HIV Self-testing Distribution Research Articles

Feasibility, acceptability and preliminary effects of a social network-based, peer-led HIV self-testing intervention among men in two Ugandan fishing communities, 2022

BackgroundSocial network-based interventions can improve uptake of health interventions. However, limited evidence exists on their feasibility and acceptability in fishing community settings. We assessed the feasibility, acceptability and preliminary effects of a social network-based, peer-led HIV self-testing (HIVST) intervention among men in Uganda.MethodsThe PEer-led HIVST intervention for MEN (PEST4MEN) is a pilot intervention conducted among men in Kalangala and Buvuma districts. Baseline data were collected in July 2022 and follow-up data in September 2022. The intervention was implemented through 22 trained lay men (“peer-leaders”) who received training in HIVST use and distribution processes and requested to refer at least 20 male members from their social networks for study eligibility screening. To be eligible, men had to be aged 15 years or older with unknown or HIV-negative status. After the baseline interview, men were requested to pick two oral fluid-based HIVST kits from their peer-leaders. The intervention was deemed feasible if peer-leaders gave-out > 80% of the kits and acceptable if > 80% of the kits’ recipients used them to self-test for HIV. At the follow-up interview, newly diagnosed HIV-positive men were asked if they had linked to HIV care. Data were descriptively analyzed using STATA version 16.0.ResultsOf 475 screened men, 400 (84.2%) met the eligibility criteria and completed the baseline interview. Of these, 56.7% (n = 227) were engaged in fishing or fishing-related activities. At follow-up, 361 men (90.2%) were interviewed; 98.3% (n = 355) received at least one kit from their peer-leaders. Nearly all (99.1%, n = 352) kits’ recipients used them to self-test for HIV. Of the 352 HIV self-testers, 51 men (14.5%) had reactive (positive) HIV self-test results. Nearly one-third of the HIV self-tested men (31.4%, n = 16) were first-time HIV-positive testers. Of these, 87.5% (n = 14) went for confirmatory HIV testing, 50.0% (n = 7) were confirmed as HIV-positive and 71.4% (n = 5) were linked to HIV care.ConclusionOur peer-led HIVST intervention was feasible and acceptable and identified newly diagnosed HIV-positive men who were linked to HIV care. However, while these results are promising, we recommend additional research in a randomized controlled trial prior to the eventual roll-out of this intervention.Trial registrationClinicalTrials.Gov: NCT05685498 (retrospectively registered on January 17, 2023).

Linkage to care and prevention after HIV self-testing: a systematic review and meta-analysis.

Effective linkage to prevention and care is a crucial step following HIV testing services. This systematic review aimed to determine the proportion of individuals linked to prevention and care after HIV self-testing (HIVST) and describe factors associated with linkage. Following PRISMA guidelines, a comprehensive search across eight databases (2010-October 2023) identified studies on linkage to care after HIVST, defined as receiving a confirmatory test or initiating antiretroviral therapy (ART) if the self-test was reactive, and/or pre-exposure prophylaxis (PrEP) if the self-test was non-reactive. A random-effects meta-analysis summarized the findings and meta-regression explored study-level covariates, such as world region, population type and service delivery model, that might explain the between-study heterogeneity. From 10,071 screened studies, 173 were included in the meta-analysis. The majority of studies focused on key populations in Africa using unassisted, oral fluid-based HIVST kits. Among those with reactive HIVST results, 92% (95% confidence interval [CI]: 88-95) were linked to confirmatory testing (n = 124 studies), and 89% (95% CI: 84-93) of newly diagnosed individuals initiated ART (n = 88 studies). Overall, 84% (95% CI: 74-93) of self-testers were linked to care (n = 69 studies). However, only 9% (95% CI: 2-19) of individuals with non-reactive HIVST results were linked to PrEP services (n = 9 studies). Assisted HIVST was associated with higher linkage rates to confirmatory testing and ART initiation compared to unassisted testing. Meta-regression revealed that the type of delivery model for the HIVST kits influenced linkage and that individuals who obtained their HIVST kits through a social network-based approach (SNA) were more likely to be linked to confirmatory testing (adjusted odds ratio = 1.28 [95% CI: 1.10-1.50], p = 0.001) compared to non-SNA service delivery model. In the context of expanding HIVST services globally, we found that linkage to confirmatory testing and ART initiation after HIVST is generally high, particularly when assisted HIVST or SNA-based distribution is used. Strengthening timely linkage is vital for improving health outcomes, reducing HIV transmission and achieving the UNAIDS 95-95-95 goal. Ongoing research and collaboration with community-based organizations are needed to overcoming barriers and ensuring positive outcomes for those using HIVST. CRD42022357570.

Acceptability and feasibility of HIV self-testing distribution modes among key populations in Morocco.

