HIV self-testing (HIVST) is feasible, highly acceptable and can increase HIV testing uptake/frequency without harm while also reducing costs. Despite HIVST's benefits, UK service provision has been sporadic partially due to policymakers and commissioners' reluctance over concerns about linkage to care/surveillance, which ultimately reduces user choice. We synthesized current evidence and in a multidisciplinary collaboration developed an Implementation Action Framework to facilitate and promote person-centred HIVST provision, focusing on reducing health inequalities among gay, bisexual and other men who have sex with men (GBMSM), trans and gender-diverse people. We do this by exploring implementation context, establishing a standard level of support for HIVST interventions and outlining intervention adaptations to support priority subgroups in the United Kingdom. A large body of published evidence demonstrates that HIVST is feasible to deliver, highly acceptable, easy to perform and can make a meaningful difference to HIV testing behaviours among GBMSM, trans and gender-diverse people without leading to substantial harm or decreases in linkage to care. Synthesizing 29 publications from the United Kingdom or other high-income settings, we demonstrate that the UK implementation context can be harnessed by emphasizing the need to expand testing to meet the 2030 HIV elimination goals. Concerns around linkage to care/surveillance can be addressed by highlighting successful linkage approaches and the importance of respecting patient autonomy. We establish a minimum standard level of support for HIVST interventions, including a results reporting system with a user opt-out option, clear information on linkage to care, inclusion of a helpline and guidance to link to clinical follow-up for those who report reactive HIVST results. To address health inequalities, person-centred intervention adaptations include innovative approaches to HIVST delivery to reach underserved groups, provision of additional tests for other sexually transmitted infections (STIs), targeted demand generation and tailored support for the most marginalized. Person-centred HIVST is critical to improving HIV testing uptake by responding to, and ultimately reducing, entrenched health inequalities in the United Kingdom. Our Framework provides a person-centred roadmap for implementing HIVST across a range of high-income settings.

Introduction: Despite global strides in HIV testing strategies in recent years, such as home testing and non-medical testing sites, HIV testing uptake and access to treatment, care, and support remain at very low access levels amongst key and priority populations, such as adolescent girls and young women (AGYW). The study assessed the barriers and facilitators influencing the use of HIV self-testing (HIVST) among AGYW in Sekhukhune Technical Vocational Education and Training college, South Africa. Methods: An institution-based descriptive exploratory qualitative study was employed in which 22 AGYW were purposively sampled. Data were collected through four focus group discussions with an average of six participants between February and April 2024. The data were analysed thematically. Results: The participants were enrolled on levels 2 to 6 of training (age range = 19 to 24 years). Fear, doubt, and anxiety regarding HIVST results, mental health concerns after self-testing, and concerns over the accuracy and the interpretation of results were barriers linked to HIVST use. Convenience, privacy, and ease of use made HIVST appealing to AGYW. Conclusion: To ensure the successful implementation of HIVST interventions, there is a need to implement a tailored modality that is appealing to AGYW. This should focus on addressing current HIVST barriers and leveraging facilitators to enhance HIVST uptake among AGYW.

Secondary distribution of HIV self-testing can expand testing among men who have sex with men. A parent quasi-experimental trial found that sexual health influencers (SHIs) identified by a machine-learning model achieved greater peer uptake than those identified by an empirical scale, but the factors driving distribution effectiveness remain unclear. We conducted a secondary analysis of the parent trial (ChiCTR2000039632) in five provinces in southern China. Participants were randomized to either the empirical scale or machine-learning identification arm, and SHIs were then selected within each arm. The current analysis included 196 SHIs with complete follow up. Effective distribution was defined as motivating at least one peer to test. Predictor variables captured sociodemographic, behavioral and network characteristics. Multivariable Poisson LASSO models with multiple imputation and cross-validation estimated adjusted incidence rate ratios (aIRRs). Among 196 SHIs (mean age28years), 46.9% achieved effective distribution. A total of 286 unique peers returned verified HIV self-testing results, of whom 118 (41.3%) were first-time testers. Peer HIV testing was associated with stronger awareness of peers' HIV status (aIRR1.31; 95% CI 1.16-1.48) and more active sharing of HIV information (aIRR1.28; 95% CI 1.10-1.50). SHIs who had been accompanied during their own HIV test recruited more newly tested peers (aIRR1.94; 95% CI 1.12-3.37). Our data have implications for secondary distribution of HIV self-test kits and suggest the need for capacity strengthening related to peer engagement in HIV self-testing.

