Community-based HIV Testing Research Articles

Community-based HIV testing services in an urban setting in western Kenya: a programme implementation study

Some countries are struggling to reach the UNAIDS target of 90% of all individuals with HIV knowing their HIV status, especially among men and youth. To identify individuals who are unaware of their HIV-positive status and achieve testing saturation, we implemented a hybrid HIV testing approach in an urban informal settlement in western Kenya. In this study, we aimed to describe the uptake of HIV testing and linkage to care and treatment during this programme. The Community Health Initiative involved community mapping, household census, multidisease community health campaigns, and home-based tracking in the informal settlement of Obunga in Kisumu, Kenya. 52 multidisease community health campaigns were held throughout the programme coverage area, at which HIV testing by certified testing service counsellors was one of the health services available. Individuals aged 15 years or older who were not previously identified as HIV-positive, children younger than 15 years who reported being sexually active or for whom testing was requested by a parent or guardian, and individuals who tested HIV-negative within the past 3 months but who reported a recent risk were all eligible for testing. Health and counselling services were tailored for men and youth to encourage their participation. Individuals identified during the census who did not attend a community health campaign were tracked using global positioning system data and offered home-based HIV testing services. We calculated the previously unidentified fraction, defined as the number of individuals who were newly identified as HIV-positive as a proportion of all individuals previously identified and newly identified as HIV-positive. Between Jan 11 and Aug 29, 2018, the Community Health Initiative programme reached 23 584 individuals, of whom 11 526 (48·9%) were men and boys and 5635 (23·9%) were aged 15-24 years. Of 12 769 individuals who were eligible for HIV testing, 12 407 (97·2%) accepted testing, including 3917 (31·6%) first-time testers. 101 individuals were newly identified as HIV-positive out of 1248 total individuals who were HIV-positive, representing an 8·1% previously unidentified fraction. The previously unidentified fraction was highest among men (9·8%) and among people aged 15-24 years (15·3%). Community-based hybrid HIV testing was successfully implemented in an urban setting. Innovative approaches that make HIV testing more accessible and acceptable, particularly to men and young people, are crucial for achieving testing and treatment saturation. Focusing on identifying individuals who are unaware of their HIV-positive status in combination with monitoring the previously unidentified fraction has the potential to achieve the UNAIDS Fast Track commitment to end AIDS by 2030. US President's Emergency Plan for AIDS Relief through the US Centers for Disease Control and Prevention.

The contribution of HIV point-of-care tests in early HIV diagnosis: community-based HIV testing monitoring in Catalonia, 1995 to 2018.

BackgroundCommunity-based HIV testing services combined with the use of point-of-care tests (POCT) have the potential to improve early diagnosis through increasing availability, accessibility and uptake of HIV testing.AimTo describe community-based HIV testing activity in Catalonia, Spain, from 1995 to 2018, and to evaluate the impact of HIV POCT on the HIV continuum of care.MethodsA community-based network of voluntary counselling and testing services in Catalonia, Spain has been collecting systematic data on activity, process and results since 1995. A descriptive analysis was performed on pooled data, describing the data in terms of people tested and reactive screening test results.ResultsBetween 1995 and 2018, 125,876 HIV tests were performed (2.1% reactive). Since the introduction of HIV POCT in 2007, a large increase in the number of tests performed was observed, reaching 14,537 tests alone in 2018 (1.3% reactive). Men who have sex with men (MSM), as a proportion of all people tested, has increased greatly over time reaching 74.7% in 2018. The highest percentage of reactive tests was found in people who inject drugs followed by MSM. The contribution of community-based HIV testing to the overall total notified cases in the Catalonia HIV registry has gradually increased, reaching 37.9% in 2018, and 70% of all MSM cases. In 2018, the percentage of individuals with a reactive screening test who were linked to care was 89.0%.ConclusionOur study reinforces the important role that community-based HIV POCT has on the diagnosis of HIV in key populations.

Implementation planning for community-based point-of-care HIV testing for infants: Recommendations from community leaders in Kenya.