HIV self-testing was introduced to enhance HIV testing uptake, especially among key populations. Despite the benefits, its use remains relatively low in the WHO Eastern Mediterranean Region. To assess the acceptability, usability and feasibility of HIV self-testing among key populations in Morocco. We assessed the usability and acceptability, as well as the feasibility of ordering online and picking up in pharmacies and of distribution by people living with HIV of an oral HIV self-testing kit among 3465 female sex workers, men having sex with men, and partners of newly diagnosed people living with HIV in Morocco. Data were collected using 4 questionnaires administered online anonymously and analysed using Stata version 14.0. A total of 3465 individuals received the HIV self-testing kits, 54.4% male, 43.7% female and 1.9% transgender. High acceptability rates of 90.2%, 86.2% and 80.4% were reported among the female sex workers, men having sex with men, and partners of newly diagnosed people living with HIV, respectively. HIV positivity rates were 1.2% among the female sex workers and men having sex with men, and 4.3% among partners of people living with HIV. Between 44.0% and 73.4% of the participants had never been tested for HIV. Our findings highlight the value of extending HIV self-testing services to key populations in Morocco and possibly other countries in the Middle East and North Africa.

Development and feasibility of the peer and nurse-led HIV Self-Testing Education and Promotion (STEP) intervention among social networks of men in Dar es Salaam, Tanzania: application of the ADAPT-ITT model

BackgroundAccording 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 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 includes male peer education and demand creation for HIVST, and nurse-led distribution of HIVST kits in a community setting.MethodsThe 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 as peer educators in 2019 to promote HIVST among their peers before recruiting 253 men who received instructions and an HIVST kit from a nurse at a community-based study tent site.ResultsOf 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.ConclusionThe findings demonstrate that the combined peer-based promotion and nurse-led distribution of HIVST intervention was acceptable and feasible, though seeking follow-up services at healthcare facilities remained low. Future research should evaluate the effectiveness of offering nurse-led community-based clinical follow-up services in addition to HIVST rather than referral to facilities.

Cost and Cost-Effectiveness of Distributing HIV Self-Tests within Assisted Partner Services in Western Kenya

Background: Assisted partner services (APS) is a recommended public health approach to promote HIV testing for sexual partners of individuals diagnosed with HIV. We evaluated the cost and cost-effectiveness of integrating oral HIV self-testing (HIVST) into existing APS programs. Methods: Within the APS-HIVST study conducted in western Kenya (2021–2022), we conducted micro-costing, time-and-motion, and provider surveys to determine incremental HIVST distribution cost (2022 USD). Using a decision tree model, we estimated the incremental cost per new diagnosis (ICND) for HIVST incorporated into APS, compared to APS with provider-delivered testing only. Scenario, parameter and probabilistic sensitivity analyses were conducted to explore influential assumptions. Results: The cost per HIVST distributed within APS was USD 8.97, largest component costs were testing supplies (38%) and personnel (30%). Under conditions of a facility-based testing uptake of <91%, or HIVST utilization rates of <27%, HIVST integration into APS is potentially cost-effective. At a willing-to-pay threshold of USD 1000, the net monetary benefit was sensitive to the effectiveness of HIVST in increasing testing rates, phone call rates, HIVST sensitivity, HIV prevalence, cost of HIVST, space allocation at facilities, and personnel time during facility-based testing. In a best-case scenario, the HIVST option was cheaper by USD 3037 and diagnosed 11 more cases (ICND = 265.82). Conclusions: Implementers and policy makers should ensure that HIVST programs are implemented under conditions that guarantee efficiency by focusing on facilities with low uptake for provider-delivered facility-based testing, while deliberately targeting HIVST utilization among the few likely to benefit from remote testing. Additional measures should focus on minimizing costs relating to personnel and testing supplies.

Assessment of the HIV Enhanced Access Testing in the Emergency Department (HEATED) program in Nairobi, Kenya: a quasi-experimental prospective study

Background Persons seeking emergency injury care are often from higher-risk and underserved key populations (KPs) and priority populations (PPs) for HIV programming. While facility-based HIV Testing Services (HTS) in Kenya are effective, emergency department (ED) delivery is limited, despite the potential to reach underserved persons. Methods This quasi-experimental prospective study evaluated implementation of the HIV Enhanced Access Testing in Emergency Departments (HEATED) at Kenyatta National Hospital ED in Nairobi, Kenya. The HEATED program was designed as a multi-component intervention employing setting appropriate strategies for HIV care sensitization and integration, task shifting, resource reorganization, linkage advocacy, skills development and education to promote ED-HTS with a focus on higher-risk persons. KPs included sex workers, gay men, men who have sex with men, transgender persons and persons who inject drugs. PPs included young persons (18–24 years), victims of interpersonal violence, persons with hazardous alcohol use and persons never HIV tested. Data were obtained from systems-level records, enrolled injured patient participants and healthcare providers. Systems and patient-level data were collected during a pre-implementation period (6 March − 16 April 2023) and post-implementation (period 1, 1 May − 26 June 2023). Additional, systems-level data were collected during a second post-implementation (period 2, 27 June − 20 August 2023). HTS data were evaluated as facility-based HIV testing (completed in the ED) and distribution of HIV self-tests independently, and aggregated as ED-HTS. Evaluation analyses were completed across reach, effectiveness, adoption, implementation and maintenance framework domains. Results All 151 clinical staff were reached through trainings and sensitizations on the HEATED program. Systems-level ED-HTS among all presenting patients increased from 16.7% pre-implementation to 23.0% post-implementation periods 1 and 2 (RR = 1.31, 95% CI: 1.21–1.43; p < 0.001). Among 605 enrolled patient participants, facilities-based HTS increased from 5.7% pre-implementation to 62.3% post-implementation period 1 (RR = 11.2, 95%CI: 6.9–18.1; p < 0.001). There were 440 (72.7%) patient participants identified as KPs (5.6%) and/or PPs (65.3%). For enrolled KPs/PPs, facilities-based HTS increased from 4.6% pre-implementation to 72.3% post-implementation period 1 (RR = 13.8, 95%CI: 5.5–28.7, p < 0.001). Systems and participant level data demonstrated successful adoption and implementation of the HEATED program. Through 16 wk post-implementation a significant increase in ED-HTS delivery was maintained as compared to pre-implementation. Conclusions The HEATED program increased overall ED-HTS and augmented delivery to KPs/PPs, suggesting that broader implementation could improve HIV services for underserved persons already in contact with health systems.

