Community-based intervention to increase HIV testing and case detection in people aged 16-32 years in Tanzania, Zimbabwe, and Thailand (NIMH Project Accept, HPTN 043): a randomised study

The impact of homelessness and housing insecurity on HIV

Homelessness is a global problem with wide-ranging causes and contexts. People experiencing homelessness and unstable housing (HUH) are disproportionately affected by HIV and face worse treatment outcomes than those with stable housing due to multiple complex barriers to care. Even in settings with universal health coverage, access to HIV prevention and treatment services remains insufficient for people experiencing HUH. Health system barriers-such as difficult-to-navigate, fragmented care systems and the mistreatment faced in health-care settings-hinder the engagement of this population in HIV care. Tailored service delivery models, including low-barrier care, mobile and street-based care, and long-acting antiretroviral medications for prevention and treatment, show promise in addressing these barriers and improving HIV outcomes among people experiencing HUH. Future research should prioritise high-quality studies of differentiated service delivery, implementation science to optimise prevention and care programmes for this population in varied settings, and expanded access to long-acting pre-exposure prophylaxis and antiretroviral therapy, particularly in low-income and middle-income countries.

Very high HIV prevalence and incidence among men who have sex with men and transgender women in Indonesia: a retrospective observational cohort study in Bali and Jakarta, 2017-2020

INTRODUCTION

There are no longitudinal HIV incidence data among men who have sex with men (MSM) and transgender women (TGW) in Indonesia. We aimed to estimate HIV prevalence and incidence and identify associated factors among clinic attendees in Jakarta and Bali.

METHODS

We conducted a retrospective cohort study using medical records from five clinics. We reviewed HIV tests among MSM/TGW aged ≥18 years who attended the clinics between 1 January 2018 to 31 December 2020 in Jakarta and 1 January 2017 to 31 December 2019 in Bali. HIV prevalence was measured at the first test. Those with an HIV-negative test and ≥1 follow-up test/s were included in the person-years (PY) at risk to determine HIV incidence. The PY at risk calculation started at the first negative test until the last recorded negative test or seroconversion. Multivariate Poisson regression was used to determine factors associated with HIV acquisition.

RESULTS

Among 5203 and 2815 individuals with an HIV test result in Jakarta and Bali, respectively, at the first HIV test, 1205 and 616 were HIV positive (HIV prevalence 23.2% and 21.9%). The longitudinal sample included 1418 and 873 individuals, respectively. The median number of tests among repeat testers was 3 in Jakarta (interquartile range [IQR] = 2-4) and 3 in Bali (IQR = 2-5). At baseline, about one-quarter were aged <25 years, >90% were MSM and >35% had been tested for HIV previously. In Jakarta, there were 127 HIV seroconversions in 1353 PY (incidence 9.39/100 PY, 95% CI = 7.89-11.17), and in Bali, 71 seroconversions in 982 PY (incidence 7.24/100 PY, 95% CI = 5.73-9.13). Compared to those aged 18-24 years, the incidence rate was lower in older patients (Jakarta-30-39 years: aRR = 0.56, 95% CI = 0.34-0.92; 40+ years: aRR = 0.34, 95% CI = 0.14-0.81; Bali-25-29 years: aRR = 0.44, 95% CI = 0.25-0.79; 30-39 years: aRR = 0.33, 95% CI = 0.18-0.61; 40+ years: aRR = 0.06, 95% CI = 0.01-0.48). In Jakarta, incidence was lower in those with university education than in those without (aRR = 0.66, 95% CI = 0.45-0.96). In Bali, those who had been referred by outreach workers had a higher incidence than those who self-presented for testing (aRR = 1.85, 95% CI = 1.12-3.07).

CONCLUSIONS

We observed very high HIV prevalence and incidence rate estimates. Measures to encourage regular testing and effective use of HIV prevention, including pre-exposure prophylaxis scale-up and demand creation, are needed.

Randomized Clinical Trial of Stigma Counseling and HIV Testing Access Interventions to Increase HIV Testing Among Black Sexual Minority Men and Transwomen

Advances in HIV prevention tools have outpaced our ability to ensure equitable access to these tools. Novel approaches to reducing known barriers to accessing HIV prevention, such as stigma and logistical-related factors, are urgently needed. To evaluate the efficacy of a randomized controlled trial with four intervention arms to address barriers to HIV/STI testing uptake (primary outcome) and PrEP use, depression, and HIV test results (secondary outcomes). We tested a 2 × 2 research design: main effect 1-stigma-focused vs. health information evaluation-focused counseling, main effect 2-offering HIV/STI testing appointments in person vs. at home with a counselor via video chat, and the interaction of the main effects. Participants (N = 474) residing in the southeastern USA were screened and enrolled in a longitudinal trial. Intervention efficacy was established using generalized linear modeling with binomial or Poisson distributions. Intervention efficacy demonstrated an increase in HIV/STI testing uptake when testing was made available at home with a counselor via video chat vs. in person (83% vs. 75% uptake, p < .05), and participants were also more likely to test positive for HIV over the course of the study in the at-home condition (14.5% vs. 9.4%, p < .05). Stigma-focused counseling resulted in lower depression scores and greater uptake of PrEP among participants < 30 years of age when compared with health information counseling (15.4% vs. 9.6%, p < .05). In order to prevent further disparities between HIV prevention advances and access to HIV prevention tools, we must prioritize improvements in linking people to care. Novel interventions, such as those proposed here, offer a practical, evidence-based path to addressing long-standing barriers to HIV prevention strategies. Trial registration: NCT03107910.

Integration of HIV Testing in a Community Intervention for Tuberculosis Screening Among Household Contacts of Patients with Tuberculosis in Cameroon and Uganda

INTRODUCTION

People living with HIV are considered at higher risk of developing severe forms of tuberculosis (TB) disease. Providing HIV testing to TB-exposed people is therefore critical. We present the results of integrating HIV testing into a community-based intervention for household TB contact management in Cameroon and Uganda.

METHODS

Trained community health workers visited the households of index patients with TB identified in 3 urban/semiurban and 6 rural districts or subdistricts as part of a cluster-randomized trial and provided TB screening to all household contacts. Voluntary HIV counseling and testing were offered to contacts aged 5 years or older with unknown HIV status. We describe the cascade of care for HIV testing and the factors associated with the acceptance of HIV testing.

RESULTS

Overall, 1983 household contacts aged 5 years or older were screened for TB. Of these contacts, 1652 (83.3%) did not know their HIV status, 1457 (88.2%) accepted HIV testing, and 1439 (98.8%) received testing. HIV testing acceptance was lower among adults than children [adjusted odds ratio (aOR) = 0.35, 95% confidence interval (CI): 0.22 to 0.55], those living in household of an HIV-positive vs HIV-negative index case (aOR = 0.56, 95% CI: 0.38 to 0.83), and contacts requiring a reassessment visit after the initial TB screening visit vs asymptomatic contacts (aOR = 0.20, 95% CI: 0.06 to 0.67) and was higher if living in Uganda vs Cameroon (aOR = 4.54, 95% CI: 1.17 to 17.62) or if another contact of the same index case was tested for HIV (aOR = 9.22, 95% CI: 5.25 to 16.18).

CONCLUSION

HIV testing can be integrated into community-based household TB contact screening and is well-accepted.

Interventions to improve young men's utilisation of HIV-testing services in KwaZulu-Natal, South Africa: perspectives of young men and health care providers

Introduction: HIV-testing services (HTS) are an important point of entry to prevention and treatment of HIV in South Africa. Despite the availability of HTS across the region and in SA, the uptake among men remains low, especially young men residing in rural and peri-urban communities. This study aimed to explore interventions that could improve the uptake of HTS among young men in KwaZulu-Natal.Methods: A descriptive exploratory qualitative study was conducted in which 17 young men and two health care providers in Ladysmith were purposively and conveniently sampled. Data were collected through semi-structured interviews using WhatsApp and landline audio calls between September and December 2021 and thematically analysed.Results: An improvement in the health care provider attitudes and service delivery, establishment of adherence clubs for young people living with HIV, ensuring a diverse and balanced health care provider staff composition at primary health care facilities, and increased demand creation in spaces frequented by men are vital for enhancing access and utilisation of HTS among young men. Additionally, health care providers believe that the presence of male health care providers, investment in health education, prioritising men in the morning at the primary health care facilities, and the establishment of male clinics within communities as key factors in improving the uptake of HTS among young men.Conclusion: To attract and retain young men in HTS and in HIV treatment and care, several improvements at primary health care facilities need to be implemented. These should focus on addressing the specific needs and preferences of young men, ensuring their comfort and engagement in health care.

Factors associated with use of community-based, peer-led sexual and reproductive health services by adolescent boys and young men aged 18-24 in Lusaka, Zambia: A case control study nested in the Yathu Yathu trial

INTRODUCTION

Adolescents and young people (AYP) aged 15-24 years have the least access to facility-based sexual and reproductive health (SRH) services, including HIV services. The Yathu-Yathu cluster-randomized trial (CRT) in Zambia tested whether a novel peer-led community-based approach increased knowledge of HIV status amongst AYP. In this nested case-control study, we aimed to identify factors associated with non-attendance to the Yathu Yathu hubs by adolescent boys and young men (ABYM) aged 18-24-years.

METHODS

Yathu Yathu was a CRT conducted in two communities in Lusaka, Zambia, with 10 intervention and 10 control zones. AYP in all zones were offered prevention points cards (PPC), which incentivized and tracked service use at the hubs and health facility. In intervention zones, services were provided to AYP through community-based spaces (hubs) led by peer support workers. In these zones, cases were defined as those not having accessed any service at a hub and controls as those that accessed at least one service. Data were collected from October 2020 to January 2021 and analysed using methods appropriate for unmatched case-control studies.

RESULTS

161 cases and 160 controls consented to participate in the study. Participants aged 20-24 years (adjOR 1.99, 95%CI 1.26-3.12, p = 0.003), who were educated up to college level (adjOR 8.47,95%CI 2.08-34.53, p = 0.001) or who reported being employed in the last 12 months (adjOR 2.15, 95%CI 1.31-3.53, p = 0.002) were more likely to not attend the hubs. ABYM who had a friend with a PPC were more likely to attend the hubs (adjOR 0.18 95%CI 0.09-0.35, p<0.001). Most cases reported having their last HIV test at the local government health facility (58%) while most controls reported HIV-testing at a Yathu Yathu hub (82%). Among the controls, 84% (134/160) rated the hub experience as excellent. Among cases, 65% (104/161) stated they didn't visit the hubs "due to employment".

CONCLUSIONS

Despite Yathu Yathu services being community-based and more accessible compared to health facilities, we found age, education and employment were associated with not attending hubs. Strategies are needed to reach employed young men who may not have access to SRH/HIV services during conventional working hours and to better utilise peer networks to increase service use.