BackgroundMen who have sex with men (MSM) face a high risk of HIV infection. The World Health Organization (WHO) recommends they test per 6–12 months. But traditional testing sites like hospitals can not fully meet MSM’s needs due to privacy issues. HIV self-testing (HIVST) offers privacy and flexibility, but improper use and incorrect result interpretation can happen. Getting feedback on HIVST results is vital for HIV prevention. The present study explores how different incentive methods affect HIVST feedback rates among MSM and why they choose to participate or not.MethodsA randomized study was conducted online among 354 individuals between January 1, 2024 and May 31, 2024. The inclusion criteria for the study required participants to be 18 years or older, self-identifying as members of the MSM population, being able to read and write Simplified Chinese and use smartphones, having engaged in male sexual activity within the past six months, and residing in Chongqing Municipality. Exclusion criteria included declining to participate, having mental or intellectual disabilities, or having serious concurrent illnesses. We randomly assigned participants into one of the 3 groups: (1) Free kit with free shipping group, (2) Extra CNY 20 incentive group; (3) Lottery incentivized group.ResultsA total 516 MSM were submitted the online informed consents and 16 were excluded and 354 MSM (68.6%) in Chongqing were recruited and randomized in three groups, respectively. 336 (94.9%) participants reported HIV imaging results to their assistant. Five participants who tested positive for HIV and five participants who tested positive for syphilis. Overall, 312 (88.1%) of participants had ever tested for HIV, 42(11.9%) of kit recipients reported never have HIV detection. Our analysis revealed no significant difference in feedback regarding HIVST services among the groups. Overall, there were no significant differences in feedback rates between the groups at all time points (P > 0.05). However, trend analysis indicated a significant difference in the feedback rate trends among the three groups (P = 0.019).ConclusionOur results show no significant differences in feedback rates across groups at follow-up time points. Significant differences in feedback rate trends among the three groups were observed, with the extra lottery incentive providing more sustained motivation for feedback. And privacy concerns are crucial for expanding HIVST among MSM via social apps.

IntroductionAdolescents and young adults (AYA) are disproportionately at risk of HIV acquisition. Person‐centred online platforms could effectively reach AYA with HIV testing services. We assessed the effectiveness of Stand By You, a mobile application, in delivering HIV‐related services to at‐risk Thai AYAs.MethodsDeidentified data from clients who accessed Stand By You services between August 2022 and February 2024 were analysed. HIV self‐testing (HIVST) services were promoted through TikTok influencers to target AYAs vulnerable to HIV. An automated chatbot provided real‐time responses to client inquiries, and trained counsellors provided confidential, text‐based counselling daily. Clients who completed risk assessments received personalized recommendations for HIVST based on their risk profile. Clients who submitted their HIVST results received post‐test counselling and linkage to care and prophylactic treatment. Multivariable logistic regression was used to assess risk factors for reactive HIVST kit results. The per unit direct cost of the programme's performance metrics were assessed.ResultsA total of 8863 clients provided 11,536 risk assessments. The majority were male (76.3%), under the age of 30 (76.0%), identified as members of key populations (60.4%) and first‐time testers (56.1%). Additionally, 27.8% had a history of sexually transmitted infections (3,202/11,536), 16.5% reported receiving money or incentives for sex (1908/11,536) and clients indicated an average of 2.6 sexual partners in the past month (SD 3.4). Out of 7585 submitted HIVST results, 3.6% were reactive (n = 274); 60.2% were linked to care (n = 165/274) and 10.4% are in the process of linkage (n = 23/274). Of the 5.3% invalid results reported (n = 401/7585), nearly all were non‐reactive by the second HIVST (117/187). A history of testing HIV negative (adjusted odds ratio [aOR] 0.54 [95% CI 0.40–0.72], p < 0.001) and receiving pre‐exposure prophylaxis (aOR 0.20 [95% CI 0.06–0.64], p = 0.007) were independently associated with reduced odds of a reactive result. Average direct cost was $18.7, $40.3 and $1100 USD per distributed HIVST kit, first‐time tester and new client linked to care, respectively.ConclusionsAYA populations at risk for HIV can be effectively reached through mobile phone applications that provide services anonymously. Online strategies for HIVST delivery and supportive text‐based counselling can generate high demand, engagement and successful linkage to care.