BackgroundEarly infant diagnosis (EID) establishes the presence of HIV infection in HIV-exposed infants and children younger than 18 months of age. EID services are hospital-based, and thus fail to capture HIV-exposed infants who are not brought to the hospital for care. Point-of-care (POC) diagnostic systems deployed in the community could increase the proportion tested and linked to treatment, but little feasibility and acceptability data is available.MethodsSemi-structured interviews (n = 74) were conducted by a Kenyan team with community members (Community Health Workers/Volunteers [CHW/CHV], Traditional Birth Attendants [TBAs], community leaders) and parents of HIV-exposed infants at four study sites in Kenya to elicit feedback on the acceptability and feasibility of community-based POC HIV testing.ResultsParticipants described existing community health resources that could be leveraged to support integration of community-based POC HIV testing; however, the added demand placed on CHW/CHV could pose a challenge. Participants indicated that other potential barriers (concerns about confidentiality, disclosure, and HIV stigma) could be overcome with strong engagement from trusted community leaders and health providers, community sensitization, and strategic location and timing of testing. These steps were seen to improve acceptability and maximize the recognized benefits (rapid results, improved reach) of community-based testing.ConclusionCommunity members felt that with strategic planning and engagement, community-based POC HIV testing could be a feasible and acceptable strategy to overcome the existing barriers of hospital-based EID.

HIV prevalence, sexual risk behaviours and HIV testing among female sex workers in three cities in Sri Lanka: Findings from respondent-driven sampling surveys.

Sri Lanka has a low-level HIV epidemic. This study aims to provide evidence on HIV, syphilis and hepatitis B (HBV) prevalence, sexual risk behaviours and utilisation of HIV prevention interventions among female sex workers (FSW) in the cities Colombo, Galle, and Kandy. Using respondent-driven sampling (RDS), we recruited a total of 458 FSW in Colombo, 360 in Galle and 362 in Kandy from November 2017 to March 2018. Participants provided biological specimens for testing for infections and completed a behavioural questionnaire. We found no HIV nor HBV infections in Galle and Kandy, and low HIV (0.4%) and HBV surface antigen (0.6%) prevalence in Colombo. FSW in Colombo had higher positivity on Treponema pallidum-particle agglutination test (8.4%) compared to Galle (2.0%) and Kandy (2.5%). About two thirds of FSW heard of HIV in each of the cities. Around 90% of FSW used condom at last sex with a client in both Colombo and Galle, but considerably less in Kandy (57.1%). However, lower proportion of FSW used condoms every time during sex with clients in the past 30 day: 22.9% of FSW in Colombo, 26.6% in Kandy and 68.4% in Galle. Across cities, 17.5%-39.5% of FSW reported being tested for HIV in the past 12 months or knowing HIV positive status. The commonest reasons for never testing for HIV was not knowing where to test (54.2% in Colombo, 41.8% in Galle, 48.1% in Kandy) followed by inconvenient testing location (23.7% in Colombo and 31.1% in Kandy). HIV has not yet been firmly established among FSW in three cities in Sri Lanka, but the vulnerability towards HIV and STIs is substantial. HIV interventions should be intensified by expanding community-based HIV testing approaches, increasingawareness of HIV risks and addressing socio-structural vulnerabilities of FSW to HIV.

Outcomes of community-based HIV testing modalities in a Mpumalanga district, South Africa.

Testing for HIV in individuals informs them of their HIV status, which in turn enables them to receive prevention, treatment and care services. HIV services should ideally be accessed before an individual's immune system is severely damaged, which could also increase the prevention of new HIV infections. The national HIV testing services (HTS) programmes aim to identify HIV-infected individuals and link them to prevention, care and treatment services. Community-based (CB) HTS reaches community members who do not have access to such services at healthcare facilities. The Foundation for Professional Development (FPD) provided CB-HTS in a Mpumalanga district, South Africa, from 1 October 2016 to 30 September 2017 (Country Operating Plan (COP16)), where 65 691 clients were tested. To determine which of the FPD CB-HTS modalities used in the Mpumalanga district during COP16 delivered the highest positivity rate, disaggregated by population segmentation. The accompanying objectives were: to describe the demographic characteristics of HTS clients in the district and to compare the different positivity rates of FPD CB-HTS modalities in the district. This cross-sectional quantitative study used all the individual, programmatic data collected for all CB-HTS clients in Ehlanzeni during COP16 as secondary data. Descriptive analysis was employed to describe participants' characteristics. The χ2 test was used for comparing variables. The mean age of clients was 29.3 (95% confidence interval (CI) 29.7 - 29.9) years. Of the clients analysed, 56.4% were females. Of the clients who were tested for HIV, 14.1% were tested for the first time; 67.7% of those were between 15 and 49 years old. The positivity rate for each modality was calculated, and it was found that home-based HTS had the best positivity rate (9.1%) in the Mpumalanga district during COP16. This study provides evidence that home-based HTS delivered the best positivity rate in the Mpumalanga district. The results should be used to replicate the programme in other districts. If similar findings are obtained in other studies, it could inform how future CB-HTS programmes should be rolled out, which could change future strategic planning and resource allocation for CB-HTS programmes.

