essential for ease of access to services and educational material. This study shows how location-allocation analysis can be used to improve allocation of HIV testing services utilizing existing publicly available data from 2015 to 2019 on HIV prevalence, testing site location, and factors related to HIV in Philadelphia, Pennsylvania.

METHODS

The ArcGIS Location-Allocation analytic tool was used to calculate locations for HIV testing sites using a method that minimizes the distance between demand-point locations and service facilities. ZIP code level demand was initially specified on the basis of the percentage of late HIV diagnoses and in a sensitivity analysis on the basis of a composite of multiple factors. Travel time and distance from demand to facilities determined the facility location allocation. This analysis was conducted from 2021 to 2022.

RESULTS

Compared with the 37 facilities located in 20 (43%) Philadelphia ZIP codes, the model proposed reallocating testing facilities to 37 (79%) ZIP codes using percent late diagnoses to define demand. On average, this would reduce distance to the facilities by 65% and travel time to the facilities by 56%. Results using the sensitivity analysis were similar.

CONCLUSIONS

A wider distribution of HIV testing services across the city of Philadelphia may reduce distance and travel time to facilities, improve accessibility of testing, and in turn increase the percentage of people with knowledge of their status.

Preferences, beliefs, and attitudes about oral fluid and blood-based HIV self-testing among truck drivers in Kenya choosing not to test for HIV

Introduction

Clinical trials in sub-Saharan Africa support that HIV self-testing (HIVST) can increase testing rates in difficult-to-reach populations. However, trials mostly evaluate oral fluid HIVST only. We describe preferences for oral fluid vs. blood-based HIVST to elucidate prior trial results and inform testing programs.

Methods

Participants were recruited from a HIVST randomized controlled trial in Nakuru County, Kenya, which aimed to test the effect of choice between oral HIVST and facility-based testing compared to standard-of-care on HIV testing among truck drivers. We conducted in-depth interviews (IDIs) with purposively sampled trial participants who declined HIV testing at baseline or who were offered access to oral fluid HIVST and chose not to pick up the kit during follow-up. IDIs were conducted with all consenting participants. We first describe IDI participants compared to the other study participants, assessing the statistical significance of differences in characteristics between the two samples and then describe preferences, beliefs, and attitudes about HIVST biospecimen type expressed in the IDIs.

Results

The final sample consisted of 16 men who refused HIV testing at baseline and 8 men who did not test during follow-up. All IDI participants had tested prior to study participation; mean number of years since last HIV test was 1.55, vs. 0.98 among non-IDI participants (p = 0.093). Of the 14 participants who answered the question about preferred type of HIVST, nine preferred blood-based HIVST, and five, oral HIVST. Preference varied by study arm with four of five participants who answered this question in the Choice arm and five of nine in the SOC arm preferring blood-based HIVST. Six key themes characterized truckers' views about test type: (1) Rapidity of return of test results. (2) Pain and fear associated with finger prick. (3) Ease of use. (4) Trust in test results; (5) fear of infection by contamination; and (6) Concerns about HIVST kit storage and disposal.

Conclusion

We found no general pattern in the themes for preference for oral or blood-based HIVST, but if blood-based HIVST had been offered, some participants in the Choice arm might have chosen to self-test. Offering choices for HIVST could increase testing uptake.

Incentives to promote accessing HIV care and viral suppression among HIV self-screening test users who obtain a reactive result

Introduction

Achieving viral suppression in people with HIV is crucial in ending the AIDS epidemic. Among users of HIV self-screening tests, low rates of linkage to care and early retention in care are key obstacles to achieving viral suppression. This study sought to evaluate the efficacy of financial incentives in supporting HIV case management.

Methods

Young adults within the inner city of Johannesburg, South Africa and surrounding areas who used HIV self-tests, were able to use WhatsApp to communicate with study personnel, reported a reactive or invalid result, and were confirmed to by HIV-positive were enrolled in the study. Participants were randomised to an intervention arm that received reminders and financial rewards for engaging in care, or to a control arm that received the standard of care. The primary outcome was HIV viral load at six months.