To reach UNAIDS 95-95-95 targets, digital HIV self-testing (HIVST) strategy aided by applications, platforms, and readers can engage young people and adults living with undetected HIV infection. Evidence on its acceptability, feasibility, impact exists, yet accuracy data are limited. A secondary data analysis of a quasi-RCT of digital HIVST in South Africa was performed. We hypothesized app-guided digital interpretation of oral self-test enhanced test accuracy. We compared accuracy between digital HIVST supervised vs. unsupervised (with/without healthcare worker). Self-test results were interpreted and uploaded by participants, compared using computer vision technology, against lab reference standard by trained healthcare professionals. 1513 digital HIVST participants reported pooled Sensitivity (Sn) = 95.52% (95% CI, 94.48%-96.56%); Specificity (Sp): 99.93% (95% CI, 99.79%-100.06%); Positive predictive value (PPV): 99.22% (95% CI, 98.78%-99.67%); Negative Predictive Value (NPV): 99.57% (95% CI, 99.24%-99.90%). 565 participants on supervised digital HIVST, reported a pooled Sn: 93.65% (95% CI, 91.64-95.66); Sp: 100.00% (95% CI, 100.00-100.00); PPV: 100.00% (95% CI, 100.00-100.00); NPV: 99.21% (95% CI, 98.48-99.94). 968 unsupervised digital HIVST participants, reported a pooled Sn: 97.18% (95% CI, 96.13-98.24); Sp: 99.89% (95% CI, 99.67-100.10); PPV: 98.57% (95% CI, 97.82-99.33); NPV: 99.77% (95% CI, 99.47-100.08). Non-digital HIVST vs. study digital HIVST data at 5% significance level - Sn: chi = 0.6495, p-value = 0.4203, Sp: chi = 0.3831, p-value = 0.5259. Supervised vs. unsupervised HIVST at 5% significance level - Sn: chi = 0.973, p-value = 0.3237, Sp: chi = 0.527, p-value = 0.4449. Digital HIVST improved interpretation of test results, increased accuracy and predictive value estimations (upper limit 98%-100%), removing subjectivity. Unsupervised digital HIVST users performed better than supervised. Digital HIVST results can potentially signal a rapid triage to therapy or prevention pathways, while awaiting lab confirmation. Findings have implications for scale up of digital HIVST initiatives in global settings.

In light of ongoing HIV diagnoses among cis women, despite decreases in other populations, such as men who have sex with men, various testing approaches, including HIV self-tests are being targeted at cis women as a means of identifying undiagnosed HIV infections and of linking those with positive test results to care. Little, however, is known about risk characteristics of cis women who access HIV self-tests in Canada. Our objectives were to examine demographic characteristics, risk factors, and test results of cis women who obtained HIV self-tests through the HIV self-testing platform, GetaKit.ca. GetaKit.ca was an observational cohort study that provided free HIV self-tests to Canadians with reported risk factors for HIV acquisition. We completed an analysis of cis women who ordered HIV self-tests from GetaKit.ca between April 1, 2021 and May 31, 2023. Data analysis involved tabulating frequencies and means, plus chi-square calculations to determine significant differences between cis women and cis men who obtained HIV self-tests. During the study period, 7420 orders for HIV self-tests were made through GetaKit.ca; 22% of these orders were made by cis women. Compared to cis men, cis women had significantly higher reported rates of injection drug use and significantly lower reported rates of prior sexually transmitted infection testing, HIV testing (with more cis women indicating their last HIV test was more than 12 months ago), and reporting HIV self-test results. Despite this, we found no differences in the number of cis women with a positive HIV self-test compared to cis men (positivity rate of 0.2% versus 0.3%, respectively). Our findings showed less overall uptake of HIV testing in cis women, despite matched risks and positive test results. Future interventions to engage cis women in HIV testing should include increased access points for HIV self-tests and enhanced linkage to care pathways to HIV pre-exposure prophylaxis or HIV treatment.

This study investigated the potential of HIV self-test (HIVST) to reach individuals who otherwise might not access testing or antiretroviral therapy (ART). The study had two main objectives: (a) to develop an HIV self-test implementation plan based on the findings from qualitative inquiries with local stakeholders and (b) to examine HIVST uptake among youths in the urban setting of Aizawl district in Mizoram. In the first phase, qualitative in-depth interviews (IDI) were conducted with HIV program officials, religious leaders, community influencers, youths, and key population groups. These inquiries guided the planning of strategic communication, community engagement, HIVST delivery, and linkages with HIV confirmatory testing services in phase two. Factors associated with the non-uptake of HIV confirmatory tests by youths following HIVST were analyzed quantitatively. Additionally, secondary data collected from attendees of the "Integrated Counselling and Testing Centre" (ICTC) were also analyzed. The in-depth interviews underscored the need to introduce HIVST among Mizo youths. The respondents emphasized the importance of diverse outreach approaches and communication strategies, including the use of social media platforms, as critical components for successful HIVST implementation. They also provided valuable insights on the optimal locations and methods for making HIVST kits accessible. Among the youths who used HIVST, the majority were first-time testers (1,772/2,101; 84.3%). Those diagnosed with an undiagnosed HIV infection were started on ART. The preference for the blood-based HIVST format (1,162/2101; 55%) was noted to be slightly higher than the saliva-based format. Confirmatory test uptake was significantly higher among those with sero-reactive HIVST results (χ 2 23.89; p < 0.001). Factors independently associated with (adjusted odds ratio; AOR with 95% CI) "no-show for HIV confirmatory tests," which hold significant programmatic implications, included "age > 20 years (1.47; 1.18-1.82)," "gender (men)" (1.25; 1.01-1.55), "education below 10th standard" (5.16; 2.66-10.01), "no prior HIV testing experience" (2.12; 1.61-2.81), and "unwillingness to undergo HIV confirmatory testing" (2.85; 2.05-3.96). Individuals who opted for the blood-based HIVST were 23% less likely (AOR 0.77; 95% CI; 0.62-0.96) to drop out of the HIV confirmatory testing process. Additionally, only 1% of respondents perceived HIVST as having self-harm potential. Sustained community engagement, effective networking with HIV program officials, and strategic communication were three critical pillars supporting the successful implementation of HIVST. There was a significant increase in HIVST uptake among young first-time testers.

