Challenges in measurement of linkage following HIV self-testing: examples from the STAR Project.

Abstract

Knowledge of HIV status through HIV testing constitutes the first step towards HIV treatment and prevention services. HIV self-testing (HIVST), whereby individuals collect their own specimen, conduct their own test and interpret the results, allows individuals to learn their HIV status conveniently and privately, as well as to decide when and where to attend posttest services. Accurate estimation of the proportion of those tested who link to additional HIV care, treatment and prevention services is critical in quantifying the health impact of HIV testing. As HIVST becomes integrated into testing programmes worldwide, implementers in diverse settings will need to measure the effectiveness of their programmes to ensure self-testers link to onward care and services. This can be challenging, and community health programmes in many contexts find it difficult to track referral uptake and equity [1]. We draw upon experience from the Self-Testing in AfRica (STAR) Initiative in 2015 to 2017 to identify three lessons for measurement of linkage following HIVST. In STAR, two pragmatic cluster-randomized trials evaluated the effectiveness of continuous HIVST distribution over 12 months in increasing testing coverage and linkage to care in Malawi and Zambia. A third trial, in Zimbabwe, evaluated the effectiveness of an incentive to promote linkage following a short, campaign-style HIVST distribution programme, and included a non-randomized component assessing the association between HIVST distribution and antiretroviral therapy (ART) initiations in nearby clinics. Details are provided elsewhere [2,3]. Each trial incorporated a household survey and data collection from health facilities to evaluate changes in HIV testing coverage and linkage to confirmatory testing, care and prevention (Table 1).