Results

Among 2,388 HIV self-test kits that were distributed, 1757/2,388 (73,58%) recipients were able to use their phones to send photos to study personnel. 142/1,757 (8,08%) of these recipients reported reactive or invalid results. Upon confirmatory testing, 99/142 (69,71%) participants were identified as being HIV-positive and were enrolled in the study. 2 (1,41%) participants received an HIV negative result, and 41(28,87%) participants were either lost to follow-up or did not complete the confirmatory testing step. 20/99 (20,2%) from the intervention arm and 18/99 (18,18%) from the control arm completed the study (i.e., attended a 6 month follow up and participated in the exit interview). 29/99 (29,29%) were virally suppressed by at 6 months. Of those achieving viral suppression 15 (51,72%) were from the intervention arm.

Conclusion

Financial incentives and reminders were not effective in promoting engagement with HIV care and viral suppression in this setting.

Sex differences in HIV testing among elders in Sub-Saharan Africa: a systematic review protocol

BACKGROUND

Elders (age 50+) HIV demographic (age and sex) data are essential to better understand their HIV service utilization and develop appropriate evidence-based responses and policies. Despite a significant prevalence rate of HIV and growing numbers of this population group, data are still scarce, and studies have neglected them in Sub-Saharan Africa. The aim of this protocol is to outline the methodological process of a systematic review that will gather qualitative and quantitative data to critically examine sex differences in HIV testing among elders (age 50+) in Sub-Saharan Africa.

METHODS

This protocol adheres to the PRISMA-P reporting guidelines. We will conduct a systematic database search to retrieve all observational and qualitative studies. Electronic search strategies will be developed for MEDLINE, EMBASE, Web of Science, Global Health, and CINAHL for studies reporting HIV data. Two reviewers will independently screen all citations, full-text articles, and abstract data. The search strategy will consist of free-text and Medical Subject Headings (MeSH) terms. Search terms for elders (50+) will include the following: "elders", "older adults", "aged", "geriatric" and "seniors". The primary outcome of interest is sex differences in the uptake of HIV counselling and testing (HCT). The study methodological quality (or bias) will be appraised using appropriate tools. Screening, data extraction, and assessments of risk of bias will be performed independently by two reviewers. Narrative synthesis will be conducted with studies that are compatible based on population and outcome. As it will be a systematic review, without human participants' involvement, there will be no requirement for ethical approval.

DISCUSSION

The systematic review will present key evidence on sex differences in HIV testing among elders in Sub-Saharan Africa. The findings will be used to inform program developers, policymakers, and other stakeholders to enhance sex disaggregated HIV data to improve access to HIV counselling and testing service for elders in Sub-Saharan Africa. The final manuscript will be disseminated through a peer-reviewed journal and scientific conferences.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42020172737 .

Stigma and healthcare access among men who have sex with men and transgender women who have sex with men in Senegal

Objectives:

Cisgender gay, bisexual, and other men who have sex with men and transgender women experience HIV incidence disparities in Senegal. These analyses determined how depression and different stigma mechanisms related to sexual behavior are associated with healthcare access, sexually transmitted infection testing, and HIV testing among cisgender gay, bisexual, and other men who have sex with men and transgender women across three cities in western Senegal.

Methods:

Logistic regression assessed the relationship of three stigma scales (stigma from family and friends, anticipated healthcare stigma, and general social stigma) and depression with these outcomes.

Results:

Depression and stigma were not associated with healthcare access, sexually transmitted infection testing, or HIV testing. However, individuals who had disclosed their sexual identity to a medical provider were more likely to test for HIV.

Conclusions:

Sexual behavior stigma experienced by cisgender gay, bisexual, and other men who have sex with men and trans women in Senegal may not limit access to routine healthcare, but may limit disclosure of sexual orientation and practices, limiting access to appropriate HIV prevention services.

Understanding socio-sexual networks: critical consideration for HIVST intervention planning among men who have sex with men in Kenya

BACKGROUND

HIV self-testing (HIVST) has emerged as a way of reaching individuals who may be less likely to access testing, including men who have sex with men (MSM). Understanding the social networks of MSM is key to tailoring interventions, such as HIVST, for particular locations.

METHODS

We undertook a socio-sexual network study to characterize and identify patterns of connection among MSM and inform an HIVST intervention in three sites in Kenya. Community researchers in each site selected eight seeds to complete a demographic form and network surveys for 15 each of their sexual and social network members. Seeds recruited three respondents, including two regular service users and one MSM who was "unreached" by the program, who then each identified three respondents, resulting with data on 290 individuals.