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).

Objective: Self-collection, self-testing, and telemedicine among high-risk populations were important strategies in increasing the accessibility of sexually transmitted infection (STI) services and facilitating their expansion. However, many previous studies have shown that the self-test kit usage and response rates are not high in the men who have sex with men (MSM) population. Different routes of recruitment may affect their response rates, however, limited evidence exists on how recruitment specifically influence STI self-testing participation among MSM populations. This study aims to analyze the differences in response rates of STI self-testing and submission rates of self-acquired samples from MSM recruited through an online platform, STI clinics, and non-governmental organizations (NGOs). Methods: Participants were enrolled via 3 different methods (STI clinics, “Aiyijian” online platform, and NGOs) from July to December 2022 in China. Self-testing kits for human immunodeficiency virus (HIV), Treponema pallidum, and hepatitis C virus, and self-sampling kits for Chlamydia trachomatis and Neisseria gonorrhea were provided to recruit MSM. The participant’s basic information was collected by using the questionnaire and the results of self-testing for HIV/syphilis and hepatitis C virus and self-sampling for Chlamydia trachomatis and Neisseria gonorrhoeae were collected. Multivariate logistic regression analysis was used to identify factors associated with self-test response rate and sample submission rates. Results: A total of 764 participants were recruited from 28 Chinese provinces. In the final analysis data, 670 participants reported their HIV self-testing results, while 644 participants mailed their self-acquired samples to the laboratory. Among the 670 participants, there were 51 patients infected with HIV, 31 infected with syphilis, and 2 infected with the hepatitis C virus. The total prevalences of Chlamydia trachomatis and Neisseria gonorrhea were 23.0% (176/637) and 7.6% (58/636), respectively. There was no significant difference among the willingness to self-test among participants recruited from 3 routines, while the HIV self-test response rate was significantly higher among participants recruited in STI clinics than among participants recruited through the “Aiyijian” platform (adjusted odds ratio [AOR] = 0.018, 95% confidence interval [CI]: 0.002–0.136) or NGOs (AOR = 0.054, 95% CI: 0.007–0.401). Compared to the participants recruited from STI clinics, the willingness of self-sample was significantly higher among participants recruited through the “Aiyijian” platform (AOR = 4.557, 95% CI: 1.445–14.271) and NGO (AOR = 2.391, 95% CI: 1.136–5.034), but the rectal sample submission rates were significantly lower among participants recruited by the “Aiyijian” platform (AOR = 0.014, 95% CI: 0.003–0.062) or NGOs (AOR = 0.062, 95% CI: 0.014–0.262). Conclusion: MSM recruited from the Aiyijian online platform and NGO were more willing to self-sample, while participants recruited from STI clinics had a greater test result response rate and self-sample submission rate than those recruited via the “Aiyijian” online platform and NGOs. In addition to STI clinics, online platforms and NGOs will play a very important role in recommending self-sampling for STIs among MSM population.

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.

In 2021, Mozambique initiated community-based oral HIV self-testing (HIVST) to increase testing access and uptake among priority groups, including adult males, adolescents, and young adults. Within an HIVST pilot project, we conducted a performance evaluation assessing participants' ability to successfully conduct HIVST procedures and interpret results. A cross-sectional study was performed between February-March 2021 among employees, students (18-24 years of age), and community members, using convenience sampling, in two rural districts of Zambézia Province, Mozambique. We quantified how well untrained users performed procedures for the oral HIVST (Oraquick®) through direct observation using a structured checklist, from which we calculated an HIVST usability index (scores ranging 0-100%). Additionally, participants interpreted three previously processed anonymous HIVST results. False reactive and false non-reactive interpretation results were presented as proportions. Bivariate analysis was conducted using Chi-square and Fisher exact tests. A total of 312 persons participated (131[42%] community members, 71[23%] students, 110[35%] employees); 239 (77%) were male; the mean age was 28 years (standard deviation 10). Average usability index scores were 80% among employees, 86% among students, and 77% among community members. Main procedural errors observed included "incorrect tube positioning" (49%), "incorrect specimen collection" (43%), and "improper waiting time for result interpretation" (42%). From the presented anonymous HIVST results, 75% (n = 234) correctly interpreted all three results, while 9 (3%) of study participants failed to correctly interpret any results. Overall, 36 (12%) gave a false non-reactive result interpretation, 21 (7%) a false reactive result interpretation, and 14 (4%) gave both false non-reactive and false reactive result interpretations. Community members generally had lower performance. Despite some observed testing procedural errors, most users could successfully perform an HIVST. Educational sessions at strategic places (e.g., schools, workplaces), and support via social media and hotlines, may improve HIVST performance quality, reducing the risk of incorrect interpretation.