Acceptability and uptake of oral HIV self-testing among rural community members in Tanzania: a pilot study

New strategies are needed to improve HIV testing rates in Tanzania, particularly among adult men. We sought to investigate if HIV oral self-testing would increase HIV testing uptake in Tanzanian rural community homes. The study design was a prospective community-randomized pilot study, in two matched villages with similar characteristics (intervention and control villages) Before data collection, we trained village health workers and research assistants for one week. We recruited male and female adults from 50 representative households in each of two villages in eastern Tanzania. We collected data at baseline and we followed-up the enrolled households after a one-month period. There was a high interest in testing for HIV, with all participants from both arms (100%; n = 259) reporting that they would like to test for HIV. After the one-month follow-up, overall, 66.1% (162/245) of study participants reported to have tested for HIV in both arms. In the intervention arm, 97.6% (124/127) reported that they tested for HIV versus in the control arm, 32.2% (38/118) tested for HIV, p-value < 0.001. In Tanzania, we found that availability of HIV self-testing was associated with an enormous increase in HIV testing uptake in a rural population.

Demand creation for HIV testing services: A systematic review and meta-analysis

BACKGROUND

HIV testing services (HTS) are the first steps in reaching the UNAIDS 95-95-95 goals to achieve and maintain low HIV incidence. Evaluating the effectiveness of different demand creation interventions to increase uptake of efficient and effective HTS is useful to prioritize limited programmatic resources. This review was undertaken to inform World Health Organization (WHO) 2019 HIV testing guidelines and assessed the research question, "Which demand creation strategies are effective for enhancing uptake of HTS?" focused on populations globally.

METHODS AND FINDINGS

The following electronic databases were searched through September 28, 2021: PubMed, PsycInfo, Cochrane CENTRAL, CINAHL Complete, Web of Science Core Collection, EMBASE, and Global Health Database; we searched IAS and AIDS conferences. We systematically searched for randomized controlled trials (RCTs) that compared any demand creation intervention (incentives, mobilization, counseling, tailoring, and digital interventions) to either a control or other demand creation intervention and reported HTS uptake. We pooled trials to evaluate categories of demand creation interventions using random-effects models for meta-analysis and assessed study quality with Cochrane's risk of bias 1 tool. This study was funded by the WHO and registered in Prospero with ID CRD42022296947. We screened 10,583 records and 507 conference abstracts, reviewed 952 full texts, and included 124 RCTs for data extraction. The majority of studies were from the African (N = 53) and Americas (N = 54) regions. We found that mobilization (relative risk [RR]: 2.01, 95% confidence interval [CI]: [1.30, 3.09], p < 0.05; risk difference [RD]: 0.29, 95% CI [0.16, 0.43], p < 0.05, N = 4 RCTs), couple-oriented counseling (RR: 1.98, 95% CI [1.02, 3.86], p < 0.05; RD: 0.12, 95% CI [0.03, 0.21], p < 0.05, N = 4 RCTs), peer-led interventions (RR: 1.57, 95% CI [1.15, 2.15], p < 0.05; RD: 0.18, 95% CI [0.06, 0.31], p < 0.05, N = 10 RCTs), motivation-oriented counseling (RR: 1.53, 95% CI [1.07, 2.20], p < 0.05; RD: 0.17, 95% CI [0.00, 0.34], p < 0.05, N = 4 RCTs), short message service (SMS) (RR: 1.53, 95% CI [1.09, 2.16], p < 0.05; RD: 0.11, 95% CI [0.03, 0.19], p < 0.05, N = 5 RCTs), and conditional fixed value incentives (RR: 1.52, 95% CI [1.21, 1.91], p < 0.05; RD: 0.15, 95% CI [0.07, 0.22], p < 0.05, N = 11 RCTs) all significantly and importantly (≥50% relative increase) increased HTS uptake and had medium risk of bias. Lottery-based incentives and audio-based interventions less importantly (25% to 49% increase) but not significantly increased HTS uptake (medium risk of bias). Personal invitation letters and personalized message content significantly but not importantly (<25% increase) increased HTS uptake (medium risk of bias). Reduced duration counseling had comparable performance to standard duration counseling (low risk of bias) and video-based interventions were comparable or better than in-person counseling (medium risk of bias). Heterogeneity of effect among pooled studies was high. This study was limited in that we restricted to randomized trials, which may be systematically less readily available for key populations; additionally, we compare only pooled estimates for interventions with multiple studies rather than single study estimates, and there was evidence of publication bias for several interventions.

CONCLUSIONS

Mobilization, couple- and motivation-oriented counseling, peer-led interventions, conditional fixed value incentives, and SMS are high-impact demand creation interventions and should be prioritized for programmatic consideration. Reduced duration counseling and video-based interventions are an efficient and effective alternative to address staffing shortages. Investment in demand creation activities should prioritize those with undiagnosed HIV or ongoing HIV exposure. Selection of demand creation interventions must consider risks and benefits, context-specific factors, feasibility and sustainability, country ownership, and universal health coverage across disease areas.

Effectiveness of community mobilisation models in improving HIV testing services uptake among women and children in Nigeria: A quasi-experimental study

Nigeria carries a high burden of HIV infections, with Taraba State having a prevalence of 2.49%. This quasi-experimental study evaluated the impact of the Lafiyan Yara project, which utilised various community-based mobilisation models, on the enhancement of HTS uptake among women during pregnancy, and children. The intervention involved the implementation of mobilisation by Traditional Birth Attendants (TBA), Village Health Workers (VHW), Patent and Proprietary Medicine Vendors (PPMVs), and a combination of the three in four study local government areas (LGA) in Taraba State. Baseline and end-line surveys were conducted focused on women aged 15-49 years who delivered a child in the past 1 year, and children in their households, in the study and a control LGA. A difference-in-difference (DID) approach was applied by using a probit regression model with interaction terms for treatment status (intervention vs. control) and survey timing to compute the DID estimates of uptake of HTS. The TBA model showed the highest impact in the referral of women to HTS, while the combined model demonstrated the greatest impact in referrals for children. Scaling up and strengthening these community mobilisation efforts can improve access to HIV testing and contribute to HIV/AIDS prevention and control in the region.

Understanding mechanisms of impact from community-led delivery of HIV self-testing: Mediation analysis of a cluster-randomised trial in Malawi

Community HIV strategies are important for early diagnosis and treatment, with new self-care technologies expanding the types of services that can be led by communities. We evaluated mechanisms underlying the impact of community-led delivery of HIV self-testing (HIVST) using mediation analysis. We conducted a cluster-randomised trial allocating 30 group village heads and their catchment areas to the community-led HIVST intervention in addition to the standard of care (SOC) or the SOC alone. The intervention used participatory approaches to engage established community health groups to lead the design and implementation of HIVST campaigns. Potential mediators (individual perceptions of social cohesion, shared HIV concern, critical consciousness, community HIV stigma) and the outcome (HIV testing in the last 3 months) were measured through a post-intervention survey. Analysis used regression-based models to test (i) intervention-mediator effects, (ii) mediator-outcome effects, and (iii) direct and indirect effects. The survey included 972 and 924 participants in the community-led HIVST and SOC clusters, respectively. The community-led HIVST intervention increased uptake of recent HIV testing, with no evidence of indirect effects from changes in hypothesised mediators. However, standardised scores for community cohesion (adjusted mean difference [MD] 0.15, 95% CI -0.03 to 0.32, p = 0.10) and shared concern for HIV (adjusted MD 0.13, 95% CI -0.02 to 0.29, p = 0.09) were slightly higher in the community-led HIVST arm than the SOC arm. Social cohesion, community concern, and critical consciousness also apparently had a quadratic association with recent testing in the community-led HIVST arm, with a positive relationship indicated at lower ranges of each score. We found no evidence of intervention effects on community HIV stigma and its association with recent testing. We conclude that the intervention effect mostly operated directly through community-driven service delivery of a novel HIV technology rather than through intermediate effects on perceived community mobilisation and HIV stigma.

Sub-district costs and efficiency of a combination HIV/AIDS prevention-intervention in the Northwest Province of South Africa

Background

We reviewed a combination prevention program to strengthen HIV prevention programming, community support mechanisms, community-based HIV testing, referral systems, and HIV prevention integration at the primary care level. The intervention included situational analysis to inform programming, community engagement and mobilization, and community-based biomedical and behavioral prevention. In support of PEPFAR's country-ownership paradigm, we costed the combination HIV prevention program to determine data needed for local ownership. This research used costing and health system perspectives.

Results

Cost per person reached with individual or small group prevention interventions ranged from $63.93 to $4,344.88. (cost per health facility strengthened). Personnel costs drove the intervention. This was true regardless of year or activity (i.e. wellness days or events, primary health care strengthening, community engagement, and wellness clubs).

Conclusions

Labor-intensive rather than capital-intensive interventions for low-income settings, like this one, are important for treating and preventing HIV/AIDS and other health conditions sustainably. Over time, costs shifted from international cost centers to in-country headquarters offices, as required for sustainable PEPFAR initiatives. Such costing center evolution reflected changes in the intervention's composition, including (1) the redesign and re-deployment of service delivery sites according to local needs, uptake, and implementation success and (2) the flexible and adaptable restructuring of intervention components in response to community needs.

A community mobilisation intervention to improve engagement in HIV testing, linkage to care, and retention in care in South Africa: a cluster-randomised controlled trial

BACKGROUND

Community mobilisation, engaging communities in a process to collectively enact change, could improve HIV testing and care engagement. In South Africa, current rates fall below those needed for epidemic control. We assessed whether community mobilisation increased HIV testing, linkage to care, and retention in care over time in intervention relative to control communities.

METHODS

We conducted a cluster-randomised controlled trial in villages in the Agincourt sub-district of the rural Mpumalanga Province in South Africa. 15 villages were randomly assigned to either a community mobilisation intervention engaging residents to address social barriers to HIV testing and treatment (intervention arm) or to a control arm using balanced randomisation. Villages were eligible if they had been fully enumerated in 2014, had not been included in previous mobilisation activities, and included over 500 permanent adult residents aged 18-49 years. Primary outcomes included quarterly rates of HIV testing, linkage to care, and retention in care documented from health facility records among residents of the intervention and control communities over the 3-year study period. Intention-to-treat analyses employed generalised estimating equations stratified by sex. This trial is registered with ClinicalTrials.gov, NCT02197793.

