Figure 1 - available via license: Creative Commons Attribution-NonCommercial 3.0 Unported
Content may be subject to copyright.
CONSORT diagram showing flow of study participants. CONSORT, Consolidated Standards of Reporting Trials; HIVST, HIV self-testing. on July 19, 2021 by guest. Protected by copyright.
Source publication
Objectives Ending HIV by 2030 is a global priority. Achieving this requires alternative HIV testing strategies, such as HIV self-testing (HIVST) to reach all individuals with HIV testing services (HTS). We present the results of a trial evaluating the impact of community-based distribution of HIVST in community and facility settings on the uptake o...
Context in source publication
Context 1
... addition to the analysis of impact, we conducted a retrospective quantitative process evaluation using survey and programme data to understand delivery and reach of the HIVST intervention. 30 To guide the process evaluation, we developed a simple framework of how the intervention was expected to have an impact on the recent HIV testing (online supplemental figure 1). ...
Similar publications
Introduction Reaching high coverage of HIV testing remains essential for HIV diagnosis, treatment and prevention. We evaluated the effectiveness and safety of door-to-door distribution of HIV self-testing (HIVST) kits in rural Malawi.
Methods This cluster randomised trial, conducted between September 2016 and January 2018, used restricted 1:1 rand...
Objective
The aim of this systematic review is to provide some evidence on the use of mobile
phone communication for improving ARV adherence during pregnancy, as well as to
investigate whether text messaging on mobile phones could improve follow up in
HIV exposed infants.
Methods
We did a systematic review and meta-analysis, using CENTRAL (Cochrane...
Some people with HIV (PWH) test positive multiple times without initiating antiretroviral therapy (ART). We surveyed 496 ART-eligible PWH following routine HIV testing at three clinics in Soweto and Gugulethu, South Africa in 2014–2015. Among repeat positive testers (RPTs) in this cohort, we compared rates of treatment initiation by prior treatment...
Introduction
The Eastern Europe and Central Asian (EECA) region has the highest increase in HIV incidence and mortality globally, with suboptimal HIV treatment and prevention. All EECA countries (except Russia) are low and middle-income (LMIC). While LMIC are home to 80% of all older people living with HIV (OPWH), defined as ≥50 years, extant liter...
Citations
... The results indicate that once men have access to the kits, they are generally willing to self-test for HIV. However results from our study are slightly lower than those from similar studies whose uptake was high at 86% and 97.7% respectively [17,18]; but higher than that of the study among men in Zambia whose uptake was at 24% respectively [19,20]. ...
Background
Oral HIV self-testing (HIVST) among men is relatively low and still inadequate in Sub-Saharan Africa. Delivering HIVST kits by pregnant women attending antenatal care to their partners is a promising strategy for increasing HIV testing among men. However, even amidst the interventions, most men do not know their HIV status. This study, aimed to determine the proportion of partners who received and used oral HIVST kits delivered by pregnant women, associated factors, barriers, and facilitators for uptake among partners.
Methods
We conducted an exploratory sequential mixed methods study among 380 sampled partners. Lists of partners in the HIVST log books whose women picked an HIVST kit were obtained and systematic random sampling was done to obtain participants. 14 male partners were purposively selected for in-depth interviews (IDIs) to identify barriers and facilitators. We used modified poison regression to determine the association between oral HIVST and independent variables. We used an inductive analysis for the qualitative analysis.
Results
Out of 380 participants, 260(68.4%) received an oral HIVST kit from their pregnant women, and 215(82.7%) used the kit for HIVST. Oral HIVST was associated with; Information Education and Communication (CPR = 1.64, 95%CI 1.48–1.82), being reached at home (CPR = 1.04, 95%CI 1.01–1.08), and being aware of the woman’s HIV status (CPR = 1.04, 95%CI 0.99–1.09). In-depth results identified barriers to uptake as, lack of trust in the HIVST kit results, fear of test outcome in the presence of the partner and inclination that the HIV status of their women is the same as theirs, and facilitators included convenience, ease to use, prior awareness of their HIV status, and fear of relationship consequences and breakup.
Conclusion
Delivery of oral HIVST kits to men through pregnant women reached a high number of men and achieved a high uptake. Accessing information, education, communication and convenience nature were the major reasons for uptake among men who received the Oral HIVST kit as trust issues of the kit affected use among partners. Scaling up the delivery of oral HIVST kits at all departments of the hospital through women seeking health services is paramount to support HIV screening among men to reach the UNAIDS 95 strategy.
... HIVST has been shown to be acceptable, empowering and easy-to-use, offering users control over the testing process [2,[9][10][11][12][13]. As part of the STAR (Self-testing Africa) Initiative [14][15][16], studies in Zambia have shown that HIVST is acceptable but overall awareness and use remains low at population-level [17] and the uptake of HIVST and impact on knowledge of HIV status varies across populations and distribution models [18][19][20][21]. Despite national-level integration of HIVST, including within Zambian regulatory frameworks and HIV testing strategies, [19,20,22], evidence demonstrating how to optimally distribute HIVST to achieve high testing coverage in Zambia remains limited. ...