HIV self-testing (HIVST) empowers individuals to decide when and where to test and with whom to share their results. From 2019 to 2022, the ATLAS program distributed ∼ 400 000 HIVST kits in Côte d’Ivoire, Mali, and Senegal. It prioritised key populations, including female sex workers and men who have sex with men, and encouraged secondary distribution of HIVST to their partners, peers and clients. To preserve the confidential nature of HIVST, use of kits and their results were not systematically tracked. Instead, an anonymous phone survey was carried out in two phases during 2021 to estimate HIVST positivity rates (phase 1) and linkage to confirmatory testing (phase 2). Initially, participants were recruited via leaflets from March to June and completed a sociobehavioural questionnaire. In the second phase (September-October), participants who had reported two lines or who reported a reactive result were recontacted to complete another questionnaire. Of the 2 615 initial participants, 89.7% reported a consistent response between the number of lines on the HIVST and their interpretation of the result (i.e., ‘non-reactive’ for 1 line, ‘reactive’ for 2 lines). Overall positivity rate based on self-interpreted HIVST results was 2.5% considering complete responses, and could have ranged from 2.4% to 9.1% depending on the interpretation of incomplete responses. Using the reported number of lines, this rate was estimated at 4.5% (ranging from 4.4% to 7.2%). Positivity rates were significantly lower only among respondents with higher education. No significant difference was observed by age, key population profile, country or history of HIV testing. The second phase saw 78 out of 126 eligible participants complete the questionnaire. Of the 27 who reported a consistent reactive response in the first phase, 15 (56%, 95%CI: 36 to 74%) underwent confirmatory HIV testing, with 12 (80%) confirmed as HIV-positive, all of whom began antiretroviral treatment. The confirmation rate of HIVST results was fast, with 53% doing so within a week and 91% within three months of self-testing. Two-thirds (65%) went to a general public facility, and one-third to a facility dedicated to key populations. The ATLAS HIVST distribution strategy reached people living with HIV in West Africa. Linkage to confirmatory testing following a reactive HIVST remained relatively low in these first years of HIVST implementation. However, if confirmed HIV-positive, almost all initiated treatment. HIVST constitutes a relevant complementary tool to existing screening services.

BackgroundDespite the many interventions that have been implemented in sub-Saharan Africa to improve the uptake of HIV testing and antiretroviral (ART) initiation services, the rates at which men are tested for HIV and initiated on ART have remained consistently lower compared to those for women. We aim to investigate barriers and facilitators for linkage to care following HIVST positive results among men aged between 18 and 49 years, and use these findings to design an intervention to improve linkage to care among men in a high-HIV prevalent district in KwaZulu-Natal province, South Africa.MethodsThis multi-method study will be conducted over 24 months in eight purposively selected HIV testing and treatment facilities from December 2023 to November 2025. For the quantitative component, a sample of 197 HIV positive men aged 18–49 years old who link to care after HIV self-test (HIVST) will be recruited into the study. HIVST kits will be distributed to a minimum of 3000 men attending community services through mobile clinics that are supported by the Health Systems Trust, at different service delivery points, including schools, taxi ranks and other hotspots. The qualitative component will consist of in-depth interviews (IDIs) with 15 HIVST users and IDIs with 15 key informants. To design and develop acceptable, feasible, effective, and sustainable models for improving linkage to care, three groups of HIVST users (2*positive (N = 12) and 1*negative (N = 12)) will be purposively select to participate in a design workshop. Chi square tests will be used to identify social and demographic factors associated with linkage, while logistic regression will be used to identify independent factors. Kaplan Meier curves and cox proportional hazard models will be used to identify factors associated with time to event. Content and thematic approaches will be used to analyze the qualitative data.DiscussionThere remains an urgent need for designing and implementing innovative intervention strategies that are convenient and tailored for addressing the needs of men for improving HIV testing and linkage to care at early stages in resource-limited settings, to improve individual health outcomes, reduce transmission from HIV and minimize HIV-related mortality rates. Our proposed study offers several important innovations aimed at improving linkage to care among men. Our study targets men, as they lag the HIV continuum but are also under-researched in public health studies.