FINDINGS

Between Aug 1, 2015, and July 31, 2018, residents in eight intervention communities (n=20 544 residents) and seven control communities (n=17 848) contributed data; 92 residents contributed to both arms. Among men, HIV testing increased quarterly by 12·1% (relative change [RC] 1·121, 95% CI 1·099 to 1·143, p<0·0001) in the intervention communities and 9·5% (1·095, 1·075 to 1·114, p=0·011) in the control communities; although increases in testing were greater in the intervention villages, differences did not reach significance (exponentiated interaction coefficient 1·024, 95% CI 0·997 to 1·052, p=0·078). Among women, HIV testing increased quarterly by 10·6% (RC 1·106, 95% CI 1·097 to 1·114, p<0·0001) in the intervention communities and 9·3% (1·093, 1·084 to 1·102, p=0·053) in the control communities; increases were greater in intervention communities (exponentiated interaction coefficient 1·012, 95% CI 1·001 to 1·023, p=0·043). Quarterly linkage increased significantly among women in the intervention communities (RC 1·013, 95% CI 1·002 to 1·023, p=0·018) only. Quarterly linkage fell among men in both arms, but decreased significantly among men in the control communities (0·977, 0·954 to 1·002, p=0·043). Quarterly retention fell among women in both arms; however, reductions were tempered among women in the intervention communities (exponentiated interaction coefficient 1·003, 95% CI <1·000 to 1·006, p=0·062). Retention fell significantly among men in both arms with difference in rates of decline.

INTERPRETATION

Community mobilisation was associated with modest improvements in select trial outcomes. The sum of these incremental, quarterly improvements achieved by addressing social barriers to HIV care engagement can impact epidemic control. However, achieving optimal impacts will probably require integrated efforts addressing both social barriers through community mobilisation and provision of improved service delivery.

FUNDING

US National Institutes of Health, National Institute of Mental Health, and United States President's Emergency Plan for AIDS Relief through Right to Care and Project SOAR.

Effect of Late Testing and Antiretroviral Treatment on Mortality Among People Living With HIV in the Era of Treat-All in Guangdong Province, China, 1992–2018: A Cohort Study

Late testing and antiretroviral therapy (ART) prevailed among people living with HIV (PLHIV) and impacted the benefit of immediate ART. This study aimed to identify the benefit of the test-and-immediate-treat policy in China, the effect of immediate ART, and the influence of late testing and ART on the whole PLHIV in Guangdong Province, China. We designed two tendency analyses in aggregative form and two cohorts (surveillance and ART cohort) in individuals' perspectives based on the HIV/AIDS Comprehensive Response Information Management System. Two interrupted time series models were conducted for tendency analysis from 2009 to 2018 to explore the all-cause and short-term mortality decrease after the test-and-immediate-treat policy. A time-dependent Cox model was performed for the surveillance cohort from 1992 to 2018 and a joint model was utilized for the ART cohort to identify the effect of immediate ART and the influence of late testing and ART on death. The tendency analysis included 324,914 and 68,679 person-year for all-cause/short-term mortality. A total of 49,289 and 26,287 PLHIV were recruited in the surveillance and ART cohort with 5,557 and 459 deaths, respectively. The short-term mortality dropped from 4.69 cases/100 person-year in January 2009 to 0.35 cases/100 person-year in December 2018 (standardized rate). The all-cause mortality saw a decreasing trend from 1.46 cases/100 person-year in January 2009 to 0.14 cases/100 person-year in December 2018 (standardized rate). The tendency analysis showed a significant short-term mortality slope decrease after the test-and-immediate-treat policy (P = 0.024). From the surveillance cohort, late testing, in general, was a risk factor for all-cause mortality [hazard ratio (HR) = 1.330, 95% CI, 1.250, 1.416]. ART cohort showed higher hazards of all-cause mortality among PLHIV with no late testing, but late ART (HR = 1.690, 95% CI, 1.166, 2.451) and both the late testing and late ART (HR = 1.335, 95% CI, 1.042, 1.710). Immediate ART might decrease the hazard of all-cause death though it is insignificant (HR = 0.923, 95% CI: 0.755, 1.129) in the ART cohort. The test-and-immediate-test policy brought benefit to PLHIV. We should enlarge HIV testing using comprehensive approaches to decrease late testing and ART and increase the benefit of immediate ART.

Community- and facility-based HIV testing interventions in northern Tanzania: Midterm results of Test & Treat Project

Test & Treat Project offers universal HIV testing and access to antiretroviral treatment in Northern Tanzania. The current cross-sectional study provides midterm results on HIV testing and counseling activities through community outreaches and facility-based services. A total 255,329 HIV tests were performed: 198,451 (77.7%) during testing campaigns in the villages, 12,592 (4.9%) during special events outreach and 44,286 (17.4%) in the health facilities. Females represented 53.8% (23,809) among those tested in the health facilities, while males were the majority in the community (54.4%, 114,835). Over one third of tests (n = 104,605, 41%) were performed among first-time testers. The overall HIV positivity rate was 1.2%, ranging from 0.7% in the community to 3.8% in the health facilities and decreased over time. Using a multivariable analysis, a positive test result was associated with age ≥ 50 years (PR 1.22, 95% CI 1.11 to 1.34), with female gender (PR 1.61, 95% CI 1.50 to 1.73), being tested in health facilities (PR 5.00, 95% CI 4.65 to 5.36) and for the first time (PR 1.86, 95% CI 1.73 to 2.00). The estimated proportion of PLHIV who knew their status of the project area increased by 28.6% (from 35.7% to 64.3%) and 11.1% (from 57.7% to 68.8%) in the project areas of Shinyanga and Simiyu regions respectively. Reaching the first UNAIDS 90 target by the end of this project seems possible. Future strategies should focus on improving PITC coverage, implementing more targeted testing modalities, together with current universal community-based approach.

Practical issues in operationalizing the design and outcome evaluation of cluster randomized trials

Trial designs using cluster-level randomization are necessary when interventions have intended effects that cannot be measured with individual randomization. When an intervention is intrinsically only able to be delivered to a cluster or when implementation of an individual level intervention is only feasibly implemented at a cluster level, cluster-level randomization is required. In designing the strategy for evaluation of the primary outcome of a cluster randomized trial, there are a multitude of important decisions to consider. While these decisions are guided primarily by the intervention-who benefits, what is the intended effect and when will it be achieved-there are important detailed choices that affect potential bias and statistical power, and implementation considerations that require compromise for considerations of feasibility and practicality. Through the lens of three large completed cluster randomized trials in HIV prevention, we present specific choices made for the overall evaluation plan, together with some of the detailed considerations, compromises and modifications that occurred during trial implementation.

Closing the gap: did delivery approaches complementary to home-based testing reach men with HIV testing services during and after the HPTN 071 (PopART) trial in Zambia?

INTRODUCTION

The HPTN 071 (PopART) trial demonstrated that universal HIV testing-and-treatment reduced community-level HIV incidence. Door-to-door delivery of HIV testing services (HTS) was one of the main components of the intervention. From an early stage, men were less likely to know their HIV status than women, primarily because they were not home during service delivery. To reach more men, different strategies were implemented during the trial. We present the relative contribution of these strategies to coverage of HTS and the impact of community hubs implemented after completion of the trial among men.

METHODS

Between 2013 and 2017, three intervention rounds (IRs) of door-to-door HTS delivery were conducted in eight PopART communities in Zambia. Additional strategies implemented in parallel, included: community-wide "Man-up" campaigns (IR1), smaller HTS campaigns at work/social places (IR2) and revisits to households with the option of HIV self-testing (HIVST) (IR3). In 2018, community "hubs" offering HTS were implemented for 7 months in all eight communities. Population enumeration data for each round of HTS provided the denominator, allowing for calculation of the proportion of men tested as a result of each strategy during different time periods.

RESULTS

By the end of the three IRs, 65-75% of men were reached with HTS, primarily through door-to-door service delivery. In IR1 and IR2, "Man-up" and work/social place campaigns accounted for ∼1 percentage point each and in IR3, revisits with the option of self-testing for ∼15 percentage points of this total coverage per IR. The yield of newly diagnosed HIV-positive men ranged from 2.2% for HIVST revisits to 9.9% in work/social places. At community hubs, the majority of visitors accepting services were men (62.8%). In total, we estimated that ∼36% (2.2% tested HIV positive) of men resident but not found at their household during IR3 of PopART accessed HTS provided at the hubs after trial completion.

CONCLUSIONS

Achieving high coverage of HTS among men requires universal, home-based service delivery combined with an option of HIVST and delivery of HTS through community-based hubs. When men are reached, they are willing to test for HIV. Reaching men thus requires implementers to adapt their HTS delivery strategies to meet men's needs.

CLINICAL TRIAL NUMBER

NCT01900977.

Shifting gender norms to improve HIV service uptake: Qualitative findings from a large-scale community mobilization intervention in rural South Africa

Background

Interventions to improve HIV service uptake are increasingly addressing inequitable and restrictive gender norms. Yet comparatively little is known about which gender norms are most salient for HIV testing and treatment and how changing these specific norms translates into HIV service uptake. To explore these questions, we implemented a qualitative study during a community mobilization trial targeting social barriers to HIV service uptake in South Africa.

Methods

We conducted 55 in-depth interviews in 2018, during the final months of a three-year intervention in rural Mpumalanga province. Participants included 25 intervention community members (48% women) and 30 intervention staff/community-opinion-leaders (70% women). Data were analyzed using an inductive-deductive approach.

Results

We identified three avenues for gender norms change which, when coupled with other strategies, were described to support HIV service uptake: (1) Challenging norms around male toughness/avoidance of help-seeking, combined with information on the health and preventive benefits of early antiretroviral therapy (ART), eased men’s fears of a positive diagnosis and facilitated HIV service uptake. (2) Challenging norms about men’s expected control over women, combined with communication and conflict resolution skill-building, encouraged couple support around HIV service uptake. (3) Challenging norms around women being solely responsible for the family’s health, combined with information about sero-discordance and why both members of the couple should be tested, encouraged men to test for HIV rather than relying on their partner’s results. Facility-level barriers such as long wait times continued to prevent some men from accessing care.

Conclusions

Despite continued facility-level barriers, we found that promoting critical reflection around several specific gender norms, coupled with information (e.g., benefits of ART) and skill-building (e.g., communication), were perceived to support men’s and women’s engagement in HIV services. There is a need to identify and tailor programming around specific gender norms that hinder HIV service uptake.

Community-based point-of-care testing to identify new HIV infections: A cross-sectional study from Pune, India

ABSTRACT

The World Health Organization recommends point-of-care testing (POCT) to detect human immunodeficiency virus (HIV) infected individuals in the community. This will help improve treatment coverage through detection of HIV infection among those who are unaware of their status.This study was planned with an objective to investigate the feasibility and acceptability of POCT for HIV in the community.A community-based cross-sectional study was conducted in rural and peri-urban areas of Pune, India. These sites were selected based on the distance from the nearest HIV testing center. Testing locations were identified in consultation with the local stakeholders and grass-root health workers to identify and capture the priority population. The POCT was performed on blood samples collected by the finger-prick method.The proportion of participants seeking HIV tests for the first time was 79.6% that signifies the feasibility of POCT. The acceptability in the peri-urban and rural areas was 70.2% and 69.7%, respectively. POCT was performed at construction sites (24.9%), nearby industries (16.1%) and parking areas of long-distance trucks (8.1%) in the peri-urban area. Three newly diagnosed HIV-infected participants (0.1%) were detected from the peri-urban areas but none from the rural areas. Two of the newly diagnosed participants and their spouses were linked to care.There was a high acceptability of POCT and wider coverage of priority population with a strategy of testing at places preferable to the study population. Therefore, we believe that community-based POCT is a promising tool for improving HIV testing coverage even in low prevalence settings with the concentrated HIV epidemic.