Potential population-level effects of HIV self-test distribution among key populations in Côte d'Ivoire, Mali, and Senegal: a mathematical modelling analysis

During 2019-21, the AutoTest VIH, Libre d'accéder à la connaissance de son Statut (ATLAS) programme distributed around 380 000 HIV self-testing kits to key populations, including female sex workers, men who have sex with men, and their partners, in Côte d'Ivoire, Mali, and Senegal. We aimed to estimate the effects of the ATLAS programme and national scale-up of HIV self-test distribution on HIV diagnosis, HIV treatment coverage, HIV incidence, and HIV-related mortality. We adapted a deterministic compartmental model of HIV transmission in Côte d'Ivoire, parameterised and fitted to country-specific demographic, behavioural, HIV epidemiological, and intervention data in Côte d'Ivoire, Mali, and Senegal separately during 1980-2020. We simulated dynamics of new HIV infections, HIV diagnoses, and HIV-related deaths within scenarios with and without HIV self-test distribution among key populations. Models were separately parameterised and fitted to country-specific sets of epidemiological and intervention outcomes (stratified by sex, risk, age group, and HIV status, if available) over time within a Bayesian framework. We estimated the effects on the absolute increase in the proportion of people with HIV diagnosed at the end of 2021 for the ATLAS-only scenario and at the end of 2028 and 2038 for the HIV self-testing scale-up scenario. We estimated cumulative numbers of additional HIV diagnoses and initiations of antiretroviral therapy and the proportion and absolute numbers of new HIV infections and HIV-related deaths averted during 2019-21 and 2019-28 for the ATLAS-only scenario and during 2019-28 and 2019-38 for the HIV self-testing scale-up scenario. Our model estimated that ATLAS could have led to 700 (90% uncertainty interval [UI] 500-900) additional HIV diagnoses in Côte d'Ivoire, 500 (300-900) in Mali, and 300 (50-700) in Senegal during 2019-21, a 0·4 percentage point (90% UI 0·3-0·5) increase overall by the end of 2021. During 2019-28, ATLAS was estimated to avert 1900 (90% UI 1300-2700) new HIV infections and 600 (400-800) HIV-related deaths across the three countries, of which 38·6% (90% UI 31·8-48·3) of new infections and 70·1% (60·4-77·3) of HIV-related deaths would be among key populations. ATLAS would avert 1·5% (0·8-3·1) of all HIV-related deaths across the three countries during this period. Scaling up HIV self-testing would avert 16·2% (90% UI 10·0-23·1) of all new HIV infections during 2019-28 in Senegal, 5·3% (3·0-8·9) in Mali, and 1·6% (1·0-2·4) in Côte d'Ivoire. HIV self-testing scale-up among key populations was estimated to increase HIV diagnosis by the end of 2028 to 1·3 percentage points (90% UI 0·8-1·9) in Côte d'Ivoire, 10·6 percentage points (5·3-16·8) in Senegal, and 3·6 percentage points (2·0-6·4) in Mali. Scaling up HIV self-test distribution among key populations in western Africa could attenuate disparities in access to HIV testing and reduce infections and deaths among key populations and their partners. Unitaid, Solthis, the UK Medical Research Council Centre for Global Infectious Disease Analysis, the EU European & Developing Countries Clinical Trials Partnership programme, and the Wellcome Trust. For the French translation of the abstract see Supplementary Materials section.

Cost-effectiveness analysis of community-led HIV self-testing among key populations in Côte d'Ivoire, Mali, and Senegal.