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.

IntroductionHIV self-testing (HIVST) is highly sensitive and specific, addresses known barriers to HIV testing (such as stigma), and is recommended by the World Health Organization as a testing option for the delivery of HIV pre-exposure prophylaxis (PrEP). Nevertheless, HIVST remains underutilized as a diagnostic tool in community-based, differentiated HIV service delivery models, possibly due to concerns about result misinterpretation, which could lead to inadvertent onward transmission of HIV, delays in antiretroviral therapy (ART) initiation, and incorrect initiation on PrEP. Ensuring that HIVST results are accurately interpreted for correct clinical decisions will be critical to maximizing HIVST's potential. Early evidence from a few small pilot studies suggests that artificial intelligence (AI) computer vision and machine learning could potentially assist with this task. As part of a broader study that task-shifted HIV testing to a new setting and cadre of healthcare provider (pharmaceutical technologists at private pharmacies) in Kenya, we sought to understand how well AI technology performed at interpreting HIVST results.MethodsAt 20 private pharmacies in Kisumu, Kenya, we offered free blood-based HIVST to clients ≥18 years purchasing products indicative of sexual activity (e.g., condoms). Trained pharmacy providers assisted clients with HIVST (as needed), photographed the completed HIVST, and uploaded the photo to a web-based platform. In real time, each self-test was interpreted independently by the (1) client and (2) pharmacy provider, with the HIVST images subsequently interpreted by (3) an AI algorithm (trained on lab-captured images of HIVST results) and (4) an expert panel of three HIVST readers. Using the expert panel's determination as the ground truth, we calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for HIVST result interpretation for the AI algorithm as well as for pharmacy clients and providers, for comparison.ResultsFrom March to June 2022, we screened 1,691 pharmacy clients and enrolled 1,500 in the study. All clients completed HIVST. Among 854 clients whose HIVST images were of sufficient quality to be interpretable by the AI algorithm, 63% (540/854) were female, median age was 26 years (interquartile range: 22–31), and 39% (335/855) reported casual sexual partners. The expert panel identified 94.9% (808/854) of HIVST images as HIV-negative, 5.1% (44/854) as HIV-positive, and 0.2% (2/854) as indeterminant. The AI algorithm demonstrated perfect sensitivity (100%), perfect NPV (100%), and 98.8% specificity, and 81.5% PPV (81.5%) due to seven false-positive results. By comparison, pharmacy clients and providers demonstrated lower sensitivity (93.2% and 97.7% respectively) and NPV (99.6% and 99.9% respectively) but perfect specificity (100%) and perfect PPV (100%).ConclusionsAI computer vision technology shows promise as a tool for providing additional quality assurance of HIV testing, particularly for catching Type II error (false-negative test interpretations) committed by human end-users. We discuss possible use cases for this technology to support differentiated HIV service delivery and identify areas for future research that is needed to assess the potential impacts—both positive and negative—of deploying this technology in real-world HIV service delivery settings.

Background: HIV self-testing (HIVST) with mobile health technology (mHealth) support is the use of mobile phone-based interventions to complement HIVST in order to improve its efficiency and uptake. Existing reviews leaves a gap in the evidence that summarizes efforts on the feasibility of mHealth to promote HIVST uptake within Sub-Saharan Africa (SSA). Objective: This study synthesized existing research on the feasibility of mobile health technology (mHealth) aimed at promoting HIV self-testing (HIVST) uptake within SSA using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Result: Eleven studies met the inclusion criteria and were narratively synthesized, 63% of which were observational studies while 37% were randomized control trials. Mobile applications, SMS or a combination of mHealth strategies were mostly used to promote HIVST uptake. Most studies were carried out in South Africa (54%), and in the general population (54%). Feasibility metrics were inconsistently reported across studies because its definitions varied, nonetheless most studies reported one or more feasibility metrics and HIVST uptake was the most common way (81%) of assessing feasibility. SMS-based interventions significantly increased HIVST uptake among hard-to-reach populations and were effective for reporting testing outcomes. Mobile applications guided participants through testing, result interpretation, and self-reporting HIVST results, and most studies reported high HIVST uptake (89.0%–100%). Compared to HIVST alone, call-based intervention enhanced HIVST uptake and linkage to care or prevention (p = 0.021). Most studies found combined mHealth interventions highly feasible (78.9%–99.2%). Conclusion: Feasibility was variable between the diverse mHealth supports used to promote HIVST uptake. While findings pave the way for greater use of mHealth supported HIVST, future research should consider using rigorous research designs and focus on populations disproportionately affected by HIV within diverse SSA regions to ensure broad applicability. Feasibility measures should also be standardized for uniform reporting across studies.