What gaps remain in the HIV cascade of care? Results of a population-based survey in Nsanje District, Malawi

INTRODUCTION

The Malawi Ministry of Health (MoH) has been in collaboration with Médecins sans Frontières (MSF) to increase access to quality HIV care through decentralization of antiretroviral therapy (ART) diagnosis and treatment from hospital to clinics in Nsanje District since 2011. A population-based household survey was implemented to provide information on HIV prevalence and cascade of care to inform and prioritize community-based HIV interventions in the district.

METHODS

A cross-sectional survey was conducted between September 2016 and January 2017. Using two-stage cluster sampling, eligible adult individuals aged ≥15 years living in the selected households were asked to participate. Participants were interviewed and tested for HIV at home. Those tested HIV-positive had their HIV-RNA viral load (VL) measured, regardless of their ART status. All participants tested HIV-positive at the time of the survey were advised to report their HIV test result to the health facility of their choice that MSF was supported in the district. HIV-RNA VL results were made available in this health facility.

RESULTS

Among 5,315 eligible individuals, 91.1% were included in the survey and accepted an HIV test. The overall prevalence was 12.1% (95% Confidence Interval (CI): 11.2-13.0) and was higher in women than in men: 14.0% versus 9.5%, P<0.001. Overall HIV-positive status awareness was 80.0% (95%CI: 76.4-83.1) and was associated with sex (P<0.05). Linkage to care was 78.0% (95%CI: 74.3-81.2) and participants in care 76.2% (95%CI: 72.4-79.5). ART coverage among participants aware of their HIV-positive status was 95.3% (95%CI: 92.9-96.9) and was not associated with sex (P = 0.55). Viral load suppression among participants on ART was 89.9% (95%CI: 86.6-92.4) and was not statistically different by sex (p = 0.40).

CONCLUSIONS

Despite encouraging results in HIV testing coverage, cascade of care, and UNAIDS targets in Nsanje District, some gap remains in the first 90, specifically among men and young adults. Enhanced community engagement and new strategies of testing, such as index testing, could be implemented to identify those who are still undiagnosed, particularly men and young adults.

Comparison of HIV-Positive Incidence Among Transgender Women and Men Who Have Sex with Men at Stand-Alone and Mobile Voluntary Counseling and Testing Facilities in Chiang Mai Province, Thailand

Human immunodeficiency virus (HIV) infection is still a major cause of death in Thais and new cases of infection are still emerging among the key population comprising men who have sex with men (MSM), sex workers and their clients, and transgender women (TGW) and people who inject drugs. The objective of this study was to compare the incidence of HIV infection between MSM and TGW who were tested at stand-alone and mobile HIV voluntary counseling and testing (VCT) centers and to identify factors associated with HIV-positive individuals from the two services. We conducted an observational study using MSM and TGW individuals with unknown HIV status from the databases at a stand-alone center and a mobile VCT belonging to the MPlus in Chiang Mai province, Thailand. Factors associated with HIV-positive status were identified using logistic regression model. HIV VCT data were obtained for 6971 individuals at both MPlus center and mobile care unit. Among 3033 and 3938 clients tested at each facility, respectively, 168 (5.6%) and 101 (2.6%) clients were HIV positive. Individuals tested at the stand-alone centers were at a 1.91-fold higher risk of being HIV positive compared with those tested at the mobile VCT unit. Individuals who were 20-24 or >24 years old, sex workers, or sexually transmitted infection positive were more likely to be HIV positive. Our results show the beneficial effect of mobile HIV VCT facilities that enable testing of more of the at-risk population. Developing mobile VCT activities that attract a particular target population is needed to be able to reach the 90-90-90 goals. This study was approved by the Ethics Committee of the Faculty of Medicine, Chiang Mai University (0BG-2562-06418).

Venue-Based HIV Testing at Sex Work Hotspots to Reach Adolescent Girls and Young Women Living With HIV: A Cross-sectional Study in Mombasa, Kenya

BACKGROUND

We estimated the potential number of newly diagnosed HIV infections among adolescent girls and young women (AGYW) using a venue-based approach to HIV testing at sex work hotspots.

METHODS

We used hotspot enumeration and cross-sectional biobehavioral survey data from the 2015 Transition Study of AGYW aged 14-24 years who frequented hotspots in Mombasa, Kenya. We described the HIV cascade among young females who sell sex (YFSS) (N = 408) versus those young females who do not sell sex (YFNS) (N = 891) and triangulated the potential (100% test acceptance and accuracy) and feasible (accounting for test acceptance and sensitivity) number of AGYW that could be newly diagnosed through hotspot-based HIV rapid testing in Mombasa. We identified the profile of AGYW with an HIV in the past year using generalized linear mixed regression models.

RESULTS

N = 37/365 (10.1%) YFSS and N = 30/828 (3.6%) YFNS were living with HIV, of whom 27.0% (N = 10/37) and 30.0% (N = 9/30) were diagnosed and aware (P = 0.79). Rapid test acceptance was 89.3%, and sensitivity was 80.4%. There were an estimated 15,635 (range: 12,172-19,097) AGYW at hotspots. The potential and feasible number of new diagnosis was 627 (310-1081), and 450 (223-776), respectively. Thus, hotspot-based testing could feasibly reduce the undiagnosed fraction from 71.6% to 20.2%. The profile of AGYW who recently tested was similar among YFSS and YFNS. YFSS were 2-fold more likely to report a recent HIV test after adjusting for other determinants [odds ratio (95% confidence interval): 2.2 (1.5 to 3.1)].

CONCLUSION

Reaching AGYW through hotspot-based HIV testing could fill gaps left by traditional, clinic-based HIV testing services.

Outcomes from a multimodal, at-scale community-based HIV counselling and testing programme in twelve high HIV burden districts in South Africa

INTRODUCTION

Facility-based HIV testing services (HTS) have been less acceptable and accessible by adolescents, men and key populations in South Africa. Community-based HIV counselling and testing (CBCT) modalities, including mobile unit and home-based testing, have been proposed to decrease barriers to HIV testing uptake. CBCT modalities and approaches may be differentially acceptable to men and women based on age. Implementation of multimodal CBCT services may improve HIV testing rates among adolescents and men, and support the roll-out of prevention services.

METHODS

A cross-sectional analysis was conducted using aggregate, routine programmatic data collected from 1 October 2015 through 31 March 2017 from a multimodal, at-scale CBCT programme implemented in 12 high-burden districts throughout South Africa. Data collection tools were aligned to reporting standards for the National Department of Health and donor requirements. HIV testing rates (i.e. number of tests performed per 100,000 population using South African census data) and testing proportions by modality were stratified by sex, age groups and heath districts. Descriptive statistics were performed using STATA 13.0.

RESULTS

Overall, 944,487 tests were performed during the 1.5-year testing period reported. More tests were conducted among females than males (53.6% vs. 46.4%). Overall, 8206 tests per 100,000 population (95% CI: 8190.2 to 8221.9) were performed; female-to-male (F:M) testing ratio was 1.11. Testing rates were highest among young women age 20 to 24 years (16,328.4; 95% CI: 16,237.9 to 16,419.1) and adolescent girls aged 15 to 19 years (12,817.0; 95% CI: 12,727.9 to 12,906.6). Home-based testing accounted for 61.3% of HIV tests, followed by near-home mobile unit testing (30.2%) and workplace mobile unit testing (4.7%). More women received HTS via home-based testing (F:M ratio = 1.29), whereas more men accessed work-place mobile testing (M:F ratio = 1.35). No sex differential was observed among those accessing near-home mobile testing (F:M ratio = 0.98).

CONCLUSIONS

Concurrent implementation of multiple, targeted CBCT modalities can reduce sex disparities in HIV testing in South Africa. Given the acceptability and accessibility of these CBCT services to adolescent girls and young women, evident from their high testing rates, leveraging community-based services delivery platforms to increase access to HIV prevention services, including pre-exposure prophylaxis (PrEP), should be considered.

The effects of HIV self-testing on the uptake of HIV testing, linkage to antiretroviral treatment and social harms among adults in Africa: A systematic review and meta-analysis

INTRODUCTION

HIV infection is still a global public health problem. More than 75% of HIV-infected people are in Africa, and up to 54% are unaware of their HIV status, limiting access to antiretroviral treatment.

CONTEXT AND PURPOSE OF THE STUDY

This review aimed to determine whether HIV self-testing (HIVST) increases the uptake of testing, the yield of new HIV-positive diagnoses, and the linkage to antiretroviral treatment, and social harms among adults in Africa.

METHODS

PubMed, The Cochrane Central Register of Controlled Trials (CENTRAL), Pan African Clinical Trials Registry, The Cochrane Database of Systematic Reviews (CDSR), Databases of Abstracts of Reviews of Effectiveness (DARE), Social Sciences Citation Index, Web of Science and African Index Medicus databases were searched from 1998 to 2019 (updated in December 2019). Eligible trials employed randomized controlled trials (RCTs), before/after studies, and interrupted time series design comparing HIVST to standard HIV testing services or comparing different approaches to HIVST among adults living in Africa were systematically sought.

RESULTS

After searching 2,617 citations eleven trials were identified including 59,119 participants from four (4) African countries. Meta-analysis of seven trials showed a significant increase in the uptake of HIVST compared to standard HIV testing services: Both fixed-effects (Rate Ratio (RR) = 2.64, 95% CI: 2.51 to 2.79), and random-effects (RR) = 3.10, 95% CI: 1.80 to 5.37, and a significant increase in the uptake of couples' HIVST (RR = 2.50, 95% CI: 2.29 to 2.73 in fixed-effects models; and RR = 2.64, 95% CI: 2.01 to 3.49 in random-effects model). A decrease in linkage to care and ART was observed in HIVST compared to standard HIV testing services (RR = 0.88, 95% CI: 0.88 to 0.95 in fixed-effects models; and RR = 0.78, 95% CI: 0. 56 to 1.08 in random-effects models). Six RCTs measured social harms, with a total of ten reported cases related to HIVST. One RCT comparing two approaches to HIVST showed that offering home-based HIVST with optional home-initiation of antiretroviral treatment increased the reporting of a positive HIV test result (RR: 1.86; 95% CI: 1.16 to 2.98), and linkage to antiretroviral treatment (RR: 2.94; 95% CI: 2.10 to 4.12), compared with facility-based linkage to antiretroviral treatment.