Community-based antiretroviral therapy versus standard clinic-based services for HIV in South Africa and Uganda (DO ART): a randomised trial

SummaryBackgroundCommunity-based delivery of antiretroviral therapy (ART) for HIV, including ART initiation, clinical and laboratory monitoring, and refills, could reduce barriers to treatment and improve viral suppression, reducing the gap in access to care for individuals who have detectable HIV viral load, including men who are less likely than women to be virally suppressed. We aimed to test the effect of community-based ART delivery on viral suppression among people living with HIV not on ART.MethodsWe did a household-randomised, unblinded trial (DO ART) of delivery of ART in the community compared with the clinic in rural and peri-urban settings in KwaZulu-Natal, South Africa and the Sheema District, Uganda. After community-based HIV testing, people living with HIV were randomly assigned (1:1:1) with mobile phone software to community-based ART initiation with quarterly monitoring and ART refills through mobile vans; ART initiation at the clinic followed by mobile van monitoring and refills (hybrid approach); or standard clinic ART initiation and refills. The primary outcome was HIV viral suppression at 12 months. If the difference in viral suppression was not superior between study groups, an a-priori test for non-inferiority was done to test for a relative risk (RR) of more than 0·95. The cost per person virally suppressed was a co-primary outcome of the study. This study is registered with ClinicalTrials.gov, NCT02929992.FindingsBetween May 26, 2016, and March 28, 2019, of 2479 assessed for eligibility, 1315 people living with HIV and not on ART with detectable viral load at baseline were randomly assigned; 666 (51%) were men. Retention at the month 12 visit was 95% (n=1253). At 12 months, community-based ART increased viral suppression compared with the clinic group (306 [74%] vs 269 [63%], RR 1·18, 95% CI 1·07–1·29; psuperiority=0·0005) and the hybrid approach was non-inferior (282 [68%] vs 269 [63%], RR 1·08, 0·98–1·19; pnon-inferiority=0·0049). Community-based ART increased viral suppression among men (73%, RR 1·34, 95% CI 1·16–1·55; psuperiority<0·0001) as did the hybrid approach (66%, RR 1·19, 1·02–1·40; psuperiority=0·026), compared with clinic-based ART (54%). Viral suppression was similar for men (n=156 [73%]) and women (n=150 [75%]) in the community-based ART group. With efficient scale-up, community-based ART could cost US$275–452 per person reaching viral suppression. Community-based ART was considered safe, with few adverse events.InterpretationIn high and medium HIV prevalence settings in South Africa and Uganda, community-based delivery of ART significantly increased viral suppression compared with clinic-based ART, particularly among men, eliminating disparities in viral suppression by gender. Community-based ART should be implemented and evaluated in different contexts for people with detectable viral load.FundingThe Bill & Melinda Gates Foundation; the University of Washington and Fred Hutch Center for AIDS Research; the Wellcome Trust; the University of Washington Royalty Research Fund; and the University of Washington King K Holmes Endowed Professorship in STDs and AIDS.

Proyecto Promover: Attempts to Roll Out an HIV Prevention and Testing Initiative Within a Mexican Immigrant Community.

Latinx immigrants and men, in particular, living in the US are disproportionally impacted by HIV. Despite these concerns, there is limited research on the development, implementation, and evaluation of community-based HIV education and HIV testing interventions. The current study describes such efforts within a historic Mexican immigrant enclave inChicago. A mixed-methods case study was used to describe intervention development, as well as preliminary evaluation data. Community intervention components were refined through early focus groups, asset mapping, community networking and consultation with cultural advisors. We exceeded our activity goals. We were successful in reaching a segment of the population that is often overlooked and remains unaware of HIV and its risks. Incorporating social network approaches could facilitate reaching at-risk community groups. Demonstration projects require more time and resources (fiscal and technical) to develop, refine, evaluate and sustain community-level intervention components.

