Supervised blood-based self-sample collection and rapid test performance: a valuable alternative to the use of saliva by HIV testing programmes with no medical or nursing staff

HIV self-test performance evaluation among priority populations in rural Mozambique: Results from a community-based observational study

BACKGROUND

In 2021, Mozambique initiated community-based oral HIV self-testing (HIVST) to increase testing access and uptake among priority groups, including adult males, adolescents, and young adults. Within an HIVST pilot project, we conducted a performance evaluation assessing participants' ability to successfully conduct HIVST procedures and interpret results.

METHODS

A cross-sectional study was performed between February-March 2021 among employees, students (18-24 years of age), and community members, using convenience sampling, in two rural districts of Zambézia Province, Mozambique. We quantified how well untrained users performed procedures for the oral HIVST (Oraquick®) through direct observation using a structured checklist, from which we calculated an HIVST usability index (scores ranging 0-100%). Additionally, participants interpreted three previously processed anonymous HIVST results. False reactive and false non-reactive interpretation results were presented as proportions. Bivariate analysis was conducted using Chi-square and Fisher exact tests.

RESULTS

A total of 312 persons participated (131[42%] community members, 71[23%] students, 110[35%] employees); 239 (77%) were male; the mean age was 28 years (standard deviation 10). Average usability index scores were 80% among employees, 86% among students, and 77% among community members. Main procedural errors observed included "incorrect tube positioning" (49%), "incorrect specimen collection" (43%), and "improper waiting time for result interpretation" (42%). From the presented anonymous HIVST results, 75% (n = 234) correctly interpreted all three results, while 9 (3%) of study participants failed to correctly interpret any results. Overall, 36 (12%) gave a false non-reactive result interpretation, 21 (7%) a false reactive result interpretation, and 14 (4%) gave both false non-reactive and false reactive result interpretations. Community members generally had lower performance.

CONCLUSIONS

Despite some observed testing procedural errors, most users could successfully perform an HIVST. Educational sessions at strategic places (e.g., schools, workplaces), and support via social media and hotlines, may improve HIVST performance quality, reducing the risk of incorrect interpretation.

Implementing community-based Dried Blood Spot (DBS) testing for HIV and hepatitis C: a qualitative analysis of key facilitators and ongoing challenges

Background

In 2018, the Community-Based Research Centre (CBRC) invited gay, bisexual, trans, queer men and Two-Spirit and non-binary people (GBT2Q) at Pride Festivals across Canada to complete in-person Sex Now surveys and provide optional dried blood spot (DBS) samples screening for human immunodeficiency virus (HIV) and hepatitis C virus (HCV). As there is a lack of research evaluating the implementation of DBS sampling for GBT2Q in community settings, we aimed to evaluate this intervention, identifying key facilitators and ongoing challenges to implementing community-based DBS screening for HIV/HCV among GBT2Q.

Methods

We conducted sixteen one-on-one interviews with individuals involved with the community-based DBS collection protocol, including research staff, site coordinators, and volunteer DBS collectors. Most individuals involved with DBS collection were “peers” (GBT2Q-identified). The Consolidated Framework for Implementation Research (CFIR) guided our data collection and analysis.

Results

Interviewees felt that DBS collection was a low-barrier, cost-effective, and simple way for peers to quickly screen a large number of Sex Now respondents. Interviewees also noted that the community and peer-based aspects of the research helped drive recruitment of Sex Now respondents. Most interviewees felt that the provision of results took too long, and that some Sex Now respondents would have preferred to receive their test results immediately (e.g., rapid or point-of-care testing).

Conclusion

Peer-based DBS sampling can be an effective and relatively simple way to screen GBT2Q at Pride Festivals for more than one sexually transmitted and blood borne infection.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13525-x.

Process evaluation of peer-to-peer delivery of HIV self-testing and sexual health information to support HIV prevention among youth in rural KwaZulu-Natal, South Africa: qualitative analysis

OBJECTIVE

Peer-to-peer (PTP) HIV self-testing (HIVST) distribution models can increase uptake of HIV testing and potentially create demand for HIV treatment and pre-exposure prophylaxis (PrEP). We describe the acceptability and experiences of young women and men participating in a cluster randomised trial of PTP HIVST distribution and antiretroviral/PrEP promotion in rural KwaZulu-Natal.

