Implementation of community and facility-based HIV self-testing under routine conditions in southern Eswatini

Men's perceptions of HIV self-testing in Eswatini: a qualitative study

Men in Eswatini test for HIV at lower rates compared to women despite the widespread availability of HIV testing services in the country. HIV self-test kits have been proposed as an HIV testing model to reach more men by bypassing the health facility, which is known to be a barrier for men using HIV testing services. In this study, we sought to understand men's perspectives on HIV self-testing in Eswatini. We conducted semi-structured interviews with 22 men, recruited from a rural community and from an urban men's clinic, to assess their awareness of HIV self-testing and their perceptions of it as an alternative HIV testing option. Findings show that men were aware of HIV self-testing but had concerns that left most feeling hesitant about adopting it. Many men expressed doubts about the accuracy of self-testing and their own technical competence to use the kit without supervision. They also expressed fears about testing, and possibly learning they were HIV positive, without adequate pre - and post-HIV test counseling. To allay men's fears and improve uptake of HIV self-testing, practitioners might consider innovative methods such as virtual counseling services and linking HIV self-testing to other community-based HIV care services.

A typology of HIV self-testing support systems: a scoping review

To maximise the benefits of HIV self-testing (HIVST), it is critical to support self-testers in the testing process and ensure that they access appropriate prevention and care. To summarise systems and tools supporting HIVST (hereafter, 'support systems') and categorise them for future analysis, we synthesised the global data on HIVST support systems and proposed a typology. We searched five databases for articles reporting on one or more HIVST support systems and included 314 publications from 224 studies. Across 189 studies, there were 539 reports of systems supporting HIVST use; while across 115 studies, there were 171 reports of systems supporting result interpretation. Most commonly, these were pictorial instructions, followed by in-person demonstrations and in-person assistance while self-testing or reading self-test results. Less commonly, virtual interventions were also identified, including online video conferencing and smartphone apps. Smartphone-based automated result readers have been used in the USA, China, and South Africa. Across 173 studies, there were 987 reports of systems supporting post-test linkage to care; most commonly, these were in-person referrals/counselling, written referrals, and phone helplines. In the USA, Bluetooth beacons have been trialled to monitor self-test use and facilitate follow-up. We found that, globally, HIVST support systems use a range of methods, including static media, virtual tools, and in-person engagement. In-person and printed approaches were more common than virtual tools. Other considerations, such as linguistic and cultural appropriateness, may also be important in the development of effective HIVST programs.

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

BACKGROUND

This study evaluates the implementation and running costs of an HIV self-testing (HIVST) distribution program in Eswatini. HIVST kits were delivered through community-based and workplace models using primary and secondary distribution. Primary clients could self-test onsite or offsite. This study presents total running economic costs of kit distribution per model between April 2019 and March 2020, and estimates average cost per HIVST kit distributed, per client self-tested, per client self-tested reactive, per client confirmed positive, and per client initiating antiretroviral therapy (ART).

METHODS

Distribution data and follow-up phone interviews were analysed to estimate implementation outcomes. Results were presented for each step of the care cascade using best-case and worst-case scenarios. A top-down incremental cost-analysis was conducted from the provider perspective using project expenditures. Sensitivity and scenario analyses explored effects of economic and epidemiological parameters on average costs.

RESULTS

Nineteen thousand one hundred fifty-five HIVST kits were distributed to 13,031 individuals over a 12-month period, averaging 1.5 kits per recipient. 83% and 17% of kits were distributed via the community and workplace models, respectively. Clients reached via the workplace model were less likely to opt for onsite testing than clients in the community model (8% vs 29%). 6% of onsite workplace testers tested reactive compared to 2% of onsite community testers. Best-case scenario estimated 17,458 (91%) clients self-tested, 633 (4%) received reactive-test results, 606 (96%) linked to confirmatory testing, and 505 (83%) initiated ART. Personnel and HIVST kits represented 60% and 32% of total costs, respectively. Average costs were: per kit distributed US$17.23, per client tested US$18.91, per client with a reactive test US$521.54, per client confirmed positive US$550.83, and per client initiating ART US$708.60. Lower rates for testing, reactivity, and linkage to care in the worst-case scenario resulted in higher average costs along the treatment cascade.

CONCLUSION

This study fills a significant evidence gap regarding costs of HIVST provision along the client care cascade in Eswatini. Workplace and community-based distribution of HIVST accompanied with effective linkage to care strategies can support countries to reach cascade objectives.

Advances in HIV self-testing: Systematic review of current developments and the road ahead in high-burden countries of Africa

Objectives

Although HIV self-testing technologies have created new opportunities for achieving national and global HIV testing goals, current developments have not been compiled to inform policy and practice, especially in high HIV burden countries of Africa. We aimed to compile and synthesize the evidence about HIV self-testing technologies, strategies, and uptake in the top-10 high HIV burden countries of Africa.

Methods

We searched CINAHL, PubMed, Web of Science, PsycINFO, Social Science Citation Index, and EMBASE to include eligible articles published in English between January 2012 and November 2022.

Results

In total, 865 articles were retrieved and only 16 studies conducted in five African countries were eligible and included in this review. The two types of HIV self-testing modalities presently being used in Africa are: The first is Home Self-Test which is done entirely at home or in another private location by using oral fluid or blood specimen. The second modality is Mail-In Self-Test (self-sampling), where the user collects their own sample and sends this to a laboratory for testing. Perceived opportunities for the uptake of HIV self-testing were autonomy and self-empowerment, privacy, suitability, creating a chance to test, and simplicity of use. The potential barriers to HIV self-testing included fear and worry of a positive test result, concern of the test results is not reliable, low literacy, and potential psychological and social harms. The oral-fluid self-testing is preferred by most users because it is easy to use, less invasive, and painless. The difficulty of instructions on how to use self-test kits, and the presence of different products of HIV self-testing kits, increase rates of user errors.