CONCLUSIONS

HIVST has the potential to increase the uptake of HIV testing compared to standard HIV testing services. Offering HIVST with optional home initiation of HIV care compared to HIVST with facility-based HIV care increases HIV positivity and linkage to antiretroviral treatment. Reported incidences of intimate partner violence related to HIVST were rare. Future research should focus on the potential of HIVST to reach first-time testers, the effect of using different approaches to HIVST, and strategies for linkage to HIV services.

SYSTEMATIC REVIEW REGISTRATION

This systematic review was prospectively registered on the Prospero International Prospective Register of Systematic Review (CRD42015023935).

Evaluation of Rapid Testing Algorithms for Venue-based Anonymous HIV Testing among Non-HIV-Positive Men Who Have Sex with Men, National HIV Behavioral Surveillance (NHBS), 2017

HIV rapid testing algorithms (RTAs) using any two orthogonal rapid tests (RTs) allow for on-site confirmation of infection. RTs vary in performance characteristics therefore the selection of RTs in an algorithm may affect identification of infection, particularly if acute. National HIV Behavioral Surveillance (NHBS) assessed RTAs among men who have sex with men recruited using anonymous venue-based sampling. Different algorithms were evaluated among participants who self-reported never having received a positive HIV test result prior to the interview. NHBS project areas performed sequential or parallel RTs using whole blood. Participants with at least one reactive RT were offered anonymous linkage to care and provided a dried blood spot (DBS) for testing at CDC. Discordant results (RT-1 reactive/RT-2 non-reactive) were tested at CDC with lab protocols modified for DBS. DBS were also tested for HIV-1 RNA (VL) and antiretroviral (ARV) drug levels. Of 6500 RTAs, 238 were RT-1 reactive; of those, 97.1% (231/238) had concordant results (RT-1/RT-2 reactive) and 2.9% (7/238) had discordant results. Five DBS associated with discordant results were available for confirmation at CDC. Four had non-reactive confirmatory test results that implied RT-1 false reactivity; one had ambiguous confirmatory test results which was non-reactive in further testing. Regardless of order and type of RT used, RTAs demonstrated high concordant results in the population surveyed. Additional laboratory testing on DBS following discordant results confirmed no infection. Implementing RTAs in the context of anonymous venue-based HIV testing could be an option when laboratory follow-up is not practicable.

Using repeated home-based HIV testing services to reach and diagnose HIV infection among persons who have never tested for HIV, Chókwè health demographic surveillance system, Chókwè district, Mozambique, 2014-2017

Background

HIV prevalence in Mozambique (12.6%) is one of the highest in the world, yet ~40% of people living with HIV (PLHIV) do not know their HIV status. Strategies to increase HIV testing uptake and diagnosis among PLHIV are urgently needed. Home-based HIV testing services (HBHTS) have been evaluated primarily as a 1-time campaign strategy. Little is known about the potential of repeating HBHTS to diagnose HIV infection among persons who have never been tested (NTs), nor about factors/reasons associated with never testing in a generalized epidemic setting.

Methods

During 2014–2017, counselors visited all households annually in the Chókwè Health and Demographic Surveillance System (CHDSS) and offered HBHTS. Cross-sectional surveys were administered to randomly selected 10% or 20% samples of CHDSS households with participants aged 15–59 years before HBHTS were conducted during the visit. Descriptive statistics and logistic regression were used to assess the proportion of NTs, factors/reasons associated with never having been tested, HBHTS acceptance, and HIV-positive diagnosis among NTs.

Results

The proportion of NTs decreased from 25% (95% confidence interval [CI]:23%–26%) during 2014 to 12% (95% CI:11% –13%), 7% (95% CI:6%–8%), and 7% (95% CI:6%–8%) during 2015, 2016, and 2017, respectively. Adolescent boys and girls and adult men were more likely than adult women to be NTs. In each of the four years, the majority of NTs (87%–90%) accepted HBHTS. HIV-positive yield among NTs subsequently accepting HBHTS was highest (13%, 95% CI:10%–15%) during 2014 and gradually reduced to 11% (95% CI:8%–15%), 9% (95% CI:6%–12%), and 2% (95% CI:0%–4%) during 2015, 2016, and 2017, respectively.

Conclusions

Repeated HBHTS was helpful in increasing HIV testing coverage and identifying PLHIV in Chókwè. In high HIV-prevalence settings with low testing coverage, repeated HBHTS can be considered to increase HIV testing uptake and diagnosis among NTs.

Successes and gaps in the HIV cascade of care of a high HIV prevalence setting in Zimbabwe: a population-based survey

INTRODUCTION

Gutu, a rural district in Zimbabwe, has been implementing comprehensive HIV care with the support of Médecins Sans Frontières (MSF) since 2011, decentralizing testing and treatment services to all rural healthcare facilities. We evaluated HIV prevalence, incidence and the cascade of care, in Gutu District five years after MSF began its activities.

METHODS

A cross-sectional study was implemented between September and December 2016. Using multistage cluster sampling, individuals aged ≥15 years living in the selected households were eligible. Individuals who agreed to participate were interviewed and tested for HIV at home. All participants who tested HIV-positive had their HIV-RNA viral load (VL) measured, regardless of their antiretroviral therapy (ART) status, and those not on ART with HIV-RNA VL ≥ 1000 copies/mL had Limiting-Antigen-Avidity EIA Assay for cross-sectional estimation of population-level HIV incidence.

RESULTS

Among 5439 eligible adults ≥15 years old, 89.0% of adults were included in the study and accepted an HIV test. The overall prevalence was 13.6% (95%: Confidence Interval (CI): 12.6 to 14.5). Overall HIV-positive status awareness was 87.4% (95% CI: 84.7 to 89.8), linkage to care 85.5% (95% CI: 82.5 to 88.0) and participants in care 83.8% (95% CI: 80.7 to 86.4). ART coverage among HIV-positive participants was 83.0% (95% CI: 80.0 to 85.7). Overall, 71.6% (95% CI 68.0 to 75.0) of HIV-infected participants had a HIV-RNA VL < 1000 copies/mL. Women achieved higher outcomes than men in the five stages of the cascade of care. Viral Load Suppression (VLS) among participants on ART was 83.2% (95% CI: 79.7 to 86.2) and was not statistically different between women and men (p = 0.98). The overall HIV incidence was estimated at 0.35% (95% CI 0.00 to 0.70) equivalent to 35 new cases/10,000 person-years.

CONCLUSIONS

Our study provides population-level evidence that achievement of HIV cascade of care coverage overall and among women is feasible in a context with broad access to services and implementation of a decentralized model of care. However, the VLS was relatively low even among participants on ART. Quality care remains the most critical gap in the cascade of care to further reduce mortality and HIV transmission.

Community HIV Screening Among MSM in Three Indonesian Cities

BACKGROUND

Indonesia lags behind its peers with regard to ART coverage of PLHIV. Insufficient HIV testing among MSM and other key affected populations remains a barrier to increasing ART coverage.

OBJECTIVE

This report presents the results of the first government-endorsed implementation research study of a community screening approach to increasing the rate of HIV testing among MSM in three cities.

METHODS

All new MSM outreach contacts meeting eligibility criteria during March-June 2017 were included in the study. HIV testing at a government health facility, which is required to qualify for government-supported ART, was advised for all new contacts. Men refusing formal testing were offered an HIV screening test in a community setting using a saliva-based rapid test and advised to get a confirmatory test at a health facility. All outreach contacts and testing activities were recorded on individual client records.

RESULTS

Of 1,149 eligible MSM, 27% were willing to be referred to receive HIV testing at a health facility, among which 83% were confirmed to have been tested. Of the 838 study subjects refusing health facility testing, 38% accepted community screening. The screening positivity rate was 14.8%. Only 38% of men with reactive screening tests received a confirmatory test at a health facility, along with 8% of those with non-reactive tests.

CONCLUSION

While community screening resulted in more MSM knowing their HIV status, reluctance to avail government health facility-based services, or indeed to be tested at all, must be addressed if community screening is to accelerate progress in getting HIV-positive MSM onto treatment.

Feasibility of home-based HIV counselling and testing and linking to HIV services among women delivering at home in Geita, Tanzania: a household longitudinal survey

Background

Substantial number of women who deliver at home (WDH) are not captured in prevention of mother-to-child transmission (PMTCT) services. This delays HIV infection detection that negatively impacts endeavours to fight the HIV pandemic and the health of mothers and children. The study objective was to determine the feasibility of home-based HIV testing and linking to care for HIV services among WDH in Geita District Council, Tanzania.

Methods

A longitudinal household survey was conducted. The study involved all mentally-able women who delivered within 2 years (WDTY) preceding the survey and their children under the age of two. The study was conducted in Geita District Council in Geita Region, Tanzania from June to July 2017. Geita is among the region with high HIV prevalence and proportion of women delivering at home.

Results

Of the 993 women who participated in the study, 981 (98.8%) accepted household-based HIV counselling and testing (HBHCT) from the research team. HIV prevalence was 5.3% (52 women). HBHCT identified 26 (2.7%) new HIV infections; 23 (23.4%) were those tested negative at ANC and the remaining three (0.3%) were those who had no HIV test during the ANC visit. Among the 51 HIV+ women, 21 (40.4%) were enrolled in PMTCT services. Of the 32 HIV+ participants who delivered at home, eight (25.8%) were enrolled in the PMTCT compared to 100% (13/13) of the women who delivered at a health facility.

Conclusion

HBHCT uptake was high. HBHCT detected new HIV infection among WDH as well as seroconversion among women with previously negative HIV tests. The study findings emphasize the importance of extending re-testing to women who breastfeed. HBHCT is feasible and can be used to improve PMTCT services among WDH.

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

BACKGROUND

Men in sub-Saharan Africa are less likely than women to get tested for HIV, less likely to present for treatment, less likely to be maintained in treatment, more likely to have detectable viral load, more likely to transmit HIV with unprotected intercourse, and more likely to progress to AIDS and die sooner from HIV. The ultimate objective of this research is to provide evidence-based strategies to improve HIV testing and treatment of HIV-infected men.

METHODS

This study is being conducted in the Greater Edendale Area and Vulindlela region in KwaZulu-Natal, South Africa. It is a two-stage design of a cluster-randomized trial and an individual randomized trial to test how structural and individual-level interventions address the demand-side factors that affect HIV testing and treatment for hard-to reach, high-risk men. It combines male-focused mobilization, community-based mobile HIV testing services, and a small incentive to determine if the strategies singly and in combination can result in more men diagnosed with HIV, and more men linked to and maintained in care with undetectable viral load.

DISCUSSION

A priority for sub-Sahara Africa is developing and evaluating novel and cost-effective strategies for identifying hard-to-reach groups such as men, linking them to HIV testing and care services, and maintaining them in care to the point of viral suppression. We propose a combination prevention intervention that addresses men's individual, interpersonal, and structural barriers to testing and care. This includes male-led mobilization to encourage uptake of testing and treatment, male-focused testing venues, male-only counselors, developing counseling models that are flexible and responsive to men, and strategies for adhering to clinic visits without missing work and navigating the healthcare system. By thoughtfully combining male-focused mobilization, and testing and addressing some of the barriers to male engagement with health facilities, this study hopes to add to the growing evidence base about how to reach, test, link, and maintain a hard-to-reach group such as men in HIV treatment and care services.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03794245. Registered on 4 January 2019.