HIV self-testing (HIVST) is a promising strategy to improve diagnosis coverage among key populations (KP). The ATLAS (Auto Test VIH, Libre d'Accéder à la connaissance de son Statut) programme implemented HIVST in three West African countries, distributing over 380,000 kits up between 2019 and 2021, focussing on community-led distribution by KP to their peers and subsequent secondary distribution to their partners and clients. We aim to evaluate the cost-effectiveness of community-led HIVST in Côte d'Ivoire, Mali and Senegal. An HIV transmission dynamics model was adapted and calibrated to country-specific epidemiological data and used to predict the impact of HIVST. We considered the distribution of HIVST among two KP-female sex workers (FSW), and men who have sex with men (MSM)-and their sexual partners and clients. We compared the cost-effectiveness of two scenarios against a counterfactual without HIVST over a 20-year horizon (2019-2039). The ATLAS-only scenario mimicked the 2-year implemented ATLAS programme, whereas the ATLAS-scale-up scenario achieved 95% coverage of HIVST distribution among FSW and MSM by 2025 onwards. The primary outcome is the number of disability-adjusted life-years (DALY) averted. Scenarios were compared using incremental cost-effectiveness ratios (ICERs). Costing was performed using a healthcare provider's perspective. Costs were discounted at 4%, converted to $USD 2022 and estimated using a cost-function to accommodate economies of scale. The ATLAS-only scenario was highly cost-effective over 20 years, even at low willingness-to-pay thresholds. The median ICERs were $126 ($88-$210) per DALY averted in Côte d'Ivoire, $92 ($88-$210) in Mali and 27$ ($88-$210) in Senegal. Scaling-up the ATLAS programme would also be cost-effective, and substantial epidemiological impacts would be achieved. The ICERs for the scale-up scenario were $199 ($122-$338) per DALY averted in Côte d'Ivoire, $224 ($118-$415) in Mali and $61 ($18-$128) in Senegal. Both the implemented and the potential scale-up of community-led HIVST programmes in West Africa, where KP are important to overall transmission dynamics, have the potential to be highly cost-effective, as compared to a scenario without HIVST. These findings support the scale-up of community-led HIVST to reach populations that otherwise may not access conventional testing services.

Investigating the effectiveness of web-based HIV self-test distribution and linkage to HIV treatment and PrEP among groups at elevated risk of HIV in Viet Nam provinces: a mixed-methods analysis of implementation from pilot to scale-up.

In Viet Nam, key populations (KPs) face barriers accessing HIV services. Virtual platforms can be leveraged to increase access for KPs, including for HIV self-testing (HIVST). This study compares reach and effectiveness of a web-based HIVST intervention from pilot to scale-up in Viet Nam. A mixed-methods explanatory sequential design used cross-sectional and thematic analysis. The pilot launched in Can Tho in November 2020, followed by Hanoi and Nghe An in April 2021. Scale-up included Can Tho and Nghe An, with 21 novel provinces from April to December 2022. After risk assessment, participants registered on the website, receiving HIVST (OraQuick®) by courier, peer educator or self-pick-up. Test result reporting and completing satisfaction surveys were encouraged. Intervention reach was measured through numbers accessing the testing, disaggregated by demographics, and proportion of individuals reporting self-testing post-registration. Effectiveness was measured through numbers reporting self-test results, testing positive and linking to care, and testing negative and using HIVST to manage pre-exposure prophylaxis (PrEP) use. Thematic content analysis of free-text responses from the satisfaction survey synthesized quantitative outcomes. In total, 17,589 participants registered on the HIVST website; 11,332 individuals ordered 13,334 tests. Participants were generally young, aged <25 years (4309/11,332, 38.0%), male (9418/11,332, 83.1%) and men who have sex with men (6437/11,332, 56.8%). Nearly half were first-time testers (5069/11,332, 44.9%). Scale-up participants were two times more likely to be assigned female at birth (scale-up; 1595/8436, 18.9% compared to pilot; 392/3727, 10.5%, p < 0.001). Fewer test results were reported in scale-up compared with pilot (pilot: 3129/4140, 75.6%, scale-up: 5811/9194, 63.2%, p < 0.001). 6.3% of all tests were reactive (pilot: 176/3129, 5.6% reactive compared to scale-up: 385/5811, 6.6% reactive, p = 0.063); of which most linked to care (509/522, 97.5%). One-fifth of participants with a negative test initiated or continued PrEP (pilot; 19.8%, scale-up; 18.5%, p = 0.124). Thematic analysis suggested that community delivery models increased programmatic reach. Live chat may also be a suitable proxy for staff support to increase result reporting. Web-based self-testing in Viet Nam reached people at elevated risk of HIV, facilitating uptake of anti-retroviral treatment and direct linkage to PrEP initiations. Further innovations such as the use of social-network testing services and incorporating features powered by artificial intelligence could increase the effectiveness and efficiency of the approach.

Findings from the First Year of a Federally Funded, Direct-to-Consumer HIV Self-Test Distribution Program - United States, March 2023-March 2024.

In September 2022, CDC funded a nationwide program, Together TakeMeHome (TTMH), to expand distribution of HIV self-tests (HIVSTs) directly to consumers by mail through an online ordering portal. To publicize the availability of HIVSTs to priority audiences, particularly those disproportionately affected by HIV, CDC promoted this program through established partnerships and tailored resources from its Let's Stop HIV Together social marketing campaign. The online portal launched March 14, 2023, and through March 13, 2024, distributed 443,813 tests to 219,360 persons. Among 169,623 persons who answered at least one question on a postorder questionnaire, 67.9% of respondents were from priority audiences, 24.1% had never previously received testing for HIV, and 24.8% had not received testing in the past year. Among the subset of participants who initiated a follow-up survey, 88.3% used an HIVST themselves, 27.1% gave away an HIVST, 11.7% accessed additional preventive services, and 1.9% reported a new positive HIVST result. Mailed HIVST distribution can quickly reach large numbers of persons who have never received testing for HIV or have not received testing as often as is recommended. TTMH can help to achieve the goal of diagnosing HIV as early as possible and provides a path to other HIV prevention and care services. Clinicians, community organizations, and public health officials should be aware of HIVST programs, initiate discussions about HIV testing conducted outside their clinics or offices, and initiate follow-up services for persons who report a positive or negative HIVST result.