Secondary distribution of HIV self-test kits from females to their male partners has increased HIV testing rates in men but little evidence exists on the potential for HIV self-test kits distribution from males to their female partners. We assessed the acceptability of secondary HIV self-test kits distribution from males to their female sexual partners in a fishing community context. This secondary analysis used data from the PEer-led HIV Self-Testing intervention for MEN (PEST4MEN), a pilot interventional study in Buvuma and Kalangala districts in Uganda. At the baseline visit, in July 2022, data were collected from 400 men aged 15+ years who self-reported a HIV-negative or unknown HIV status. Enrolled men were asked to pick two oral fluid HIV self-test kits from a trained male distributor. At the first follow-up visit, in September 2022, men were asked about the number of kits that they received and if they gave kits to anyone, including to their female sexual partners. We used a modified Poisson regression model to determine the factors independently associated with giving kits to sexual partners. Data were analyzed using STATA version 16.0. Of 361 men interviewed at follow-up, 98.3% (355) received at least one kit; 79.7% (283) received two kits. Of those who received two kits, 64% (181) gave the second kit to anyone else; of these, 74.6% (132/177) gave it to a sexual partner. Being currently married (adjusted prevalence ratio [adj. PR] = 1.39; 95% confidence interval [95%CI]: 1.10, 1.75) and having difficulty in reading text prepared in the local language (adj. PR = 1.26; 95%CI: 1.03, 1.55) were significantly associated with men giving kits to their female sexual partners. Ninety-seven per cent (112/132) of the men reported that they knew their sexual partners' HIV self-test results. Of these, 93.7% (n = 105) reported that their partners were HIV-negative while 6.3% (n = 7) reported that they were HIV-positive. Only 28.6% (n = 2) of the HIV-positive sexual partners were reported to have initiated HIV care. Secondary distribution of HIV self-test kits from males to their female sexual partners is well accepted by women in the fishing communities, suggesting that distribution of kits through men in the fishing communities can help to improve HIV testing uptake among their female sexual partners.

Mobile health (mHealth) interventions among adolescents and young adults (AYAs) are increasingly available in African low- and middle-income countries (LMICs). For example, the unstructured supplementary service data (USSD) could be used to verify HIV self-testing (HIVST) among AYAs with poor bandwidth. The aim of this study is to describe the creation of an USSD platform and determine its feasibility and usability to promote the verification of HIVST results among AYAs in Nigeria. We developed and evaluated a USSD platform to verify HIVST results using a user-centered approach. The USSD platform guided AYAs in performing HIVST, interpreting the result, and providing linkage to care after the test. Following the usability assessment, the USSD platform was piloted. We used a mixed methods study to assess the platform's usability through a process of quantitative heuristic assessment, a qualitative think-aloud method, and an exit interview. Descriptive statistics of quantitative data and inductive thematic analysis of qualitative variables were organized. A total of 19 AYAs participated in the usability test, with a median age of 19 (IQR 16-23) years. There were 11 females, 8 males, and 0 nonbinary individuals. All individuals were out-of-school AYAs. Seven of the 10 Nielsen usability heuristics assessed yielded positive results. The participants found the USSD platform easy to use, preferred the simplicity of the system, felt no need for a major improvement in the design of the platform, and were happy the system provided linkage to care following the interpretation of the HIVST results. The pilot field test of the platform enrolled 164 out-of-school AYAs, mostly young girls and women (101, 61.6%). The mean age was 17.5 (SD 3.18) years, and 92.1% (151/164) of the participants reported that they were heterosexual, while 7.9% (13/164) reported that they were gay. All the participants in the pilot study were able to conduct HIVST, interpret their results, and use the linkage to care feature of the USSD platform without any challenge. A total of 7.9% (13/164) of the AYAs had positive HIV results (reactive to the OraQuick kit). This study demonstrated the usability and feasibility of using a USSD system as an alternative to mobile phone apps to verify HIVST results among Nigerian youth without smartphone access. Therefore, the use of a USSD platform has implications for the verification of HIVST in areas with low internet bandwidth. Further pragmatic trials are needed to scale up this approach.