... As part of the STAR (Self-testing Africa) Initiative [14][15][16], studies in Zambia have shown that HIVST is acceptable but overall awareness and use remains low at population-level [17] and the uptake of HIVST and impact on knowledge of HIV status varies across populations and distribution models [18][19][20][21]. Despite national-level integration of HIVST, including within Zambian regulatory frameworks and HIV testing strategies, [19,20,22], evidence demonstrating how to optimally distribute HIVST to achieve high testing coverage in Zambia remains limited. ...
Background
Although Zambia has integrated HIV-self-testing (HIVST) into its Human Immunodeficiency Virus (HIV) regulatory frameworks, few best practices to optimize the use of HIV self-testing to increase testing coverage have been documented. We conducted a prospective case study to understand contextual factors guiding implementation of four HIVST distribution models to inform scale-up in Zambia.
Methods
We used the qualitative case study method to explore user and provider experiences with four HIVST distribution models (two secondary distribution models in Antenatal Care (ANC) and Antiretroviral Therapy (ART) clinics, community-led, and workplace) to understand factors influencing HIVST distribution. Participants were purposefully selected based on their participation in HIVST and on their ability to provide rich contextual experience of the distribution models. Data were collected using observations (n = 31), group discussions (n = 10), and in-depth interviews (n = 77). Data were analyzed using the thematic approach and aligned to the four Consolidated Framework for Implementation Research (CFIR) domains.
Results
Implementation of the four distribution models was influenced by an interplay of outer and inner setting factors. Inadequate compensation and incentives for distributors may have contributed to distributor attrition in the community-led and workplace HIVST models. Stockouts, experienced at the start of implementation in the secondary-distribution and community-led distribution models often disrupted distribution. The existence of policy and practices aided integration of HIVST in the workplace. External factors complimented internal factors for successful implementation. For instance, despite distributor attrition leading to excessive workload, distributors often multi-tasked to keep up with demand for kits, even though distribution points were geographically widespread in the workplace, and to a less extent in the community-led models. Use of existing communication platforms such as lunchtime and safety meetings to promote and distribute kits, peers to support distributors, reduction in trips by distributors to replenish stocks, increase in monetary incentives and reorganisation of stakeholder roles proved to be good adaptations.
Conclusion
HIVST distribution was influenced by a combination of contextual factors in variable ways. Understanding how the factors interacted in real world settings informed adaptations to implementation devised to minimize disruptions to distribution.
... The World Health Organization has recommended HIV self-testing (HIVST) as a strategy to increase HIV testing [16], but the tool has been underutilized to support health systems. Many studies have demonstrated that HIVST increases recent and frequent HIV testing among diverse populations (e.g., female sex workers [FSWs], HIV serodiscordant couples, men, and women) and settings, including Kenya [17][18][19][20][21]. However, few interventions have explored how HIVST could facilitate linkage to HIV services, and those that have primarily focused on linkage to treatment services [22][23][24][25]. ...
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.
... Furthermore, many early studies on HIVSTand RTþC have focused on specific population groups, such as MSM, young adults, and female sex workers (FSW) [10]. Although more recent studies examine the feasibility, awareness, and uptake of these types of HIV testing modalities in the general population, their sampling often explicitly excludes individuals over the age of 49 years, includes only small shares of middle-aged and older adults, and lack analyses dedicated to older population groups [11][12][13][14][15][16]. As efforts to scale HIVST in sub-Saharan Africa are made, studies focusing specifically on middle-aged and older adults are urgently needed -especially given that agerelated differences in perceived HIV risk and preventive health behavior, hesitancy towards adopting new technology, lower mobility rates, and greater need for linkage to care for both HIVand other comorbidities may all affect the efficiency and safety of home-based HIV testing in this population group [17][18][19][20][21][22]. ...
Objective
More than one in four adults over 40 with HIV in South Africa are unaware of their status and not receiving antiretroviral therapy (ART). HIV self-testing may offer a powerful approach to closing this gap for aging adults. Here, we report the results of a randomized comparative effectiveness trial of three different home-based HIV testing strategies for middle-aged and older adults in rural South Africa.
Design
2,963 individuals in the ‘Health and Ageing in Africa: a Longitudinal Study of an INDEPTH Community in South Africa (HAALSI)’ cohort study were randomized 1:1:1 to one of three types of home-based and home-delivered HIV testing modalities: (1) rapid testing with counseling; (2) self-testing, and (3) both rapid testing with counselling and self-testing.
Method
In modified Poisson and OLS regression analyses, we estimated the treatment effects on HIV testing and HIV testing frequency at about one year after delivery. Finally, we assessed the potential adverse effects of these strategies on the secondary outcomes of depressive symptom as assessed by the CESD-20, linkage to care, and risky sexual behavior.