METHODS

Between March and September 2019, 24 pairs of trained peer navigators were randomised to two approaches to distribute HIVST packs (kits+HIV prevention information): incentivised-peer-networks where peer-age friends distributed packs within their social network for a small incentive, or direct distribution where peer navigators distributed HIVST packs directly. Standard-of-care peer navigators distributed information without HIVST kits. For the process evaluation, we conducted semi-structured interviews with purposively sampled young women (n=30) and men (n=15) aged 18-29 years from all arms. Qualitative data were transcribed, translated, coded manually and thematically analysed using an interpretivist approach.

RESULTS

Overall, PTP approaches were acceptable and valued by young people. Participants were comfortable sharing sexual health issues they would not share with adults. Coupled with HIVST, peer (friends) support facilitated HIV testing and solidarity for HIV status disclosure and treatment. However, some young people showed limited interest in other sexual health information provided. Some young people were wary of receiving health information from friends perceived as non-professionals while others avoided sharing personal issues with peer navigators from their community. Referral slips and youth-friendly clinics were facilitators to PrEP uptake. Family disapproval, limited information, daily pills and perceived risks were major barriers to PrEP uptake.

CONCLUSION

Both professional (peer navigators) and social network (friends) approaches were acceptable methods to receive HIVST and sexual health information. Doubts about the professionalism of friends and overly exclusive focus on HIVST information materials may in part explain why HIVST kits, without peer navigators support, did not create demand for PrEP.

Willingness to Participate in At-Home HIV Testing Among Young Adults Who Use Opioids in Rural Appalachia

New HIV infections associated with injection drug use are of major concern in rural US communities. This study explores acceptability of, consent for, and uptake of free at-home HIV testing among people who use drugs (PWUD) in one of the nation’s epicenters for drug-related harms and HIV vulnerability: Rural Central Appalachia. Eligible participants were 18–35 years old, lived in Appalachian Kentucky, and reported using opioids to get high in the previous 30 days. A majority reported being likely (63.6%, 96/151) to take a free at-home HIV tests and 66.9% (101/151) consented to receive one. Among those who were randomly selected to receive a Home Access HIV-1 test kit (n = 37), 37.8% mailed in blood spots and 21.6% called to receive results. This study provides evidence that PWUD may be willing to take an at-home test, but other barriers may inhibit actual completion.

SMARTtest: A Smartphone App to Facilitate HIV and Syphilis Self- and Partner-Testing, Interpretation of Results, and Linkage to Care

Acceptability of rapid HIV self-testing is high but potential users remain concerned about correct use, interpretation of test results, and linkage to care. This article describes user preferences for a smartphone app to mitigate these challenges and how these were integrated into the SMARTtest app to support self- and partner-testing using the INSTI Multiplex^®. Sixty men and transgender women who have sex with men self-tested for HIV and syphilis while guided by a prototype app that provided a video, pictorial step-by-step instructions, and sample test results presented textually ("positive," "negative"). Subsequently, participants provided feedback on revisions and additional app content. Participants recommended offering different user modes (self, partner, both), and retaining the video, step-by-step instructions, and textual test results. They strongly favored the ability to save and send test results to sexual partners or providers. These features were integrated into the SMARTtest app to facilitate HIV/syphilis self- and partner-testing, HIV/syphilis status awareness and disclosure, and linkage to care.

HIV testing strategies outside of health care settings in the European Union (EU)/European Economic Area (EEA): a systematic review to inform European Centre for Disease Prevention and Control guidance

OBJECTIVES

In recent years, new technologies and new approaches to scale up HIV testing have emerged. The objective of this paper was to synthesize the body of recent evidence on strategies aimed at increasing the uptake and coverage of HIV testing outside of health care settings in the European Union (EU)/European Economic Area (EEA).