RESULTS

Findings illustrate the interconnectedness of community-based organization (CBO) members and non-members. In networks where a majority of members had a CBO membership, members had better contacts with programs and were more likely to have accessed health services. Larger networks had more HIV testing and seeds with frequent testing had a positive influence on their network members also being tested frequently. HIVST was tried in very few networks. Almost all network members were willing to use HIVST.

CONCLUSION

Willingness to use HIVST was nearly universal and points to the importance of networks for reaching individuals not enrolled in programs. Network analysis can help in understanding which type of networks had higher testing and how network-based approaches can be useful to promote HIVST in certain contexts.

Assessing the efficacy of an integrated intervention to create demand for fishermen’s schistosomiasis and HIV services (FISH) in Mangochi, Malawi: Study protocol for a cluster randomized control trial

Background

Both HIV and schistosomiasis are major public health problems worldwide with 1.8 million new HIV infections, and up to 110 million untreated schistosomiasis cases globally. Although a causal link has not been established, there are strong suggestions that having schistosomiasis increases onward transmission of HIV from co-infected men to women. With both HIV and schistosomiasis treatment readily available in Malawi, there is a need to investigate the feasibility, acceptability and health impacts of joint management of these two hazards, with special focus on health education and demand-creation for fishermen. The aim of this project is to identify optimal models of delivering integrated HIV and schistosomiasis services for fishermen, particularly investigating the effect of using social networks, HIV self-test kits and beach clinic services in Mangochi, Malawi.

Methods

We have mapped 45 boat teams or landing sites for a 3-arm cluster randomized trial using “boat team” as the unit of randomization. The three arms are: 1) Standard of care (SOC) with leaflets explaining the importance of receiving presumptive treatment for schistosomiasis (praziquantel) and HIV services for fishermen, and two intervention arms of 2) SOC + a peer explaining the leaflet to his fellow fishermen in a boat team; and 3) arm 2 with HIV self-test kits delivered to the boat team fishermen by the peer. The primary outcomes measured at 9 months of trial delivery will compare differences between arms in the proportions of boat-team fishermen: 1) who self-report starting antiretroviral therapy or undergoing voluntary medical male circumcision; and 2) who have ≥1 S. haematobium egg seen on light microscopy of the filtrate from 10mls urine (“egg-positive”).

Discussion

This is the first evaluation of an integrated HIV and schistosomiasis services intervention for fishermen, particularly investigating the effect of using social networks, HIVST kits and beach clinic services. The findings will support future efforts to integrate HIVST with other health services for fishermen in similar settings if found to be efficacious.

Trial registration

This trial is registered in the ISRCTN registry: ISRCTN14354324; date of registration: 05 October 2020. https://www.isrctn.com/ISRCTN14354324?q=ISRCTN14354324&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10&searchType=basic-search.

Linked to protocol version number 1.4 of 11 January 2021.

Perceived benefits, challenges, and recommendations for HIV research dissemination and implementation science efforts in Tanzania: Findings from the HIV/AIDS Research Forum brainstorming session

Although several international and national HIV/AIDS conferences exist, there was not a national conference in Tanzania focusing on HIV/AIDS disseminating and implementation research conducted in the country and abroad. This created a missed opportunity for researchers to share their research findings with local policymakers and HIV program implementers who can influence the adoption and implementation of promising research in public health and clinical practice settings. In response, the first HIV/AIDS D&I Research Forum designed to enhance local D&I efforts for HIV research, was organized in Tanzania in 2018. This paper explores the perceived benefits of the HIV/AIDS D&I Research Forum and potential challenges of developing similar forums and recommendation for future HIV research D&I conference in Tanzania. During the second day of the Forum, which was held in September 2018 in Morogoro, Tanzania, a 1-hour structured brainstorming session was conducted with the Forum attendees (n = 50), including researchers, medical professionals, policymakers, representatives from different ministries. Transcription of the brainstorming session was analyzed to identify benefits of the Forum, perceived challenges for organizing similar HIV/AIDS research dissemination events, and recommendations for addressing the challenges. Overall, participants perceived the forum to be beneficial because it provided opportunities for strategic collaborations between researchers, policymakers, and other stakeholders and for them to discuss challenges for D&I efforts. Forum attendees also identified several potential challenges for future D&I research forums such as the abstract requirement which may deter non-researchers, costs, meeting frequencies, and lack of funding and coordination between organizations involved in D&I research efforts. To address these concerns, a recommendation was made to host a biennial national conference in order to allow more time for ethical review and feedback that can enhance contribution of the project to D&I efforts and to raise funds. The benefits identified for the Forum highlight the importance of organizing similar D&I meetings for HIV-related research at the national level in Tanzania. However, the potential challenges discussed need to be addressed in order to develop a sustainable national D&I research conference by incorporating recommendations that forum attendees proposed.