Decentralized HIV testing: comparing peer and mail-based distribution strategies to improve the reach of HIV self-testing among people who use drugs in Florida

IntroductionPeople who use drugs (PWUD) are at increased risk for HIV infection. HIV self-testing (HIVST) is a promising method for identifying new infections, but optimal distribution strategies remain understudied.MethodsTo characterize PWUD by HIVST distribution strategy (peers vs. mail), we examined data from July 2022 to June 2023 collected from a real-world HIVST program led by the non-profit, Florida Harm Reduction Collective. We used descriptive statistics and Poisson regressions with robust error variance to compare those who received HIVST through peers or via mail by socio-demographics, Ending the HIV Epidemic (EHE) county designation, and HIV testing experience.ResultsAmong 728 participants, 78% received HIVST from peers, 47% identified as cisgender female, 48% as heterosexual, and 45% as non-White; 66% resided in an EHE county, and 55% had no HIV testing experience. Compared to those who received an HIV self-test from peers, those who received tests via mail were less likely to be cisgender male (vs. cisgender female; prevalence ratio [PR] = 0.59, 95% confidence interval [CI]: 0.43, 0.81), non-Hispanic Black (vs. non-Hispanic White; PR = 0.57, 95% CI: 0.36, 0.89) or from EHE counties (vs. non-EHE counties; PR = 0.33, 95% CI: 0.25, 0.44). Those who received tests via mail were also more likely to identify their sexual orientation as “Other/Undisclosed” (vs. straight/heterosexual; PR = 2.00, 95% CI: 1.51, 2.66).ConclusionOur findings support the role of community-based HIVST distribution strategies in increasing HIV testing coverage among PWUD. Additional research could help inform the equitable reach of HIVST.

A Machine Learning Model for Identifying Sexual Health Influencers to Promote the Secondary Distribution of HIV Self-Testing Among Gay, Bisexual, and Other Men Who Have Sex With Men in China: Quasi-Experimental Study.

Sexual health influencers (SHIs) are individuals actively sharing sexual health information with their peers, and they play an important role in promoting HIV care services, including the secondary distribution of HIV self-testing (SD-HIVST). Previous studies used a 6-item empirical leadership scale to identify SHIs. However, this approach may be biased as it does not consider individuals' social networks. This study used a quasi-experimental study design to evaluate how well a newly developed machine learning (ML) model identifies SHIs in promoting SD-HIVST compared to SHIs identified by a scale whose validity had been tested before. We recruited participants from BlueD, the largest social networking app for gay men in China. Based on their responses to the baseline survey, the ML model and scale were used to identify SHIs, respectively. This study consisted of 2 rounds, differing in the upper limit of the number of HIVST kits and peer-referral links that SHIs could order and distribute (first round ≤5 and second round ≤10). Consented SHIs could order multiple HIV self-testing (HIVST) kits and generate personalized peer-referral links through a web-based platform managed by a partnered gay-friendly community-based organization. SHIs were encouraged to share additional kits and peer-referral links with their social contacts (defined as "alters"). SHIs would receive US $3 incentives when their corresponding alters uploaded valid photographic testing results to the same platform. Our primary outcomes included (1) the number of alters who conducted HIVST in each group and (2) the number of newly tested alters who conducted HIVST in each. We used negative binomial regression to examine group differences during the first round (February-June 2021), the second round (June-November 2021), and the combined first and second rounds, respectively. In January 2021, a total of 1828 men who have sex with men (MSM) completed the survey. Overall, 393 SHIs (scale=195 and ML model=198) agreed to participate in SD-HIVST. Among them, 229 SHIs (scale=116 and ML model=113) ordered HIVST on the web. Compared with the scale group, SHIs in the ML model group motivated more alters to conduct HIVST (mean difference [MD] 0.88, 95% CI 0.02-2.22; adjusted incidence risk ratio [aIRR] 1.77, 95% CI 1.07-2.95) when we combined the first and second rounds. Although the mean number of newly tested alters was slightly higher in the ML model group than in the scale group, the group difference was insignificant (MD 0.35, 95% CI -0.17 to -0.99; aIRR 1.49, 95% CI 0.74-3.02). Among Chinese MSM, SHIs identified by the ML model can motivate more individuals to conduct HIVST than those identified by the scale. Future research can focus on how to adapt the ML model to encourage newly tested individuals to conduct HIVST. Chinese Clinical Trials Registry ChiCTR2000039632; https://www.chictr.org.cn/showprojEN.html?proj=63068. RR2-10.1186/s12889-021-11817-2.