METHODS

Systematic searches to identify studies describing effective HIV testing interventions and barriers to testing were run in five databases (2010-2017) with no language restrictions; the grey literature was searched for similar unpublished studies (2014-2017). Study selection, data extraction and critical appraisal were performed by two independent reviewers following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Eighty studies on HIV testing in non-health care settings were identified, the majority set in Northern Europe. Testing was implemented in 65 studies, with men who have sex with men the risk group most often targeted. Testing coverage and positivity/reactivity rates varied widely by setting and population group. However, testing in community and outreach settings was effective at reaching people who had never previously been tested and acceptability of HIV testing, particularly rapid testing, outside of health care settings was found to be high. Other interventions aimed to increase HIV testing identified were: campaigns (n = 8), communication technologies (n = 2), education (n = 3) and community networking (n = 1).

CONCLUSIONS

This review has identified several strategies with potential to achieve high HIV testing coverage outside of health care settings. However, the geographical spread of studies was limited, and few intervention studies reported before and after data, making it difficult to evaluate the impact of interventions on test coverage.

Cluster randomised controlled trial to determine the effect of peer delivery HIV self-testing to support linkage to HIV prevention among young women in rural KwaZulu-Natal, South Africa: a study protocol

INTRODUCTION

A cluster randomised controlled trial (cRCT) to determine whether HIV self-testing (HIVST) delivered by peers either directly or through incentivised peer-networks, could increase the uptake of antiretroviral therapy and pre-exposure prophylaxis (PrEP) among young women (18 to 24 years) is being undertaken in an HIV hyperendemic area in KwaZulu-Natal, South Africa.

METHODS AND ANALYSIS

A three-arm cRCT started mid-March 2019, in 24 areas in rural KwaZulu-Natal. Twenty-four pairs of peer navigators working with ~12 000 young people aged 18 to 30 years over a period of 6 months were randomised to: (1) incentivised-peer-networks: peer-navigators recruited participants 'seeds' to distribute up to five HIVST packs and HIV prevention information to peers within their social networks. Seeds receive an incentive (20 Rand = US$1.5) for each respondent who contacts a peer-navigator for additional HIVST packs to distribute; (2) peer-navigator-distribution: peer-navigators distribute HIVST packs and information directly to young people; (3) standard of care: peer-navigators distribute referral slips and information. All arms promote sexual health information and provide barcoded clinic referral slips to facilitate linkage to HIV testing, prevention and care services. The primary outcome is the difference in linkage rate between arms, defined as the number of women (18 to 24 years) per peer-navigators month of outreach work (/pnm) who linked to clinic-based PrEP eligibility screening or started antiretroviral, based on HIV-status, within 90 days of receiving the clinic referral slip.

ETHICS AND DISSEMINATION

This study was approved by the Institutional Review Boards at the WHO, Switzerland (Protocol ID: STAR CRT, South Africa), London School of Hygiene and Tropical Medicine, UK (Reference: 15 990-1), University of KwaZulu-Natal (BFC311/18) and the KwaZulu-Natal Department of Health (Reference: KZ_201901_012), South Africa. The findings of this trial will be disseminated at local, regional and international meetings and through peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT03751826; Pre-results.

Utility of oral fluid samples for hepatitis B antibody detection in real life conditions

BACKGROUND

Hepatitis B virus (HBV) testing in oral fluid samples may provide advantages in diagnosis, screening or prevalence studies, especially among individuals with venous access difficulties. This study aims to optimize one commercially available assay for detecting total anti-HBc marker in oral fluid samples and to evaluate its utility under real life conditions in different settings for the purposes of prevalence and diagnostic studies.

METHODS

Oral fluid was collected using a Salivette device and some parameters were initially evaluated: type of elution buffer and sample volume. Thereafter, the utility of oral fluid samples for detection of anti-HBc was evaluated in real life conditions in which, 1296 individuals gave serum and oral fluid samples. All serum samples were submitted to commercial EIAs to detect total anti-HBc, according to the manufacturer's instructions and oral fluid samples according to previous optimization.

RESULTS

In optimization evaluation, PBS/BSA 0.5% and 100 μL of oral fluid (volume was two-fold increased compared to serum in EIA) were chosen as transport buffer and sample volume. In the field study, anti-HBc was detected in 211 out of 1296 serum samples giving overall oral fluid sensitivity of 52.6% and specificity of 96%. Concordance was higher in ambulatory setting (67.7) compared to general population (31.8). Mean ± standard deviation values of optical density/cutoff (OD/CO) in serum samples were higher in false-negative oral fluid samples than those seen in true positive samples. Sensitivity was higher in those presenting active infection compared to anti-HBc isolate and past infection. Sensitivity also increased in the ambulatory group when HCV individuals were excluded.