Process elements contributing to community mobilization for HIV risk reduction and gender equality in rural South Africa

Community mobilization has been recognized as a critical enabler for HIV prevention and is employed for challenging gender inequalities. We worked together with community partners to implement the ‘One Man Can’ intervention in rural Mpumalanga, South Africa to promote gender equality and HIV risk reduction. During the intervention, we conducted longitudinal qualitative interviews and focus group discussions with community mobilizers (n = 26), volunteer community action team members (n = 22) and community members (n = 52) to explore their experience of being part of the intervention and their experiences of change associated with the intervention. The objective of the study was to examine processes of change in community mobilization for gender equity and HIV prevention. Our analysis showed that over time, participants referred to three key elements of their engagement with the intervention: developing respect for others; inter-personal communication; and empathy. These elements were viewed as assisting them in adopting a ‘better life’ and associated with behaviour change in the intervention’s main focus areas of promoting gender equality and HIV risk reduction behaviours. We discuss how these concepts relate to the essential domains contained within our theoretical framework of community mobilization—specifically critical consciousness, shared concerns and social cohesion -, as demonstrated in this community. We interpret the focus on these key elements as significant indicators of communities engaging with the community mobilization process and initiating movement towards structural changes for HIV prevention.

Enhancing financial security of female sex workers through a community-led intervention in India: Evidence from a longitudinal survey

Introduction

Community-led organizations (COs) have been an integral part of HIV prevention programs to address the socio-economic and structural vulnerabilities faced by female sex workers (FSWs). The current study examines whether strengthening of community-led organizations and community collectivization have been instrumental in reducing the financial vulnerability and empowering FSWs in terms of their self-efficacy, confidence, and individual agency in India.

Data and methods

This study used a panel data of 2085 FSWs selected from 38 COs across five states of India. Two rounds of data (Round 1 in 2015 and Round 2 in 2017) were collected among FSWs. Data were collected both at CO and individual level. CO level data was used to assess the CO strength. Individual level data was used to measure financial security, community collectivization, and individual empowerment.

Results

There was a significant improvement in CO strength and community collectivization from Round 1 to Round 2. High CO strength has led to improved financial security among FSWs (R2: 85% vs. R1: 51%, AOR: 2.5; 95% CI: 1.5–4.1) from Round 1 to Round 2. High collective efficacy and community ownership have improved the financial security of FSWs during the inter-survey period. Further, the improvement in financial security in the inter-survey period led to increased or sustained individual empowerment (in terms of self-confidence, self-efficacy, and individual agency) among FSWs.

Conclusions

Institutional strengthening and community mobilization programs are key to address the structural issues and the decrease of financial vulnerability among FSWs. In addition, enhanced financial security is very important to sustain or improve the individual empowerment of FSWs. Further attention is needed to sustain the existing community advocacy and engagement systems to address the vulnerabilities faced by marginalized populations and build their empowerment.

Community-led delivery of HIV self-testing to improve HIV testing, ART initiation and broader social outcomes in rural Malawi: study protocol for a cluster-randomised trial

BACKGROUND

Prevention of new HIV infections is a critical public health issue. The highest HIV testing gaps are in men, adolescents 15-19 years old, and adults 40 years and older. Community-based HIV testing services (HTS) can contribute to increased testing coverage and early HIV diagnosis, with HIV self-testing (HIVST) strategies showing promise. Community-based strategies, however, are resource intensive, costly and not widely implemented. A community-led approach to health interventions involves supporting communities to plan and implement solutions to improve their health. This trial aims to determine if community-led delivery of HIVST can improve HIV testing uptake, ART initiation, and broader social outcomes in rural Malawi.

METHODS

The trial uses a parallel arm, cluster-randomised design with group village heads (GVH) and their defined catchment areas randomised (1:1) to community-led HIVST or continue with the standard of the care (SOC). As part of the intervention, informal community health cadres are supported to plan and implement a seven-day HIVST campaign linked to HIV treatment and prevention. Approximately 12 months after the initial campaign, intervention GVHs are randomised to lead a repeat HIVST campaign. The primary outcome includes the proportion of adolescents 15-19 years old who have tested for HIV in their lifetime. Secondary outcomes include recent testing in adults 40 years and older and men; ART initiation; knowledge of HIV prevention; and HIV testing stigma. Outcomes will be measured through cross-sectional surveys and clinic registers. Economic evaluation will determine the cost per person tested, cost per person diagnosed, and incremental cost effectiveness ratio.

DISCUSSION

To the best of our knowledge, this is the first trial to assess the effectiveness of community-led HTS, which has only recently been enabled by the introduction of HIVST. Community-led delivery of HIVST is a promising new strategy for providing periodic HIV testing to support HIV prevention in rural communities. Further, introduction of HIVST through a community-led framework seems particularly apt, with control over healthcare concurrently devolved to individuals and communities.

TRIAL REGISTRATION

Clinicaltrials.gov registry ( NCT03541382 ) registered 30 May 2018.

Optimal HIV testing strategies for South Africa: a model-based evaluation of population-level impact and cost-effectiveness

Although many African countries have achieved high levels of HIV diagnosis, funding constraints have necessitated greater focus on more efficient testing approaches. We compared the impact and cost-effectiveness of several potential new testing strategies in South Africa, and assessed the prospects of achieving the UNAIDS target of 95% of HIV-positive adults diagnosed by 2030. We developed a mathematical model to evaluate the potential impact of home-based testing, mobile testing, assisted partner notification, testing in schools and workplaces, and testing of female sex workers (FSWs), men who have sex with men (MSM), family planning clinic attenders and partners of pregnant women. In the absence of new testing strategies, the diagnosed fraction is expected to increase from 90.6% in 2020 to 93.8% by 2030. Home-based testing combined with self-testing would have the greatest impact, increasing the fraction diagnosed to 96.5% by 2030, and would be highly cost-effective compared to currently funded HIV interventions, with a cost per life year saved (LYS) of $394. Testing in FSWs and assisted partner notification would be cost-saving; the cost per LYS would also be low in the case of testing MSM ($20/LYS) and self-testing by partners of pregnant women ($130/LYS).

The effects of HIV self-testing kits in increasing uptake of male partner testing among pregnant women attending antenatal clinics in Kenya: a randomized controlled trial

Introduction

HIV self-testing could add a new approach to scaling up HIV testing with potential of being high impact, low cost, confidential, and empowering for users.

Methods

Pregnant women attending antenatal clinics (ANC) and their male partners were recruited in 14 clinics in the eastern and central regions of Kenya and randomly allocated to intervention or control arms at a ratio of 1:1:1. Arm 1 received the standard of care, which involved invitation of the male partner to the clinic through word of mouth, arm 2 received an improved invitation letter, and arm 3 received the same improved letter and, two self-testing kits. Analysis was done using adjusted odds ratios (aOR) at 95% confidence intervals (CI) to calculate and determine effects of HIV self-testing in increasing uptake of male partner testing.

Results

A total of 1410 women and 1033 men were recruited; 86% (1217) women and 79% (1107) couples were followed up. In arm 3, over 80% (327) of male partners took HIV test, compared to only 37% (133) in arm 2 and 28% (106) in arm one. There was a statistical significance between arm one and two (p-value=0.01) while arm three was statistically significant compared to arm two (p-value<0.001). Men in arm three were twelve times more likely to test compared to arm one (aOR 12.45 (95% CI 7.35, 21.08)).

Conclusion

Giving ANC mothers test kits and improved male invitation letter increased the likelihood of male partner testing by twelve times. These results demonstrate that HIV self-test kits could complement routine HIV testing methods in the general population.

Sustained high HIV case-finding through index testing and partner notification services: experiences from three provinces in Zimbabwe

INTRODUCTION

Several countries in southern Africa have made significant progress towards reaching the Joint United Nations Programme on HIV/AIDS goal of ensuring that 90% of people living with HIV are aware of their status. In Zimbabwe, progress towards this "first 90" was estimated at 73% in 2016. To reach the remaining people living with HIV who have undiagnosed infection, the Zimbabwe Ministry of Health and Child Care has been promoting index testing and partner notification services (PNS). We describe the implementation of index testing and PNS under the Zimbabwe HIV Care and Treatment (ZHCT) project and the resulting uptake, HIV positivity rate and links to HIV treatment.

METHODS

The ZHCT project has been implemented since March 2016, covering a total of 12 districts in three provinces. To assess the project's performance on index testing, we extracted data on HIV testing from the district health information system (DHIS 2) from March 2016 to May 2018, validated it using service registers and calculated monthly HIV positivity rates using Microsoft Excel. Data were disaggregated by district, province, sex and service delivery point. We used SPSS to assess for statistical differences in paired monthly HIV positivity rates by sex, testing site, and province.

RESULTS

The average HIV positivity rate rose from 10% during the first six months of implementation to more than 30% by August 2016 and was sustained above 30% through May 2018. The overall facility HIV positivity rate was 4.1% during the same period. The high HIV positivity rate was achieved for both males and females (mean monthly HIV positivity rate of 31.3% for males and 33.7% for females), with females showing significantly higher positivity compared to males (p < 0.001). The ZHCT mean monthly HIV positivity rate from index testing (32.6%) was significantly higher than that achieved through provider-initiated testing and counselling and other facility HIV testing modalities (4.1%, p < 0.001).

CONCLUSIONS

The ZHCT project has demonstrated successes in implementing index testing and PNS by attaining a high HIV positivity rate sustained over the study period. As the country moves towards HIV epidemic control, index testing and PNS are critical strategies for targeted HIV case identification.

Mapping evidence of intervention strategies to improving men's uptake to HIV testing services in sub-Saharan Africa: A systematic scoping review

BACKGROUND

HIV testing serves as a critical gateway for linkage and retention to care services, particularly in sub-Saharan African countries with high burden of HIV infections. However, the current progress towards addressing the first cascade of the 90-90-90 programme is largely contributed by women. This study aimed to map evidence on the intervention strategies to improve HIV uptake among men in sub-Saharan Africa.

METHODS

We conducted a scoping review guided by Arksey and O'Malley's (2005) framework and Levac et al. (2010) recommendation for methodological enhancement for scoping review studies. We searched for eligible articles from electronic databases such as PubMed/MEDLINE; American Doctoral Dissertations via EBSCO host; Union Catalogue of Theses and Dissertations (UCTD); SA ePublications via SABINET Online; World Cat Dissertations; Theses via OCLC; and Google Scholar. We included studies from January 1990 to August 2018. We used the PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. The Mixed Method Appraisal Tool version 2018 was used to determine the methodological quality of the included studies. We further used NVivo version 11 to aid with content thematic analysis.