Frameworks, measures, and interventions for HIV-related internalised stigma and stigma in healthcare and laws and policies: systematic review protocol

INTRODUCTION

There is strong global commitment to eliminate HIV-related stigma. Wide variation exists in frameworks and measures, and many strategies to prevent, reduce or mitigate stigma have been proposed but critical factors determining success or failure remain elusive.

METHODS AND ANALYSIS

Building on existing knowledge syntheses, we designed a systematic review to identify frameworks, measures and intervention evaluations aiming to address internalised stigma, stigma and discrimination in healthcare, and stigma and discrimination at the legal or policy level. The review addresses four key questions (KQ): KQ1: Which conceptual frameworks have been proposed to assess internal stigma, stigma and discrimination experienced in healthcare settings, and stigma and discrimination entrenched in national laws and policies? KQ2: Which measures of stigma have been proposed and what are their descriptive properties? KQ3: Which interventions have been evaluated that aimed to reduce these types of stigma and discrimination or mitigate their adverse effects and what are the effectiveness and unintended consequences? KQ4: What common 'critical factors for success or failure' can be identified across interventions that have been evaluated? We will search PubMed, PsycINFO, Web of Science, Universal Human Rights Index, HeinOnline, PAIS, HIV Legal Network, CDSR, Campbell Collaboration, PROSPERO and Open Science Framework. Critical appraisal will assess the source, processes and consensus finding for frameworks; COnsensus-based Standards for the selection of health Measurement Instruments criteria for measures; and risk of bias for interventions. Quality of evidence grading will apply . A gap analysis will provide targeted recommendations for future research. We will establish a compendium of frameworks, a comprehensive catalogue of available measures, and a synthesis of intervention characteristics to advance the science of HIV-related stigma.

PROSPERO REGISTRATION NUMBER

CRD42021249348.

Using Human-Centered Design to Develop a Program to Engage South African Men Living With HIV in Care and Treatment

Human-centered design (HCD) is a useful methodology for understanding the lived realities, needs, and preferences of men living with HIV and engaging them in the design and pilot of a peer-support program to support their engagement in care.

Background:

Although HIV care is widely available in South Africa, men are less likely than women to know their HIV status, begin treatment upon diagnosis, and adhere to treatment. Men are also more likely to die from causes related to HIV compared to women. To overcome this inequity, tailored approaches designed with men’s specific needs are required.

Methods:

As part of the Testing and Treatment for Men project, a 3-year multicomponent, mixed-methods study that aimed to better understand young South African men’s needs concerning HIV testing and treatment, we used human-centered design (HCD) methods to identify, develop, and pilot test a male-friendly peer-support intervention. We engaged key stakeholders in the development of several prototype interventions to improve men’s engagement across the HIV cascade, one of which was selected for further development.

Results:

Use of HCD methods, informed by the results of our team’s prior qualitative and quantitative research, led to the development of Coach Mpilo, a peer-support intervention to engage and retain men living with HIV in South Africa in care and treatment. By designing with empathy for the lived experiences of these men, our intervention achieved the authenticity and credibility required to build trusting relationships in the affected communities. Preliminary results of Coach Mpilo have demonstrated a high level of acceptability by men living with HIV as well as key government and other implementing partners.

Conclusion:

HCD as a critical ingredient became an integral and essential component in developing and field-testing the Coach Mpilo pilot. The key elements of our HCD approach that resulted in the successful generation of the Coach Mpilo pilot intervention and its implementation were understanding and addressing the specific issues identified by men living with HIV and leveraging newly created empathy with men as an approach to solving the issues collaboratively and innovatively.

Values and preferences for hepatitis C self-testing among the general population and healthcare workers in Rwanda

Background

In 2018, Rwanda launched a 5-year hepatitis C virus (HCV) elimination plan as per the World Health Organization global targets to eliminate HCV by 2030. To improve awareness of HCV status, strategies are needed to ensure easy access to HCV testing by as-yet unreached populations. HCV-self-testing, an innovative strategy, could further increase HCV testing uptake. This assessment explores perceptions around HCV self-testing among members of the public and healthcare workers in Rwanda.