Conclusion

Adopting HIV self-testing by overcoming the challenging potential barriers could enable early detection, care, treatment, and prevention of the disease to achieve the 95-95-95 goal by 2030. Further study is necessary to explore the actual practices related to HIV self-testing among different populations in Africa.

A Cross-Sectional Assessment of HIV Self-Testing Preferences and Uptake Among Key Populations in Phnom Penh, Cambodia

Offering HIV self-testing services to key populations in Cambodia expanded HIV testing access to a large proportion of individuals with no prior testing history and resulted in high rates of new HIV case detection and subsequent linkages to HIV treatment.

Background:

HIV self-testing (HIVST) is recommended by the World Health Organization, but implementation remains limited. This cross-sectional study evaluated HIVST uptake among female entertainment workers (EWs), men who have sex with men (MSM), and transgender women in Phnom Penh, Cambodia, to inform national implementation.

Methods:

Between December 2018 and September 2019, individuals reached through community outreach or via online advertising were offered HIVST or referrals to facility-based testing. Participants opting for HIVST could choose between test kits employing oral-fluid or finger-prick-based sample collection; and between an “assisted” option in which outreach staff offered instructions and assistance and an “unassisted” option in which participants received a kit with instructions for use. A structured questionnaire was administered to facilitate descriptive statistics and tests for associations between participant characteristics and HIV testing preferences and outcomes.

Results:

Among 1,241 eligible individuals; 1,210 (97.5%) provided responses for analysis. Of these, 1,203 (99.4%) were recruited through outreach; 7 (0.6%) through online advertising. Among those recruited by outreach, 1,186 (98.6%) opted for assisted HIVST, and 1,065 (88.5%) opted for oral-fluid versus finger-prick testing. All individuals recruited through online advertisements opted for unassisted oral-fluid testing. Among all participants, 455 (37.6%) were MSM, 325 (26.9%) were transgender women, 430 (35.5%) were female EWs, and overall, 71.7% reported never previously testing for HIV. A total of 84 participants (6.9%) received reactive screening results and 81 (97.5%) were linked to treatment.

Conclusion:

Uptake of HIVST was high, and most participants preferred oral-fluid over finger-prick-based testing. Many individuals (72%) who had never previously accessed HIV testing services participated in HIVST, with high rates of reactivity.

Law, human rights and gender in practice: an analysis of lessons from implementation of self-care interventions for sexual and reproductive health

Self-care interventions for health are becoming increasingly available, and among the preferred options, including during the COVID-19 pandemic. This research assessed the extent of attention to laws and policies, human rights and gender in the implementation of self-care interventions for sexual and reproductive health (SRH), to identify where additional efforts to ensure an enabling environment for their use and uptake will be useful. A literature review of relevant studies published between 2010 and 2020 was conducted using PubMed, Scopus and Web of Science. Relevant data were systematically abstracted from 61 articles. In March–April 2021, semi-structured interviews were conducted with 10 key informants, selected for their experience implementing self-care interventions for SRH, and thematically analysed. Laws and policies, rights and gender are not being systematically addressed in the implementation of self-care interventions for SRH. Within countries, there is varied attention to the enabling environment including the acceptability of interventions, privacy, informed consent and gender concerns as they impact both access and use of specific self-care interventions, while other legal considerations appear to have been under-prioritised. Operational guidance is needed to develop and implement supportive laws and policies, as well as to ensure the incorporation of rights and gender concerns in implementing self-care interventions for SRH.

Implementation outcomes of HIV self-testing in low- and middle- income countries: A scoping review

INTRODUCTION

HIV self-testing (HIV-ST) is an effective means of improving HIV testing rates. Low- and middle-income countries (LMIC) are taking steps to include HIV-ST into their national HIV/AIDS programs but very few reviews have focused on implementation in LMIC. We performed a scoping review to describe and synthesize existing literature on implementation outcomes of HIV-ST in LMIC.

METHODS

We conducted a systematic search of Medline, Embase, Global Health, Web of Science, and Scopus, supplemented by searches in HIVST.org and other grey literature databases (done 23 September 2020) and included articles if they reported at least one of the following eight implementation outcomes: acceptability, appropriateness, adoption, feasibility, fidelity, cost, penetration, or sustainability. Both quantitative and qualitative results were extracted and synthesized in a narrative manner.

RESULTS AND DISCUSSION

Most (75%) of the 206 included articles focused on implementation in Africa. HIV-ST was found to be acceptable and appropriate, perceived to be convenient and better at maintaining confidentiality than standard testing. The lack of counselling and linkage to care, however, was concerning to stakeholders. Peer and online distribution were found to be effective in improving adoption. The high occurrence of user errors was a common feasibility issue reported by studies, although, diagnostic accuracy remained high. HIV-ST was associated with higher program costs but can still be cost-effective if kit prices remain low and HIV detection improves. Implementation fidelity was not always reported and there were very few studies on, penetration, and sustainability.

CONCLUSIONS

Evidence supports the acceptability, appropriateness, and feasibility of HIV-ST in the LMIC context. Costs and user error rates are threats to successful implementation. Future research should address equity through measuring penetration and potential barriers to sustainability including distribution, cost, scale-up, and safety.