Learnings from a decade experience of a community-based HIV and STI testing and counseling center in Lisbon – Portugal

Abstract Background In the context of an increased number of men who have sex with men (MSM) being diagnosed with HIV infection in many European countries, it became a matter of maximum priority to consider new strategies to monitor and tackle the epidemic. In this scenario, CheckpointLX and a cohort study were projected as a sexual health and research center oriented towards MSM in Portugal. Methods In 2011 CheckpointLX was launched in Lisbon as a community-based center for anonymous and free rapid HIV and other sexually transmitted diseases (STI) testing with a strong component of counseling for sexual health, specially targeted at MSM. In the case of a reactive test, a medical appointment is proposed and scheduled. The Lisbon Cohort of MSM is an ongoing observational prospective study conducted at CheckpointLX. Collected data include sexual behaviors, preventive strategies, and history of STI. Results Until July 2019, 7,351 HIV-negative MSM chose to participate in the Lisbon Cohort of MSM. 3,523 had at least one follow-up visit. The median age was 29 (IQR 25 - 37), and 27% were born in a foreign country, including 15% born in Africa and South America. HIV incidence increased up until 2015, reaching 5 reactive tests per 100 tested annually. There has been a sustained decrease in HIV observed since 2015. The use of HIV prevention tools was provided: 31% used condoms consistently, 3% reported PrEP, and 4% PEP. Conclusions A decade since the beginning of this experience shows positive results, such as increased access and testing. We promoted a stigma-free service that facilitated MSM's and other key population's access to sexual health care. We contribute unique data for assisting in the monitoring of the Dublin Declaration in Portugal.

14.H. Workshop: Ecosystems of HIV risk among key populations in Europe: empirical findings and solutions

Abstract Key populations, such as men who have sex with men and persons who inject drugs (PWID) have an increased risk of HIV. These same key populations experience extensive barriers in accessing HIV/AIDS services that are acceptable, accessible, and of high quality. These issues are particularly acute in Eastern Europe where stigma and structural barriers to HIV services are large. This workshop is important because of the rising incidence of HIV in Europe. This is particularly a challenge in Eastern Europe, the only geographical region in the world experiencing rising rates of HIV. Thus, understanding key population's specific HIV risk factors are crucial to address their needs and prevent new infections. This workshop will give examples of studies on the health and HIV situation of key populations in Europe. The workshop will identify the social and structural contexts that create the specific determinants of HIV risks among the population in the region. The workshop will also discuss avenues and interventions to address their HIV risks. Kristefer Stojanovski (USA) will present results on a European analysis regarding the role of policy and laws in shaping HIV risk among MSM. Sladjana Baros (Serbia) will present findings on the barriers that persons living with HIV (PLHIV) in Serbia face, particularly stigma, that limits their access treatment and access to services. Elizabeth King (USA) will present on stigma's role in perpetuating HIV risk among women who inject drugs in Russia, including ways to address the issues. Lastly, Francisco Fernandes (Portugal) will present results from their work over the last 10 years providing community-based HIV and STI testing and counseling in Portugal. After the individual presentations, the audience will be invited to a monitored open discussion on the papers, and how the findings can help inform public health and policy to address HIV in Europe. The situation for HIV and key populations in Europe is worrisome from a public health standpoint, especially as research shows how structural factors can drive HIV risk and infection. Our workshop aims to facilitate a conversation on understanding the structural situation and exploring ways to reduce the disproportionate health burden and risk factors. Given this year's theme of public health for the future of humanity, we believe our workshop asks salient questions to address HIV risk, globally. Key messages Key populations in Europe have an elevated risk of structurally induced stigma, which influences HIV risk. Disproportionate HIV burdens among key populations require urgent attention from public health professionals given the rising rates of HIV in Europe.

Implementation of Universal HIV Testing and Treatment to Reduce HIV Incidence in Botswana: the Ya Tsie Study.