Acceptability of venue-based HIV testing and prevention interventions for men who have sex with transgender women and transgender women in Lima, Perú: a formative, qualitative study

Background Despite being at elevated risk for HIV, men who have sex with transgender women (MSTW) are an overlooked population in the global HIV response. Venue-based HIV interventions have previously had success reaching other HIV priority populations, including transgender women (TW). Similar approaches could be applied for MSTW. Objective To evaluate the prospective acceptability of venue-based HIV testing and prevention interventions for MSTW and TW in Lima, Peru. Methods In this exploratory qualitative study, we conducted in-depth interviews (IDI) and focus group discussions (FGD) with three types of participants: MSTW (7 IDIs, 1 FGD), TW (1 FGD), and owners of social venues frequented by MSTW/TW in Lima (2 IDIs). We elicited participants’ attitudes and perceptions related to the following four hypothetical interventions delivered at social venues in Lima: rapid HIV testing; HIV self-test distribution; condom/lubricant distribution; and enrolment in a mobile app supporting HIV prevention. We performed a mixed deductive-inductive thematic analysis using the framework method, then applied the Theoretical Framework of Acceptability to classify the overall acceptability of each intervention. Results Condom/lubricant distribution and app-based HIV prevention information were highly acceptable among all participant types. The two HIV testing interventions had relatively lower acceptability; however, participants suggested this could be overcome if such interventions focused on ensuring discretion, providing access to healthcare professionals, and offering appropriate incentives. Conclusions Overall, MSTW and TW shared similar favourable attitudes towards venue-based HIV interventions. Venue-based outreach warrants further exploration as a strategy for engaging MSTW and TW in HIV prevention activities.

Experience of social harms among female sex workers following HIV self-test distribution in Malawi: results of a cohort study

BackgroundIn Malawi, female sex workers (FSW) have high HIV incidence and regular testing is suggested. HIV self-testing (HIVST) is a safe and acceptable alternative to standard testing services. This study assessed; whether social harms were more likely to be reported after HIVST distribution to FSW by peer distributors than after facility-based HIV testing and whether FSW regretted HIVST use or experienced associated relationship problems.MethodsPeer HIVST distributors, who were FSW, were recruited in Blantyre district, Malawi between February and July 2017. Among HIVST recipients a prospective cohort was recruited. Interviews were conducted at baseline and at end-line, 3 months later. Participants completed daily sexual activity diaries. End-line data were analysed using logistic regression to assess whether regret or relationship problems were associated with HIVST use. Sexual activity data were analysed using Generalised Estimating Equations to assess whether HIVST use was temporally associated with an increase in social harms.ResultsOf 265 FSW recruited and offered HIVST, 131 completed both interviews. Of these, 31/131(23.7%) reported initial regret after HIVST use, this reduced to 23/131(17.6%) at the 3-month follow-up. Relationship problems were reported by 12/131(9.2%). Regret about HIVST use was less commonly reported in those aged 26–35 years compared to those aged 16–25 years (OR immediate regret—0.40 95% CI 0.16–1.01) (OR current regret—0.22 95% CI 0.07 – 0.71) and was not associated with the HIVST result. There was limited evidence that reports of verbal abuse perpetrated by clients in the week following HIVST use were greater than when there was no testing in the preceding week. There was no evidence for increases in any other social harms. There was some evidence of coercion to test, most commonly initiated by the peer distributor.ConclusionsLittle evidence was found that the peer distribution model was associated with increased levels of social harms, however programmes aimed at reaching FSW need to carefully consider possible unintended consequences of their service delivery approaches, including the potential for peer distributors to coerce individuals to test or disclose their test results and alternative distribution models may need to be considered.

Costs of distributing HIV self-testing kits in Eswatini through community and workplace models

BackgroundThis study evaluates the implementation and running costs of an HIV self-testing (HIVST) distribution program in Eswatini. HIVST kits were delivered through community-based and workplace models using primary and secondary distribution. Primary clients could self-test onsite or offsite. This study presents total running economic costs of kit distribution per model between April 2019 and March 2020, and estimates average cost per HIVST kit distributed, per client self-tested, per client self-tested reactive, per client confirmed positive, and per client initiating antiretroviral therapy (ART).MethodsDistribution data and follow-up phone interviews were analysed to estimate implementation outcomes. Results were presented for each step of the care cascade using best-case and worst-case scenarios. A top-down incremental cost-analysis was conducted from the provider perspective using project expenditures. Sensitivity and scenario analyses explored effects of economic and epidemiological parameters on average costs.ResultsNineteen thousand one hundred fifty-five HIVST kits were distributed to 13,031 individuals over a 12-month period, averaging 1.5 kits per recipient. 83% and 17% of kits were distributed via the community and workplace models, respectively. Clients reached via the workplace model were less likely to opt for onsite testing than clients in the community model (8% vs 29%). 6% of onsite workplace testers tested reactive compared to 2% of onsite community testers. Best-case scenario estimated 17,458 (91%) clients self-tested, 633 (4%) received reactive-test results, 606 (96%) linked to confirmatory testing, and 505 (83%) initiated ART.Personnel and HIVST kits represented 60% and 32% of total costs, respectively. Average costs were: per kit distributed US$17.23, per client tested US$18.91, per client with a reactive test US$521.54, per client confirmed positive US$550.83, and per client initiating ART US$708.60. Lower rates for testing, reactivity, and linkage to care in the worst-case scenario resulted in higher average costs along the treatment cascade.ConclusionThis study fills a significant evidence gap regarding costs of HIVST provision along the client care cascade in Eswatini. Workplace and community-based distribution of HIVST accompanied with effective linkage to care strategies can support countries to reach cascade objectives.