CONCLUSIONS

It was possible to optimize a commercial EIA for detecting anti-HBc in oral fluid samples and where the highest concordance was found in ambulatory settings and among individuals with active infection.

Acceptability, feasibility, and individual preferences of blood-based HIV self-testing in a population-based sample of adolescents in Kisangani, Democratic Republic of the Congo

Background

Adolescents living in sub-Saharan Africa constitute a vulnerable population at significant risk of HIV infection. This study aims to evaluate the acceptability, feasibility, and accuracy of home-based, supervised HIV self-testing (HIVST) as well as their predictors among adolescents living in Kisangani, Democratic Republic of the Congo (DRC).

Methods

A cross-sectional, door-to-door survey using a blood-based HIV self-test and a peer-based supervised HIVST approach was conducted from July to August 2018 in Kisangani, DRC. The acceptability and feasibility of HIVST were assessed among adolescents’ consenting to use and interpret HIV self-test. The accuracy of HIVST was estimated by the sensibility and specificity of adolescent-interpreted HIV self-test. Factors associated with acceptability and feasibility of HIVST were analyzed with logistic regression.

Results

A total of 628 adolescents (including 369 [58.8%] females) aged between 15 and 19 years were enrolled. Acceptability of HIVST was high (95.1%); 96.1% of participants correctly used the self-test, and 65.2% asked for verbal instructions. The majority of adolescents (93.5%) correctly interpreted their self-test results. The Cohen’s κ coefficient between the results read by adolescents and by supervisors was 0.62. The correct interpretation decreased significantly when adolescents had no formal education or attended primary school as compared to those currently attending university (37.0% versus 100%; adjusted OR: 0.01 [95% CI: 0.004–0.03]). In the hands of adolescents at home, the sensitivity of the Exacto Test HIV Self-test was estimated at 100%, while its specificity was 96.0%. The majority of participants (68.0%) affirmed that post-test counseling was essential, and that face-to-face counseling (78.9%) was greatly preferred.

Conclusions

Home-based, supervised HIVST using a blood-based self-test and peer-based approach can be used with a high degree of acceptability and feasibility by adolescents living in Kisangani, DRC. Misinterpretation of test results is challenging to obtaining good feasibility of HIVST among adolescents with poor educational level. Face-to-face post-test counseling seems to be preferred among Kisangani’s adolescents.

Evaluation of the practicability and virological performance of finger-stick whole-blood HIV self-testing in French-speaking sub-Saharan Africa

BACKGROUND

Opportunities for HIV testing could be enhanced by offering HIV self-testing (HIVST) in populations that fear stigma and discrimination when accessing conventional HIV counselling and testing in health care facilities. Field experience with HIVST has not yet been reported in French-speaking African countries.

METHODS

The practicability of HIVST was assessed using the prototype the Exacto® Test HIV (Biosynex, Strasbourg, France) self-test in 322 adults living in Kisangani and Bunia, Democratic Republic of the Congo, according to World Health Organization's recommendations. Simplified and easy-to-read leaflet was translated in French, Lingala and Swahili.

RESULTS

Forty-nine percent of participants read the instructions for use in French, while 17.1% and 33.9% read the instructions in Lingala and Swahili, respectively. The instructions for use were correctly understood in 79.5% of cases. The majority (98.4%) correctly performed the HIV self-test; however, 20.8% asked for oral assistance. Most of the participants (95.3%) found that performing the self-test was easy, while 4.7% found it difficult. Overall, the results were correctly interpreted in 90.2% of cases. Among the positive, negative, and invalid self-tests, misinterpretation occurred in 6.5%, 11.2%, and 16.0% of cases, respectively (P<0.0001). The Cohen's κ coefficient was 0.84. The main obstacle for HIVST was educational level, with execution and interpretation difficulties occurring among poorly educated people. The Exacto® Test HIV self-test showed 100.0% (95% CI; 98.8-100.0) sensitivity and 99.2% (95% CI; 97.5-99.8) specificity.