Antiretroviral treatment (ART) can dramatically reduce the risk of HIV transmission, but the feasibility of scaling up HIV testing, linkage and treatment to very high population levels, and its impact on population HIV incidence, were unknown. We review key findings from a community-randomized trial in which we evaluated the impact of "universal test and treat" (UTT) on population HIV incidence in Botswana, a resource-constrained country with both high HIV prevalence and high ART coverage before study inception. We conducted a community-randomized trial (the "Ya Tsie" trial or Botswana Combination Prevention Project (BCPP)) in 30 villages in Botswana from 2013 to 2018, with the goal of determining whether a combination of prevention interventions-with a focus on universal HIV testing and treatment-would reduce population-level HIV incidence. The intervention included universal HIV testing (home-based and mobile), active linkage to HIV care and treatment with patient tracing for persons not linking, universal ART coverage, rapid ART start (at the first clinic visit), and enhanced male circumcision services. Botswana had very high HIV diagnosis, treatment, and viral suppression levels (approaching the UNAIDS "90-90-90" targets) prior to intervention roll-out. By study end, we were able to exceed the overall 95-95-95 coverage target of 86%: an estimated 88% of all persons living with HIV were on ART and had viral suppression in the Ya Tsie intervention arm. In addition, annual HIV incidence was 30% lower in the intervention arm as compared with the control arm over a 29-month follow-up period. With universal HIV testing and relatively simple linkage activities, it was possible to achieve one of the highest reported population levels of HIV diagnosis, linkage to care, and viral suppression globally and to reduce population HIV incidence by about one-third over a short period of time (< 3years). We were able to significantly increase population viral suppression and to decrease HIV incidence even in a resource-constrained setting with pre-existing very high testing and treatment coverage. Universal community-based HIV testing and tracing of individuals through the HIV care cascade were key intervention components.

Using HIV self-testing to increase the affordability of community-based HIV testing services.

Objectives:This study estimates the costs of community-based HIV testing services (HTS) in Lesotho and assesses the potential efficiency gains achieved by adding HIV self-testing (HIVST) and then self-testing booths.Design:Micro-costing analysis using longitudinal data from a real-world intervention.Methods:We collected data prospectively on provider's costs and programmatic outcomes over three time periods of approximately 8 months each, between May 2017 and April 2019. The scope of services was extended during each period as follows: HTS only, HTS and HIVST, HTS and HIVST with individual HIVST booths wherein clients were encouraged to self-test on-site followed by on-site confirmative testing for those with reactive self-test. For each implementation period, we estimated the full financial and economic implementation costs, the incremental costs of adding HIVST onto conventional HTS and the cost per HIV positive case identified.Results:Costs per HIV-positive case identified increased between period 1 (US$956) and period 2 (US$1249) then dropped in period 3 (US$813). Full versus incremental cost analyses resulted in large differences in the magnitude of costs, attributable to methods rather than resource use: for example, in period 3, the average full and incremental cost estimates for HTS were US$34.3 and US$23.5 per person tested, and for HIVST were US$37.7 and US$14.0 per kit provided, respectively.Conclusion:In Lesotho, adding HIVST to community-based HTS improves its overall affordability for HIV-positive case finding. The reporting of both full and incremental cost estimates increase transparency for use in priority setting, budgeting and financial planning for scale-up.

Rapid point-of-care CD4 testing at mobile units and linkage to HIV care: an evaluation of community-based mobile HIV testing services in South Africa

BackgroundMobile HIV testing services (HTS) are effective at reaching undiagnosed people living with HIV. However, linkage to HIV care from mobile HTS is often poor, ranging from 10 to 60%. Point-of-care (POC) CD4 testing has shown to increase retention in health facilities, but little evidence exists about their use in mobile HTS. This study assessed the feasibility of POC CD4 test implementation and investigated linkage to HIV care among clients accepting a POC test at community-based mobile HTS.MethodsThis retrospective study used routinely collected data from clients who utilized community-based mobile HTS in the City of Cape Town Metropolitan district, South Africa between December 2014 and September 2016. A POC CD4 test was offered to all clients with an HIV positive diagnosis during this period, and a CD4 cell count was provided to clients accepting a POC CD4 test. Random effects logistic regression was used to assess factors associated with POC CD4 test uptake and self-reported linkage to care among clients accepting a POC test. Models were adjusted for sex, age, previous HIV test done, tuberculosis status and year of HIV diagnosis.ResultsOne thousand three hundred twenty-five of Thirty-nine thousand seven hundred ninety clients utilizing mobile HTS tested HIV positive (3%). 51% (679/1325) accepted a POC test. The age group with the highest proportion accepting a POC test was 50+ years (60%). Females were less likely to accept a POC test than males (odds ratio = 0.7, 95%CI = 0.6–0.8). Median CD4 count was 429 cells/μl (interquartile range = 290–584). Among 679 clients who accepted a POC CD4 test, 491 (72%) linked to HIV care. CD4 cell count was not associated with linkage to care.ConclusionOur findings suggest that mobile HTS can identify early HIV infection, and show that a high proportion of clients with a POC test result linked to care. Future research should assess factors associated with POC test acceptance and assess the impact of POC CD4 testing in comparison to alternative strategies to engage HIV positive people in care.