RESULTS

This study revealed that teaching men about HIV; Community-Based HIV testing; Home-Based HIV testing; Antenatal Care HIV testing; HIV testing incentives and HIV Self-testing are important strategies to improving HIV testing among men in sub-Saharan Africa. The need for improving programmes aimed at giving more information to men about HIV that are specifically tailored for men, especially given their poor uptake of HIV testing services was also found. This study further revealed the need for implementing Universal Test and Treat among HIV positive men found through community-based testing strategies, while suggesting the importance of restructuring home-based HIV testing visits to address the gap posed by mobile populations.

CONCLUSION

The community HIV testing, as well as, HIV self-testing strategies showed great potential to increase HIV uptake among men in sub-Saharan Africa. However, to address poor linkage to care, ART should be initiated soon after HIV diagnosis is concluded during community testing services. We also recommend more research aimed at addressing the quality of HIV self-testing kits, as well as, improving the monitoring systems of the distributed HIV self-testing kits.

The gendered experience of HIV testing: factors associated with prior testing differ among men and women in rural Tanzania

HIV testing remains below UNAIDS 90–90–90 goals in sub-Saharan Africa. The aim of this study was to understand gender-specific factors related to HIV testing in Kisarawe, Tanzania. Informed by Social Action Theory, we analyzed cross-sectional data from a population-based random sample using bivariate and multivariate logistic regression to identify the contextual, behavioral, and interpersonal factors associated with prior HIV testing – specifically, any prior testing and testing within the past year. Of 644 participants, 63.1% of men and 85.5% of women reported ever testing for HIV. Younger men and women (aged 18–25 years) had significantly lower odds of prior HIV testing compared with older participants. For men, low levels of anticipated stigma and having ever talked about HIV were both positively associated with any prior testing. Men who knew if a sexual partner had received an HIV test had almost three times the odds of receiving a recent HIV test compared to men with no knowledge of their partners’ testing status (aOR = 2.96, 95% CI: 1.22–7.17, p = 0.01). For women, knowing someone who is HIV-positive was associated with increased odds of any prior testing (aOR = 2.74, 95% CI: 1.24–6.07, p = 0.01). Gender-specific, proactive interventions are needed to increase testing uptake, especially for young people and men.

Methods, outcomes, and costs of a 2.5 year comprehensive facility-and community-based HIV testing intervention in Bukoba Municipal Council, Tanzania, 2014-2017

To diagnose ≥90% HIV-infected residents (diagnostic coverage), the Bukoba Combination Prevention Evaluation (BCPE) implemented provider-initiated (PITC), home- (HBHTC), and venue-based (VBHTC) HIV testing and counseling (HTC) intervention in Bukoba Municipal Council, a mixed urban and rural lake zone community of 150,000 residents in Tanzania. This paper describes the methods, outcomes, and incremental costs of these HTC interventions. PITC was implemented in outpatient department clinics in all eight public and three faith-based health facilities. In clinics, lay counselors routinely screened and referred eligible patients for HIV testing conducted by HTC-dedicated healthcare workers. In all 14 wards, community teams offered HTC to eligible persons encountered at 31,293 home visits and at 79 male- and youth-frequented venues. HTC was recommended for persons who were not in HIV care or had not tested in the prior 90 days. BCPE conducted 133,695 HIV tests during the 2.5 year intervention (PITC: 88,813, 66%; HBHTC: 27,407, 21%; VBHTC: 17,475, 13%). Compared with other strategies, PITC conducted proportionally more tests among females (65%), and VBHTC conducted proportionally more tests among males (69%) and young-adults aged 15-24 years (42%). Of 5,550 (4.2% of all tests) HIV-positive tests, 4,143 (75%) clients were newly HIV diagnosed, including 1,583 males and 881 young adults aged 15-24 years. Of HIV tests conducted 3.7%, 1.8%, and 2.1% of PITC, HBHTC, and VBHTC clients, respectively, were newly HIV diagnosed; PITC accounted for 79% of all new diagnoses. Cost per test (per new diagnosis) was $4.55 ($123.66), $6.45 ($354.44), and $7.98 ($372.67) for PITC, HBHTC, and VBHTC, respectively. In a task-shifting analysis in which lay counselors replaced healthcare workers, estimated costs per test (per new diagnosis) would have been $3.06 ($83.15), $ 4.81 ($264.04), and $5.45 ($254.52), for PITC, HBHTC, and VBHTC, respectively. BCPE models reached different target groups, including men and young adults, two groups with consistently low coverage. Implementation of multiple models is likely necessary to achieve ≥90% diagnostic coverage.

A Systematic Review of Interventions that Promote Frequent HIV Testing

As of 2017, the Centers for Disease Control and Prevention (CDC) HIV testing guidelines recommend that those at increased risk for HIV are tested two to four times per year. Evidence-based interventions that promote frequent and repeated testing remain sparse. We conducted a systematic review to: (1) identify frequent testing interventions; and (2) determine which were successful in increasing frequent testing rates. We searched PubMed, PsycINFO, Web of Science, Embase, and CINAHL for peer-reviewed articles published between January 1, 2010 and September 30, 2017. Ten studies met inclusion criteria. Operationalization of frequent HIV testing varied widely across studies. Four interventions involved text message reminders for HIV testing, three involved community-based testing, two self-testing, and one rapid testing. Text message reminder interventions were most successful in increasing rates of frequent HIV testing. Future research should standardize frequent testing measurement to allow for more robust comparisons of intervention efficacy.

Designing an Individually Tailored Multilevel Intervention to Increase Engagement in HIV and Substance Use Treatment Among People Who Inject Drugs With HIV: HPTN 074

People who inject drugs (PWID) face barriers to engagement in antiretro-viral treatment (ART) and medication-assisted treatment (MAT). We detail the design, rapid preparation and adaptation, and systematic implementation of a flexible, individually tailored intervention for PWID in multiple settings: Indonesia, Ukraine, and Vietnam. HPTN 074 integrated systems navigation and counseling to facilitate entry and adherence to ART and MAT. Site-level guidance on the intervention involved in-depth interviews (IDIs) among PWID and their supporters and site-specific document review. IDIs emphasized ART misinformation and importance of social support for adherence. The document review revealed differences in health care system barriers, requiring an intervention that was flexible and tailored enough to address key outcomes. Implementation included regular debriefs for iterative adaptations based on participants' needs, including booster counseling sessions and subsidizing pre-ART testing. HPTN 074 provides a unique framework implementing a flexible and scalable intervention to improve ART and MAT outcomes among PWID across multiple settings.

Targeted HIV testing for male partners of HIV-positive pregnant women in a high prevalence setting in Nigeria

BACKGROUND

Partner HIV testing during pregnancy has remained abysmally low in sub-Saharan Africa, particularly in Nigeria. Males rarely attend antenatal clinics with their female partners, limiting the few opportunities available to offer them HIV testing. In this study, we evaluated the scale-up of the Healthy Beginning Initiative (HBI), a community-driven evidenced-based intervention to increase HIV testing among pregnant women and their male partners. Our objectives were to determine the: (1) male partner participation rate; (2) prevalence of HIV among male partners of pregnant women; (3) factors associated with HIV positivity among male partners of HIV-positive pregnant women.

METHODS

We reviewed program data of expectant parents enrolled in HBI in Benue State, north-central Nigeria. During HBI, trained lay health workers provided educational and counseling sessions, and offered free onsite integrated testing for HIV, hepatitis B virus and sickle cell genotype to pregnant women and their male partners who participated in incentivized, church-organized baby showers. Each participant completed an interviewer-administered questionnaire on demographics, lifestyle habits, and HIV testing history. Chi-square test was used to compare the characteristics of HIV-positive and HIV-negative male partners. Simple and multivariable logistic regression models were used to determine the association between participants' characteristics and HIV positivity among male partners of HIV-positive women.

RESULTS

Male partner participation rate was 57% (5264/9231). Overall HIV prevalence was 6.1% (891/14495) with significantly higher rates in women (7.4%, 681/9231) compared to men (4.0%, 210/5264). Among the 681 HIV-positive women, 289 male partners received HIV testing; 37.7% (109/289) were found to be HIV-positive. In multivariate analysis, older age (adjusted odds ratio [aOR]: 2.45, 95% confidence interval [CI]: 1.27-4.72 for age 30-39 years vs. <30 years; aOR: 2.39, CI: 1.18-4.82 for age ≥40 years vs. <30 years) and self-reported daily alcohol intake (vs. never (aOR: 0.35, CI: 0.13-0.96)) were associated with HIV positivity in male partners of HIV-positive women.

CONCLUSION

The community-based congregational approach is a potential strategy to increase male partner HIV testing towards achieving the UNAIDS goal of 90% HIV screening. Targeting male partners of HIV-positive women for screening may provide a higher yield of HIV diagnosis and the opportunity to engage known positives in care in this population.

HIV self-testing: South African young adults' recommendations for ease of use, test kit contents, accessibility, and supportive resources

BACKGROUND

The uptake of HIV self-testing (HIVST) could address socio-structural barriers that prevent South African youth from utilizing the testing resources available in their communities. However, to facilitate this, we must tailor components of the HIVST kit and process to ensure that we reach and encourage youth to test. The purpose of this study to elucidate concerns and issues regarding HIVST rollout among South African youth.

METHODS

This study was conducted in two phases: 1) focus group discussions with rural, South African youth aged 18-24 and 2) direct observations of participants completing with an oral HIVST kit and/or a blood based HIVST kit. In phase 2a participants were invited to try both an oral and blood-based HIVST kit. In phase 2b, participants selected the HIVST kit of their choice.

RESULTS

We enrolled 35 unique participants in phase 1, 20 participants in phase 2a, and 40 participants in phase 2b. While the focus group discussions highlighted hypothetical HIVST use only, participants appreciated the privacy that the HIVST could afford them. However, they expressed concerns about whether HIVST could be trusted due to false positives and negatives, as well as whether a person would be able to emotionally handle the results if they tested alone. They suggested that the kits be used alongside someone who could provide support. In phases 2a and 2b, participants were overwhelmingly positive about both kits regarding ease of use and whether their results could be trusted. The participants, however, experienced more challenges with the blood-based versus oral test. When given the choice in phase 2b, most participants (80%) chose the oral HIVST over the blood-based HIVST.

CONCLUSIONS

During the focus group discussions, participants raised concerns about the validity of HIVST, lack of emotional support when testing alone, and the cost of HIVST kits, all of which could be addressed through current testing campaigns. Most of those who actually tested had positive experiences with HIVST and would recommend it to their friends. When offered a choice, most preferred the oral test.

TRIAL REGISTRATION

NCT03162965 , registered 19th May 2017.