Organisation of testing services, structural barriers and facilitators of routine HIV self-testing during sexually transmitted infection consultations: a qualitative study of patients and providers in Abidjan, Côte d’Ivoire

BackgroundConsultations for sexually transmitted infection (STI) provide an opportunity to offer HIV testing to both patients and their partners. This study describes the organisation of HIV self-testing (HIVST) distribution during STI consultations in Abidjan (Côte d’Ivoire) and analyse the perceived barriers and facilitators associated with the use and redistribution of HIVST kits by STI patients.Materials and methodsA qualitative study was conducted between March and August 2021 to investigate three services providing HIVST: an antenatal care clinic (ANC), a general health centre that also provided STI consultations, and a dedicated STI clinic. Data were collected through observations of medical consultations with STI patients (N = 98) and interviews with both health professionals involved in HIVST distribution (N = 18) and STI patients who received HIVST kits for their partners (N = 20).ResultsIn the ANC clinic, HIV testing was routinely offered during the first prenatal visit. HIVST was commonly offered to women who had been diagnosed with an STI for their partner’s use (27/29 observations). In the general health centre, two parallel pathways coexisted: before the consultation, a risk assessment tool was used to offer HIV testing to eligible patients and, after the consultation, patients who had been diagnosed with an STI were referred to a care assistant for HIVST. Due to this HIV testing patient flow, few offers of HIV testing and HIVST were made in this setting (3/16). At the dedicated STI clinic, an HIVST video was played in the waiting room. According to the health professionals interviewed, this video helped reduce the time required to offer HIVST after the consultation. Task-shifting was implemented there: patients were referred to a nurse for HIV testing, and HIVST was commonly offered to STI patients for their partners’ use (28/53). When an HIVST was offered, it was generally accepted (54/58). Both health professionals and patients perceived HIVST positively despite experiencing a few difficulties with respect to offering HIVST to partners and structural barriers associated with the organisation of services.ConclusionThe organisation of patient flow and task-shifting influenced HIV testing and offers of HIVST kits. Proposing HIVST is more systematic when HIV testing is routinely offered to all patients. Successful integration requires improving the organisation of services, including task-shifting.

Real world outcomes of distributing Lucira Check-It® COVID self-tests in Ontario, Canada: the GetaKit COVID study

BackgroundIn Ontario, Canada we developed and implemented an online screening algorithm for the distribution of HIV self-tests, known as GetaKit. During the COVID pandemic, we adapted the GetaKit algorithm to screen for COVID based on population and infection data and distributed COVID rt-LAMP self-tests (using the Lucira Check-It®) to eligible participants.MethodsGetaKit/COVID was a prospective observational study that occurred over a 7-month period from September 2021 to April 2022. All potential participants completed an online registration and risk assessment, including demographic information, COVID symptoms and risk factors, and vaccination status. Bivariate comparisons were performed for three outcomes: results reporting status, vaccination status, and COVID diagnosis status. Data were analysed using Chi-Square for categorial covariates and Independent Samples T-Test and Mann-Whitney U test for continuous covariates. Bivariate logistic regression models were applied to examine associations between the covariates and outcomes.ResultsDuring the study period, we distributed 6469 COVID self-tests to 4160 eligible participants; 46% identified as Black, Indigenous or a Person of Colour (BIPOC). Nearly 70% of participants reported their COVID self-test results; 304 of which were positive. Overall, 91% also reported being vaccinated against COVID. Statistical analysis found living with five or fewer people, having tested for COVID previously, and being fully vaccinated were positive factors in results reporting. For COVID vaccination, people from large urban centers, who identified their ethnicity as white, and who reported previous COVID testing were more likely to be fully vaccinated. Finally, being identified as a contact of someone who had tested positive for COVID and the presence of COVID-related symptoms were found to be positive factors in diagnosis.ConclusionsWhile most participants who accessed this service were vaccinated against COVID and the majority of diagnoses were identified in participants who had symptoms of, or an exposure to, COVID, our program was able to appropriately link participants to recommended follow-up based on reported risks and results. These findings highlight the utility of online screening algorithms to provide health services, particularly for persons with historical barriers to healthcare access, such as BIPOC or lower-income groups.

Factors Associated with the First-time HIV Testing Among Chinese men who have sex with men Who Received HIV Self-tests from Partners or Friends.