PrEP Implementation Behaviors of Community-Based HIV Testing Staff: A Mixed-Methods Approach Using Latent Class Analysis.

Pre-exposure Prophylaxis (PrEP) is an important option for HIV prevention, but the approach has reached a limited number of people at risk of HIV infection. A mixed-methods concurrent triangulation design was used to investigate unobserved subgroups of staff who provide community-based, publicly funded HIV testing in Florida (USA). PrEP implementation groups, or classes, were determined using latent class analysis. Generalized linear mixed models were used to estimate PrEP implementation as a function of staff characteristics. In-depth interviews based on the Consolidated Framework for Implementation Research were analyzed thematically. Based on fit statistics and theoretical relevance, a 3-class latent class analysis was selected. Class 1 ("Universal") staff were highly likely to talk about PrEP with their clients, regardless of client eligibility. Class 2 ("Eligibility dependent") staff were most likely to discuss PrEP if they believed their client was eligible. Class 3 ("Limited") staff sometimes spoke to clients about PrEP, but not systematically. In multivariate analyses, only race and sexual orientation remained significant predictors of the PrEP implementation group. Staff who identified as a racial or sexual minority were less likely to be in the Limited group than their heterosexual or white counterparts. Age, gender, ever having taken PrEP, and HIV status did not impact the odds of being in a specific PrEP implementation group. A subset of HIV testing staff differentially discuss PrEP based on perceived client eligibility; others inconsistently talk to clients about PrEP. Targeted training based on PrEP implementation groups may be beneficial.

Establishment of a national surveillance system to monitor community HIV testing, Ireland, 2018.

HIV continues to be an important public health issue. Voluntary community-based HIV testing (VCBT) helps to reduce the undiagnosed population of HIV-positive individuals, enabling early diagnosis and treatment. Monitoring is essential to determine whether at-risk groups are being effectively reached. Our aim was to pilot and then introduce sustained monitoring of VCBT in Ireland, through collaboration between statutory and non-statutory organisations. The study was initiated by the Health Protection Surveillance Centre in 2018. Steps included forming a multisectoral steering group and developing a minimum standardised dataset. De-identified case-based data were requested for VCBT carried out from 1 January 2017 onwards; this paper includes data for 2018. Six organisations participated; all four NGOs involved in VCBT, one medical charity, and the Health Service Executive National Social Inclusion Office.Methods were rapid point-of-care testing (POCT) (54%) or laboratory based (46%). Total HIV test reactivity was 1.7% (1.5% excluding persons later identified as previously diagnosed HIV positive). All POCT data were case based; the test reactivity rate was 0.8% and was higher in bar/club settings (1.2%). Most (74%) laboratory testing data were in aggregate format; the test positivity rate in one asylum centre was 5.0%.Ongoing challenges include testing among persons later identified as previously diagnosed HIV positive, monitoring case-based testing in asylum settings, and suboptimal data on confirmatory testing and linkage to care. Sustained national monitoring in community settings will help inform HIV testing guidelines and will enable assessment of the impact of local and regional community HIV testing strategies.

Reaching the first 90 in the Democratic Republic of the Congo: a programme to optimise HIV case finding through intensified index testing

BackgroundTo meet the first aim of the UNAIDS 90-90-90 targets, to help end the global HIV epidemic, 90% of people living with HIV should know their status by 2020. In the Democratic Republic of the Congo (DRC), however, UNAIDS estimates that less than 60% of people living with HIV know their status. To improve targeted HIV testing in Kinshasa and Haut-Katanga provinces of DRC, ICAP at Columbia University, New York, USA, launched an intensive index-testing programme in October, 2017. Here, we describe the programme and report testing yields before and after the intervention. MethodsOur programme increased efforts to elicit information on sexual partners from people who newly test HIV positive or who were receiving antiretroviral therapy (index clients). All index clients were counselled on options for partner notification and tracing, including using peer counsellors who can anonymously notify and test past sexual partners in the community or provide referral to health facilities. We recorded the number of people referred by index clients and describe HIV testing yield (the proportion of people referred by index clients who tested HIV positive) for both male and female clients older than 15 years. We used χ2 tests to compare the testing yield at the start of the intervention to that 10 months after the start of programme implementation. FindingsBetween Oct 1, 2017, and Sept 30, 2018, 2167 male index clients referred 2624 adult female partners (1·2 contacts per index client) of whom 770 (29·3%) tested HIV-positive; 5135 adult female index clients referred 2593 male partners (0·5 contacts per client) of whom 866 (33·4%) were HIV positive. HIV testing yield increased over the course of implementation. At the start of implementation (Oct 1 to Nov 30, 2017, a total of 60 days), 507 adult female partners of index clients were tested for HIV with a testing yield of 12% and 386 adult male partners were tested with a yield of 15%. Between August 1 and Sept 30, 2018 (a total of 60 days), 396 adult female partners were tested with a yield of 38·4% (pre vs post, p<0·0001) and 547 adult male partners were tested with a yield of 41·7% (p<0·0001). InterpretationThese results show the importance of index testing and partner notification in finding people who are living with HIV but unaware of their status. Identification of a client's sexual partners in the HIV testing service and conducting tracking and community-based HIV testing can improve HIV testing yield. FundingCDC and PEPFAR