External quality assessment for HIV rapid tests: challenges and opportunities in Haiti

HIV rapid diagnostic tests (RDTs) are instrumental in scaling-up HIV testing services (HTS) in low-income and middle-income countries (LMICs). HIV misdiagnosis is a growing concern in the era of expanded and decentralised access to HTS. External quality assurance (EQA) programme including proficiency testing (PT) for HIV RDTs is a priority to guarantee the accuracy and reliability of the patients’ result. Here we are sharing Haiti’s 11 years’ experience in implementing HIV RDTs EQA programme to help address some of the challenges faced by other LMICs. HTS is expanding beyond laboratory walls and HIV RDTs are increasingly performed by non-laboratory personnel and closer to the community. EQA programmes for HIV RDTs in Haiti have faced significant challenges. In expanded HTS settings, non-laboratory personnel (nurses, aid-nurses) involved in HIV RDT are usually undertrained and participate poorly in PT programs. In more than half of the lab enrolled in the PT programme in Haiti, the panels are always tested by the most experienced technician, defying the purpose of the program which is to evaluate the performance of the technician performing the test daily. EQA programme in Haiti and other LMICs are usually not tailored to address community HIV testing challenges. With decreased funding and absence of government financial commitment to HIV RDTs EQA programmes, more innovative and cost-efficient strategies are sought to ensure the quality of HIV diagnosis in LMICs. Qualified human resources, continuous training, supervision and community-tailored PT programmes remain key components for the success of HIV RDT quality management.

Impact of a "Diagonal" Intervention on Uptake of Sexual and Reproductive Health Services by Female Sex Workers in Mozambique: A Mixed-Methods Implementation Study

Background

Female sex workers (FSWs) have high risks for adverse sexual and reproductive health (SRH) outcomes, yet low access to services. Within an implementation research project enhancing uptake of SRH services by FSWs, we piloted a “diagonal” intervention, which combined strengthening of FSW-targeted services (vertical) with making public health facilities more FSW-friendly (horizontal), and tested its effect.

Methods

The study applied a convergent parallel mixed-methods design to assess changes in access to SRH services. Results of structured interviews with FSWs pre-intervention (N = 311) and thereafter (N = 404) were compared with the findings of eight post-intervention focus group discussions (FGDs) with FSWs and two with FSW-peer educators (PEs).

Results

Marked and statistically significant rises occurred in consistent condom use with all partners (55.3–67.7%), ever use of female condoms (37.9–54.5%), being tested for HIV in the past 6 months (56.0–76.6%), using contraception (84.5–95.4%), ever screened for cervical cancer (0.0–16.9%) and having ≥10 contacts with a PE in the past year (0.5–24.45%). Increases mostly resulted from FSW-targeted outreach, with no rise detected in utilization of public health facilities. FGD participants reported that some facilities had become more FSW-friendly, but barriers such as stock-outs, being asked for bribes and disrespectful treatment persisted.

Conclusion

The combination of expanding FSW-targeted SRH services with improving access to the public health services resulted in an overall increased uptake of services, but almost exclusively because of the strengthened targeted (vertical) outreach services. Utilization of public SRH services had not yet increased and many barriers to access remained. Our diagonal approach was thus only successful in its vertical component. Improving access to the general health services remains nevertheless important and further research is needed how to reduce barriers. Ideally, the combination approach should be maintained and more successful approaches to increase utilization of public services should be explored.

Access to antiretroviral therapy in HIV-infected children aged 0-19 years in the International Epidemiology Databases to Evaluate AIDS (IeDEA) Global Cohort Consortium, 2004-2015: A prospective cohort study

INTRODUCTION

Access to antiretroviral therapy (ART) is a global priority. However, the attrition across the continuum of care for HIV-infected children between their HIV diagnosis and ART initiation is not well known. We analyzed the time from enrollment into HIV care to ART initiation in HIV-infected children within the International Epidemiology Databases to Evaluate AIDS (IeDEA) Global Cohort Consortium.

METHODS AND FINDINGS

We included 135,479 HIV-1-infected children, aged 0-19 years and ART-naïve at enrollment, between 1 January 2004 and 31 December 2015, in IeDEA cohorts from Central Africa (3 countries; n = 4,948), East Africa (3 countries; n = 22,827), West Africa (7 countries; n = 7,372), Southern Africa (6 countries; n = 93,799), Asia-Pacific (6 countries; n = 4,045), and Latin America (7 countries; n = 2,488). Follow-up in these cohorts is typically every 3-6 months. We described time to ART initiation and missed opportunities (death or loss to follow-up [LTFU]: last clinical visit >6 months) since baseline (the date of HIV diagnosis or, if unavailable, date of enrollment). Cumulative incidence functions (CIFs) for and determinants of ART initiation were computed, with death and LTFU as competing risks. Among the 135,479 children included, 99,404 (73.4%) initiated ART, 1.9% died, 1.4% were transferred out, and 20.4% were lost to follow-up before ART initiation. The 24-month CIF for ART initiation was 68.2% (95% CI: 67.9%-68.4%); it was lower in sub-Saharan Africa-ranging from 49.8% (95% CI: 48.4%-51.2%) in Central Africa to 72.5% (95% CI: 71.5%-73.5%) in West Africa-compared to Latin America (71.0%, 95% CI: 69.1%-72.7%) and the Asia-Pacific (78.3%, 95% CI: 76.9%-79.6%). Adolescents aged 15-19 years and infants <1 year had the lowest cumulative incidence of ART initiation compared to other ages: 62.2% (95% CI: 61.6%-62.8%) and 66.4% (95% CI: 65.7%-67.0%), respectively. Overall, 49.1% were ART-eligible per local guidelines at baseline, of whom 80.6% initiated ART. The following children had lower cumulative incidence of ART initiation: female children (p < 0.01); those aged <1 year, 2-4 years, 5-9 years, and 15-19 years (versus those aged 10-14 years, p < 0.01); those who became eligible during follow-up (versus eligible at enrollment, p < 0.01); and those receiving care in low-income or lower-middle-income countries (p < 0.01). The main limitations of our study include left truncation and survivor bias, caused by deaths of children prior to enrollment, and use of enrollment date as a proxy for missing data on date of HIV diagnosis, which could have led to underestimation of the time between HIV diagnosis and ART initiation.

CONCLUSIONS

In this study, 68% of HIV-infected children initiated ART by 24 months. However, there was a substantial risk of LTFU before ART initiation, which may also represent undocumented mortality. In 2015, many obstacles to ART initiation remained, with substantial inequities. More effective and targeted interventions to improve access are needed to reach the target of treating 90% of HIV-infected children with ART.

Age-Related Differences in Socio-demographic and Behavioral Determinants of HIV Testing and Counseling in HPTN 043/NIMH Project Accept

Youth represent a large proportion of new HIV infections worldwide, yet their utilization of HIV testing and counseling (HTC) remains low. Using the post-intervention, cross-sectional, population-based household survey done in 2011 as part of HPTN 043/NIMH Project Accept, a cluster-randomized trial of community mobilization and mobile HTC in South Africa (Soweto and KwaZulu Natal), Zimbabwe, Tanzania and Thailand, we evaluated age-related differences among socio-demographic and behavioral determinants of HTC in study participants by study arm, site, and gender. A multivariate logistic regression model was developed using complete individual data from 13,755 participants with recent HIV testing (prior 12 months) as the outcome. Youth (18-24 years) was not predictive of recent HTC, except for high-risk youth with multiple concurrent partners, who were less likely (aOR 0.75; 95% CI 0.61-0.92) to have recently been tested than youth reporting a single partner. Importantly, the intervention was successful in reaching men with site specific success ranging from aOR 1.27 (95% CI 1.05-1.53) in South Africa to aOR 2.30 in Thailand (95% CI 1.85-2.84). Finally, across a diverse range of settings, higher education (aOR 1.67; 95% CI 1.42, 1.96), higher socio-economic status (aOR 1.21; 95% CI 1.08-1.36), and marriage (aOR 1.55; 95% CI 1.37-1.75) were all predictive of recent HTC, which did not significantly vary across study arm, site, gender or age category (18-24 vs. 25-32 years).

Actual Versus Perceived HIV Testing Norms, and Personal HIV Testing Uptake: A Cross-Sectional, Population-Based Study in Rural Uganda

HIV testing is an essential part of treatment and prevention. Using population-based data from 1664 adults across eight villages in rural Uganda, we assessed individuals' perception of the norm for HIV testing uptake in their village and compared it to the actual uptake norm. In addition, we examined how perception of the norm was associated with personal testing while adjusting for other factors. Although the majority of people had been tested for HIV across all villages, slightly more than half of men and women erroneously thought that the majority in their village had never been tested. They underestimated the prevalence of HIV testing uptake by 42 percentage points (s.d. = 17 percentage points), on average. Among men, perceiving that HIV testing was not normative was associated with never testing for HIV (AOR = 2.6; 95% CI 1.7-4.0, p < 0.001). Results suggest an opportunity for interventions to emphasize the commonness of HIV testing uptake.

Understanding low sensitivity of community-based HIV rapid testing: experiences from the HPTN 071 (PopART) trial in Zambia and South Africa

Introduction: Population-wide HIV testing services (HTS) must be delivered in order to achieve universal antiretroviral treatment (ART) coverage. To accurately deliver HTS at such scale, non-facility-based HIV point-of-care testing (HIV-POCT) is necessary but requires rigorous quality assurance (QA). This study assessed the performance of community-wide HTS in Zambia and South Africa (SA) as part of the HPTN 071 (PopART) study and explores the impact of quality improvement interventions on HTS performance.

Methods: Between 2014 and 2016, HIV-POCT was undertaken within households both as part of the randomly selected HPTN 071 research cohort (Population Cohort [PC]) and as part of the intervention provided by community HIV-care providers. HIV-POCT followed national algorithms in both countries. Consenting PC participants provided a venous blood sample in addition to being offered HIV-POCT. We compared results obtained in the PC using a laboratory-based gold standard (GS) testing algorithm and HIV-POCT. Comprehensive QA mechanisms were put in place to support the community-wide testing. Participants who were identified as having a false negative or false positive HIV rapid test were revisited and offered retesting.

Results: We initially observed poor sensitivity (45–54%, 95% confidence interval [CI] 31–69) of HIV-POCT in the PC in SA compared to sensitivity in Zambia for the same time period of 95.8% (95% CI 93–98). In both countries, specificity of HIV-POCT was >98%. With enhanced QA interventions and adoption of the same HIV-POCT algorithm, sensitivity in SA improved to a similar level as in Zambia.

Conclusions: This is one of the first reports of HIV-POCT performance during wide-scale delivery of HTS compared to a GS laboratory algorithm. HIV-POCT in a real-world setting had a lower sensitivity than anticipated. Appropriate choice of HIV-POCT algorithms, intensive training and supervision, and robust QA mechanisms are necessary to optimize HIV-POCT test performance when testing is delivered at a community level. HIV-POCT in clients who did not disclose that they were on ART may have contributed to false negative HIV-POCT results and should be the topic of future research.