Secondary distribution of HIV self-testing (HIVST) among individual social networks was an effective approach to expanding HIV testing among men who have sex with men (MSM). However, understanding the factors associated with first-time HIV testing behaviors in the secondary distribution of HIVST programs is limited. Hence, this study aims to identify factors related to first-time testers in the secondary distribution of HIVST. Participants were recruited from five provinces in southern China through Blued, a geo-social gay networking app in China from January 2021 to December 2021. Eligible consented participants (referred to as "seeds") finished a baseline survey and then applied for up to five HIVST kits. They were encouraged to distribute HIVST kits to other MSM (referred to as "alters") and alters were encouraged to scan a QR code to return their photographed testing results. All alters were invited to finish an online survey. In total, 229 seeds reached 292 alters, among whom 126 (43.2%) were first-time testers whereas 166 (56.8%) were non-first-time testers. Importantly, our results demonstrated that the first-time HIV testers were more likely to self-report as heterosexual (aOR = 4.88, 95% CI 1.01-23.61), disclose sexual orientation and/or SSB (aOR = 1.73, 95% CI 1.01-2.96), and receive HIVST knowledge from the seeds (aOR = 3.25, 95% CI 1.02-10.34). However, those who had sex with male partners in the last three months were less likely to be first-time testers (aOR = 0.43, 95% CI 0.23-0.82). Practical implications and limitations were also discussed to improve future HIV prevention programs.

"Test-To-PrEP": Assessing Reach and Adoption of a New Approach to Increase HIV Testing and PrEP Knowledge Using HIV Self-Test Kit Distribution Through PrEP Clients' Social Networks.

HIV self-testing (HIVST) can increase the reach of HIV testing. Preexposure prophylaxis (PrEP) clients may be ideal distributors of HIVST kits and PrEP information within their social networks. This study uses the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework to evaluate the distribution of HIVST bundled with PrEP information ("Test-to-PrEP" kits) among egocentric friendship networks of PrEP users. The study was conducted in Miami from November 2021 to March 2022. Enrolled PrEP clients (egos; n = 100) were offered Test-to-PrEP kits for distribution. Egos and Test-to-PrEP kit users completed brief online surveys. Descriptive statistics are reported for participants, their reported network members, and users of the Test-to-PrEP kits. Logistic and Poisson regression assessed the relationship between characteristics of egos, alters, and the distribution of Test-to-PrEP kits. The 100 enrolled egos reported a total of 414 alters. Participants received 293 Test-to-PrEP kits for distribution with 47 of the 100 participants distributing at least 1 kit. Of those who scanned the quick-response code and responded to the survey, 16.2% reported no previous HIV test and 38.5% reported no prior knowledge of PrEP; 32.5% reported interest in distributing Test-to-PrEP kits, 3 successfully distributed kits, and 2 initiated PrEP. An approach using PrEP clients' social networks can disseminate HIVST bundled with PrEP information to critical populations including individuals lacking knowledge of PrEP or who have never been tested for HIV. Future studies will assess whether this use of network effects can increase reach and efficiency of HIV testing and PrEP information distribution.

Identification of Key Influencers for Secondary Distribution of HIV Self-Testing Kits Among Chinese Men Who Have Sex With Men: Development of an Ensemble Machine Learning Approach.

HIV self-testing (HIVST) has been rapidly scaled up and additional strategies further expand testing uptake. Secondary distribution involves people (defined as "indexes") applying for multiple kits and subsequently sharing them with people (defined as "alters") in their social networks. However, identifying key influencers is difficult. This study aimed to develop an innovative ensemble machine learning approach to identify key influencers among Chinese men who have sex with men (MSM) for secondary distribution of HIVST kits. We defined three types of key influencers: (1) key distributors who can distribute more kits, (2) key promoters who can contribute to finding first-time testing alters, and (3) key detectors who can help to find positive alters. Four machine learning models (logistic regression, support vector machine, decision tree, and random forest) were trained to identify key influencers. An ensemble learning algorithm was adopted to combine these 4 models. For comparison with our machine learning models, self-evaluated leadership scales were used as the human identification approach. Four metrics for performance evaluation, including accuracy, precision, recall, and F1-score, were used to evaluate the machine learning models and the human identification approach. Simulation experiments were carried out to validate our approach. We included 309 indexes (our sample size) who were eligible and applied for multiple test kits; they distributed these kits to 269 alters. We compared the performance of the machine learning classification and ensemble learning models with that of the human identification approach based on leadership self-evaluated scales in terms of the 2 nearest cutoffs. Our approach outperformed human identification (based on the cutoff of the self-reported scales), exceeding by an average accuracy of 11.0%, could distribute 18.2% (95% CI 9.9%-26.5%) more kits, and find 13.6% (95% CI 1.9%-25.3%) more first-time testing alters and 12.0% (95% CI -14.7% to 38.7%) more positive-testing alters. Our approach could also increase the simulated intervention's efficiency by 17.7% (95% CI -3.5% to 38.8%) compared to that of human identification. We built machine learning models to identify key influencers among Chinese MSM who were more likely to engage in secondary distribution of HIVST kits. Chinese Clinical Trial Registry (ChiCTR) ChiCTR1900025433; https://www.chictr.org.cn/showproj.html?proj=42001.