Social franchising of community-based HIV counselling and testing services to increase HIV testing and linkage to care in Tshwane, South Africa: study protocol for a non-randomised implementation trial

BackgroundMeeting the ambitious UN 90–90-90 HIV testing, treatment and viral load suppression targets requires innovative strategies and approaches in Sub-Saharan Africa. To date no known interventions have been tested with community health workers (counsellors) as social franchisees or owner-managed businesses in Community-based HIV counselling and testing (CBCT) work. The aim of this methods paper is to describe a Social franchise (SF) CBCT implementation trial to increase HIV testing and linkage to care for individuals at community levels in comparison with an existing CBCT programme methods.Methods/designThis is a two arm non-randomised community implementation trial with a once off round of post-test follow-up per HIV positive participant to assess linkage to care in low income communities. The intervention arm is a social franchise CBCT in which unemployed, self-employed or employed community members are recruited, contracted and incentivised to test at least 100 people per month, identifying at least 5 HIV positive tests and linking to care at least 4 of them. Social franchisees receive approximately $3.20 per HIV test and $8 per client linked to care. In the control arm, full-time employed HIV counsellors conduct CBCT on a fixed monthly salary. Primary study outcomes are HIV testing uptake rate, HIV positivity, Linkage to care and treatment rate and average counsellors’ remuneration cost. Data collection will be conducted using both paper-based and electronic data applications by CBCT or SF counsellors. Data analysis will compare proportions of HIV testing, positivity, linkage to HIV care and treatment rates and counsellors’ cost in the two study arms.DiscussionThe study will provide important insight into whether the SF-delivered CBCT programme increases testing coverage and linkage to care as well as reducing CBCT cost per HIV test and per HIV positive person linked to care.Trial registrationPan African Clinical Trial Registry PACTR201809873079121. The trial was retrospectively registered on 11 September 2018.

A community-based HIV counselling and testing programme found a decreasing proportion of new HIV testers in South Africa

This article assesses the history of HIV testing among community-based HIV counselling and testing (CBCT) clients between 2014 and 2018 in 13 South African districts. Consenting clients were tested for HIV and interviewed to categorise as first-time testers or repeat testers. Of the 1 800 753 clients tested for HIV, 15.7% (95% CI [15.6–15.7]) were first-time testers. The rate of identifying first-time testers decreased by 10.7% in four years from 18.4% in year one to 7.7% in year four. A substantial proportion (5.5% [5.4–5.6]) of HIV-positive people not yet on antiretroviral treatment sought HIV re-test, of whom nearly half (48.4% [47.1–49.6]) did not disclose their HIV-positive status during pre-counselling and were re-tested. A decreasing proportion of first-time testers may signal positive progress towards universal HIV testing. This downward trend should be sustained to control the HIV epidemic.