HIV self-testing (HIVST) refers to the process in which individuals collect their own specimens (e.g. blood, saliva and urine), perform the test and interpret the results at a convenient time and place [1]. HIVST has been recognized as an innovative and promising approach to increase testing uptake, expand the HIV testing rate and enhance HIV testing coverage [1, 2]. Moreover, a large body of HIVST programmes and research worldwide also proved the feasibility, acceptability and effectiveness of HIVST in HIV prevention [1, 3]. Hence, the World Health Organization (WHO) recommended HIVST as the alternative and promising way to decentralize HIV testing and further increase the uptake of HIV testing, especially in low- and middle-income countries [4]. More importantly, the experiences learned from HIVST programmes can be utilized to facilitate other sexually transmitted infection (STI) prevention programmes. Although the STI epidemic has become a global public health issue, it was often overlooked and underfunded. Given the advantages of self-testing, scholars and health practitioners proposed STI self-testing as an alternative way to facilitate the STI testing rate and coverage outside clinical settings. However, previous self-testing research and implementation programmes focused on HIVST or STI self-testing separately [5], which lost the opportunity to promote HIV and STI testing simultaneously. Here, we advocate that integrating STI self-testing with HIVST may be useful for expanding STI testing. First, the high feasibility of HIVST has opened a pathway for STI self-testing. HIVST is easy, convenient [6] and less stigmatized [7]. By integrating STI self-testing with HIVST, the demand generated by HIVST can be leveraged to improve STI testing coverage. For example, a clinical trial conducted in China demonstrated that rapid dual self-testing for HIV and syphilis expanded syphilis testing uptake among men who have sex with men (MSM) in China [8]. Studies in several other countries (e.g. the United States and Australia) also confirmed this finding. As a result, the WHO recommended the dual HIV/syphilis rapid test as the alternative option to expand HIV and syphilis testing rate [4]. Second, the integration would be more cost-effective than HIV or STI self-testing alone. By integrating programmes, resources can be leveraged for multiple STI testing instead of HIVST alone. Since HIVST alone is already a cost-effective strategy for promoting HIV screening [9], integrating STI self-testing with HIVST would be more cost-effective. With the increasing burden of syphilis and other STIs globally, there is a strong need to promote STI testing [6]. The HIV-STI integrated model should be affordable in diverse settings, especially in low- and middle-income countries. Third, the integrated self-testing model can decentralize STI testing, improving the coverage of STI testing. Traditional STI testing mainly relies on clinic testing, which may be more stigmatized, centralized and hard to access for at-risk individuals [8]. With the shifting budgets and closure of clinics due to COVID-19 and other issues, a lack of access to STI testing may further exacerbate the STI epidemic [10]. This has been demonstrated in a study conducted in the United States [11]. To address this problem, decentralized STI testing and promoting a people-centred STI testing strategy is essential, while integrating STI self-testing with HIVST can empower and facilitate routine STI tests. More high-quality rapid test kits that can be used in diverse settings are needed. Many Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) rapid testing kits in many parts of the world have poor accuracy [12, 13], which thwarted the scale-up of the integrated self-testing model. Generally, those self-testing kits may have lower sensitivity than laboratory-based tests, which can produce false-negative results (Table 1). Therefore, we advocate that more high-quality rapid test kits are needed for the integrated model while acknowledging the important role of those rapid test kits in supplementing other’ screening approaches. Self-testing kits that can separate ongoing and past infections are needed to capture new infections of syphilis. This recommendation was derived from the evidence that dual HIV/syphilis self-testing kits may not distinguish new from old infections [8]. Some kits can only identify whether the patients are ever infected rather than separating new and past infections. Given its importance, we encourage research and development focusing on integrated self-testing kits, which can distinguish new from past infections. More innovative solutions are needed to link self-reported data with national surveillance. Integrated self-testing might reduce the opportunities for tracing people with positive results and linking them to care [6]. Furthermore, the self-testing relied on self-reported data, which generated missing national data, and might lead to insufficient evidence of shifts in patterns of HIV and STIs infection [6]. To tackle this issue, we suggest the establishment of a national digital reporting platform as a promising solution to incorporate more self-reported data into the national data repository. Individuals who undertake HIV and STI self-testing are encouraged to share their results on this platform, thereby enabling them to keep track of their HIV and STI status while assisting the Centers for Diseases Prevention and Control (CDC) in acquiring more individual-level data. Hence, more innovative ways can be adopted to link self-reported and national data in terms of HIV and STI self-testing results. In summary, given the experiences obtained from HIVST programmes, we are recommending integrated HIV and STI self-testing models to facilitate simultaneous HIV and STI testing. We propose that the integrated self-testing kit could be the alternative approach to address this issue. Our proposal relied on a series of advantages proffered by the integrated self-testing kit, including its high feasibility, cost-effectiveness and the decentralization of facilitating STI tests outside of clinical settings. Despite those benefits, there are still barriers inhibiting the scale-up of the integrated self-testing model. Hence, to roll out STI tests with HIVST, we call for high-quality rapid test kits on the one hand. On the other hand, we advocate conducting more empirical studies to provide substantial experience which will be beneficial for the future implementation of the integrated model. The authors declare no competing interests. DW drafted the manuscript. WT made revisions. RT, GM and JDT provided feedback on the draft and revision. All authors equally contributed to this response. All authors read and approved the final version. We would like to thank the journal editors for giving us the opportunity to discuss this important topic.