Methods

A qualitative study was undertaken in Masaka District Hospital, comprising individual interviews, group interviews and participatory action research (PAR) activities. Purposive and snowball sampling methods guided the selection of informants. Informed consent was obtained from all participants. A thematic analysis approach was used to analyse the findings.

Results

The participants comprised 36 members of the public and 36 healthcare workers. Informants appreciated HCV self-testing as an innovative means of increasing access to HCV testing, as well as an opportunity to test privately and subsequently autonomously decide whether to seek further HCV care. Informants further highlighted the need to make HCV self-testing services free of charge at the nearest health facility. Disadvantages identified included the lack of pre/post-test counselling, as well as the potential psychosocial harm which may result from the use of HCV self-testing.

Conclusion

HCV self-testing is perceived to be an acceptable method to increase HCV testing in Rwanda. Further research is needed to assess the impact of HCV self-testing on HCV cascade of care outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06773-6.

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

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

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

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

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

Geographical variation in HIV testing in South Africa: Evidence from the 2017 national household HIV survey

Background

Identification of the geographical areas with low uptake of HIV testing could assist in spatial targeting of interventions to improve the uptake of HIV testing.

Objectives

The objective of this research study was to map the uptake of HIV testing at the district level in South Africa.

Method

The secondary analysis used data from the Human Sciences Research Council's 2017 National HIV Prevalence, Incidence, Behaviour and Communication Survey, where data were collected using a multistage stratified random cluster sampling approach. Descriptive spatial methods were used to assess disparities in the proportion of those ever tested for HIV at the district level in South Africa.

Results

The districts with the highest overall coverage of people ever having tested for HIV (> 85%) include West Rand in Gauteng, Lejweleputswa and Thabo Mofutsanyane in Free State, and Ngaka Modiri Molema in North-West. These provinces also had the least variation in HIV testing coverage between their districts. Districts in KwaZulu-Natal had the widest variation in coverage of HIV testing. The districts with the lowest uptake of HIV testing were uMkhanyakude (54.7%) and Ugu (61.4%) in KwaZulu-Natal and Vhembe (61.0%) in Limpopo. Most districts had a higher uptake of HIV testing amongst female than male participants.

Conclusion

The uptake of HIV testing across various districts in South Africa seems to be unequal. Intervention programmes must improve the overall uptake of HIV testing, especially in uMkhanyakude and Ugu in KwaZulu-Natal and Vhembe in Limpopo. Interventions must also focus on enhancing uptake of HIV testing amongst male participants in most districts. Strategies that would improve the uptake of HIV testing include HIV self-testing and community HIV testing, specifically home-based testing.

Overview of the epidemiological conditions of HIV among key populations in Africa

INTRODUCTION

Despite extraordinary progress in HIV treatment coverage and expanding access to HIV prevention services and that multiple African countries are on track in their efforts to reach 90-90-90 goals, the epidemic continues to persist, with prevalence and incidence rates too high in some parts of the continent to achieve epidemic control. While data sources are improving, and research studies on key populations in specific contexts have improved, work on understanding the HIV burdens and barriers to services for these populations remains sparse, uneven and absent altogether in multiple settings. More data have become available in the last several years, and data published in 2010 or more recently are reviewed here for each key population. This scoping review assesses the current epidemiology of HIV among key populations in Africa and the social and political environments that contribute to the epidemic, both of which suggest that without significant policy reform, these epidemics will likely continue.

RESULTS AND DISCUSSION

Across Africa, the HIV epidemic is most severe among key populations including women and men who sell or trade sex, men who have sex with men, people who inject drugs, transgender women who have sex with men and prisoners and detainees. These groups account for the majority of new infections in West and Central Africa, and an estimated 25% of new infections in East and Southern Africa, despite representing relatively small proportions of those populations. The HIV literature in Africa emphasizes that despite significant health needs, key populations experience barriers to accessing services within the healthcare and legal justice systems. Current shortcomings of surveillance systems in enumerating key populations impact the way funding mechanisms and resources are allocated and distributed. Adapting more equitable and epidemiologically sound frameworks will be necessary for current and future HIV programming investments.

CONCLUSIONS

Through this review, the available literature on HIV epidemiology among key populations in Africa brings to light a number of surveillance, programmatic and research gaps. For many communities, interventions targeting the health and security conditions continue to be minimal. Compelling evidence suggests that sweeping policy and programmatic changes are needed to effectively tackle the persistent HIV epidemic in Africa.