Qualitative Contributions to Implementation Research on HIV Prevention and Treatment

The advantages of conducting implementation research as part of the development, as well as delivery and use of HIV prevention and treatment interventions, are increasingly being recognized. Qualitative methods are gaining recognition in implementation-oriented research on HIV as vehicles for examining particular implementation outcomes and for identifying barriers and facilitators to intervention uptake. However, they have more to offer. This article presents 3 case examples illustrating the use of qualitative research to explain intervention processes and outcomes, with the goal of clarifying "how and why" they work. The first example identifies active ingredients in an intervention aimed at improving antiretroviral therapy (ART) adherence. The second proposes an explanation of the processes through which community-based HIV testing with follow-up support may bring about linkage to care and prevention services. The third unpacks the dynamics of a novel strategy of delivering oral pre-exposure prophylaxis and ART to HIV serodiscordant couples, showing how the organization of services positively impacted participating couples, enabling them to use oral pre-exposure prophylaxis and ART effectively to prevent HIV transmission. Qualitative methods contribute to implementation research for HIV intervention development by (1) offering an alternative to framework-driven investigation, (2) providing tools for understanding user experience of interventions, and (3) developing local explanations of intervention processes and outcomes. In various ways, qualitative methods contribute to implementation research by deepening and "thickening" conceptualization of implementation problems. Stronger conceptualizations lead to stronger implementation strategies and, thus, to increased use of evidence-based interventions for HIV prevention and treatment as they are made available to the public worldwide.

Zwakala Ndoda: a cluster and individually randomized trial aimed at improving testing, linkage, and adherence to treatment for hard-to reach men in KwaZulu-Natal, South Africa

BackgroundMen in sub-Saharan Africa are less likely than women to get tested for HIV, less likely to present for treatment, less likely to be maintained in treatment, more likely to have detectable viral load, more likely to transmit HIV with unprotected intercourse, and more likely to progress to AIDS and die sooner from HIV. The ultimate objective of this research is to provide evidence-based strategies to improve HIV testing and treatment of HIV-infected men.MethodsThis study is being conducted in the Greater Edendale Area and Vulindlela region in KwaZulu-Natal, South Africa. It is a two-stage design of a cluster-randomized trial and an individual randomized trial to test how structural and individual-level interventions address the demand-side factors that affect HIV testing and treatment for hard-to reach, high-risk men. It combines male-focused mobilization, community-based mobile HIV testing services, and a small incentive to determine if the strategies singly and in combination can result in more men diagnosed with HIV, and more men linked to and maintained in care with undetectable viral load.DiscussionA priority for sub-Sahara Africa is developing and evaluating novel and cost-effective strategies for identifying hard-to-reach groups such as men, linking them to HIV testing and care services, and maintaining them in care to the point of viral suppression. We propose a combination prevention intervention that addresses men’s individual, interpersonal, and structural barriers to testing and care. This includes male-led mobilization to encourage uptake of testing and treatment, male-focused testing venues, male-only counselors, developing counseling models that are flexible and responsive to men, and strategies for adhering to clinic visits without missing work and navigating the healthcare system. By thoughtfully combining male-focused mobilization, and testing and addressing some of the barriers to male engagement with health facilities, this study hopes to add to the growing evidence base about how to reach, test, link, and maintain a hard-to-reach group such as men in HIV treatment and care services.Trial registrationClinicalTrials.gov, NCT03794245. Registered on 4 January 2019.

Implementation of a Community-Based Hybrid HIV Testing Services Program as a Strategy to Saturate Testing Coverage in Western Kenya.

Knowledge of HIV status is the entry point for linkage to prevention, care, and treatment, and the first step toward achieving the UNAIDS 90-90-90 targets. Most countries rely on proxies for estimating testing saturation, including periodic population-based sampling and yield (number positive among those tested). We conducted a community-based "Hybrid" HIV testing services (HTS) program to identify persons unaware of their HIV-positive status. Homa Bay County, Kenya; July-September, 2016. We conducted community mapping, household census, multi-disease community health campaigns (CHCs), and home-based tracking. HIV testing eligibility was based on 2015 national guidelines. The previously unidentified fraction (PUF) was defined as the proportion of newly identified persons living with HIV (PLWH) out of all previously identified and newly identified PLWH. The Hybrid HTS program reached 28,885 persons in total: 25,340 residents and 3545 nonresidents. There were 19,288 persons reached through CHCs and tracking. Of 11,316 individuals eligible for HIV testing, 9463 (83%) accepted testing, including 1230 (13%) first-time testers. There were 115 newly identified PLWH of 1589 total HIV-positive persons, representing a 7.2% PUF. Of 93 newly identified PLWH at the CHCs, 68% initiated same-day antiretroviral therapy. The Hybrid HTS program identified persons previously unaware of their HIV-positive status, thereby enabling linkage to care and same-day treatment and reducing onward transmission risk. An approach focused on identifying persons unaware of their HIV-positive status in combination with ascertaining the PUF has the potential to better target testing strategies to identify >90% of PLWH in a community.