Results
There were no significant differences in HIV testing uptake or testing frequency across groups. However, respondents in the self-testing treatment arms were more likely to shift from testing at home and a facility (ST: RR 0.86, 95% CI 0.76 – 0.97; ST+RT+C: RR 0.85, 95% CI 0.75 – 0.95) to testing only at home (ST: RR 1.67, 95% CI 1.17 – 2.39; ST+RT+C: RR 1.62, 95% CI 1.13 – 2.32) – suggesting a revealed preference for self-testing in this population. We also found no adverse effects of this strategy on linkage to care for HIV and common comorbidities, recent sexual partners, or condom use. Finally, those in the self-testing only arm had significantly decreased depressive symptom scores by 0.58 points (95% CI: -1.16 – -0.01).
Conclusions
We find HIV self-testing to be a safe and seemingly preferred home-based testing option for middle-aged and older adults in rural South Africa. This approach should be expanded to achieve the UNAIDS 95-95-95 targets.
Introduction:
HIV self-testing (HIVST), whereby an individual performs and interprets their own rapid screening test at home, is another tool to increase the proportion of at-risk individuals who know their status. Globally, HIVST has rapidly been adopted through global partnerships to ensure equitable access to tests in low- and middle-income countries (LMIC).
Area covered:
This review discusses the regulatory burdens of HIV self-testing within the United States while examining the use of HIV self-tests on a global scale. While the United States only has one approved HIV self-test, numerous tests have been prequalified by the WHO.
Expert opinion:
Despite the US Food and Drug Administration (FDA) clearance of the first and only self-test in 2012, there have been no other tests that have undergone FDA consideration due to regulatory barriers. This, in turn, has stifled market competition. Despite existing evidence that such programs are an innovative approach to testing hesitant or hard-to-reach populations, high individual test cost and bulky packaging make large-scale, mail-out, and HIV self-testing programs expensive. COVID-19 pandemic has accelerated the public demand for self-testing - HIV self-test programs should capitalize on this to increase the proportion of at-risk people who know their status and are linked to care to contribute to ending the HIV epidemic.
Introduction Measuring linkage after community-based testing, particularly HIV self-testing (HIVST), is challenging. Here, we use data from studies of community-based HIVST distribution, conducted within the STAR Initiative, to assess initiation of antiretroviral therapy (ART) and factors driving differences in linkage rates.
Methods Five STAR studies evaluated HIVST implementation in Malawi, Zambia and Zimbabwe. New ART initiations during the months of intervention at clinics in HIVST and comparison areas were presented graphically, and study effects combined using meta-analysis. Meta-regression was used to estimate associations between the impact of community-based HIVST distribution and indicators of implementation context, intensity and reach. Effect size estimates used (1) prespecified trial definitions of ART timing and comparator facilities and (2) exploratory definitions accounting for unexpected diffusion of HIVST into comparison areas and periods with less distribution of HIVST than was expected.
Results Compared with arms with standard testing only, ART initiations were higher in clinics in HIVST distribution areas in 4/5 studies. The prespecified meta-analysis found positive but variable effects of HIVST on facility ART initiations (RR: 1.14, 95% CI 0.93 to 1.40; p=0.21). The exploratory meta-analysis found a stronger impact of HIVST distribution on ART initiations (RR: 1.29, 95% CI 1.08 to 1.55, p=0.02).
ART initiations were higher in studies with greater self-reported population-level intensity of HIVST use (RR: 1.12; 95% CI 1.04 to 1.21; p=0.02.), but did not differ by national-level indicators of ART use among people living with HIV, number of HIVST kits distributed per 1000 population, or self-reported knowledge of how to link to care after a reactive HIVST.
Conclusion Community-based HIVST distribution has variable effect on ART initiations compared with standard testing service alone. Optimising both support for and approach to measurement of effective and timely linkage or relinkage to HIV care and prevention following HIVST is needed to maximise impact and guide implementation strategies.
Background
We conducted a systematic review and network meta-analysis to identify which HIV self-testing (HIVST) distribution strategies are most effective.
Methods
We abstracted data from randomized controlled trials and observational studies published between June 4, 2006 and June 4, 2019.
Results
We included 33 studies, yielding six HIVST distribution strategies. All distribution strategies increased testing uptake compared to standard testing: in sub-Saharan Africa, partner HIVST distribution ranked highest (78% probability); in North America, Asia and the Pacific regions, web-based distribution ranked highest (93% probability), and facility based distribution ranked second in all settings. Across HIVST distribution strategies HIV positivity and linkage was similar to standard testing.
Conclusion
A range of HIVST distribution strategies are effective in increasing HIV testing. HIVST distribution by sexual partners, web-based distribution, as well as health facility distribution strategies should be considered for implementation to expand the reach of HIV testing services.