CONCLUSIONS

Our field observations demonstrate: (i) the need to adapt the instructions for use to the Congolese general public, including adding educational pictograms as well as instructions for use in the local vernacular language(s); (ii) frequent difficulties understanding the instructions for use in addition to frequent misinterpretation of test results; and (iii) the generally good practicability of the HIV self-test despite some limitations. Supervised use of HIVST is recommended among poorly-educated people.

Acceptability and Usability Evaluation of Finger-Stick Whole Blood HIV Self-Test as An HIV Screening Tool Adapted to The General Public in The Central African Republic

Background:

Opportunities for HIV testing could be enhanced by offering HIV self-testing (HIVST) in populations that fear stigma and discrimination when accessing conventional HIV counselling and testing. Field experience with HIVST was poorly reported in French-speaking African countries.

Objective:

To investigate the usability of HIVST in Bangui, Central African Republic.

Methods:

The prototype self-test Exacto^® Test HIV (Biosynex, Strasbourg, France) was used to assess the usability of HIVST in 300 adults living in Bangui, according to WHO technical recommendations. Simplified and easy-to-read leaflet was translated in French and Sango.

Results:

Preliminary survey in 3,484 adult volunteers including students, men who have sex with men and female sex workers living in Bangui showed that previous HIV testing in conventional centres for HIV counselling and testing was relatively infrequent and that acceptability of HIVST was elevated, although high heterogeneity could be observed between groups. The notice in French and Sango of Exacto^® Test HIV were chosen in 242/300 (80.6%) and 58/300 (19.4%), respectively. It was correctly understood in 273/300 (91.0%). The majority (275/300; 91.6%) correctly performed the HIV self-test; however, 71/300 (23.0%) asked for oral assistance. Most of the participants (273/300; 91.0%) found that performing of the self-test was very easy or easy, and less than Most of participants (273/300; 91.0%) found that performing of the self-test was very easy or easy and less than 1.0% (2/300) found it difficult. Overall the result were correctly interpreted in 96.9% (3,782/3,900), the reading/interpretion errors concerned the positive (96/1,800;5.3%), invalid (17/600;2.8%) and negative (5/1,500; 0.3%) self-test. The Cohen's coefficient κwas 0.94. The main obstacle for HIVST was the educational level, with interpretation difficulties in poorly educated people.

Conclusions:

Our observations on profane adults living in Central African Republic, demonstrate: (i) the need to adapt the notice of instruction to African public, including educational pictograms as well as notice in vernacular language(s); (ii) the frequent difficulties in understanding the notice with frequent misinterpretation of test results; (iii) and the generally good usability of the HIV self-test despite these latter pitfalls. More research on exploring the best strategy (i.e. supervised versus unsupervised strategies) for different high- and low- risk populations in resource-constrained settings remains needed.

High acceptability of rapid HIV self-testing among a diverse sample of MSM from Buenos Aires, Argentina

INTRODUCTION

The objective of this study was to explore the acceptability of rapid HIV self-testing (RHST) among men who have sex with men (MSM).

METHODS

During 2006-2009, a sample of 500 MSM was recruited through Respondent Driven Sampling for an HIV prevalence/incidence study. Attitude toward RHST was explored among HIV negative MSM. Data were weighted prior to analyses.

RESULTS

Participants reported they were likely to buy RHST (74%), test themselves more frequently than they currently do (77%), and that the procedure would simplify testing (70%). Furthermore, 71% reported they would probably use it alone, 66% would use it with a steady partner, and 56% with a friend/partner. While a majority acknowledged that RHST use would deprive them of receiving counseling (61%), 74% declared they would go for help if they tested positive; 57% would use an RHST in order to avoid condoms. Probability of use surpassed 70% among gay and non-gay identified MSM as well as those with and without a previous HIV test. Those likely to buy RHST were older (p = 0.025) and more likely to identify as gay (p = 0.036). A total of 17% said they would think about killing themselves and 9% would attempt suicide if they tested positive. These MSM were more likely to be younger (p<0.001), with lower mood level (p<0.001) and greater feelings of loneliness (p = 0.026).

CONCLUSIONS

The high acceptability of RHST found among MSM should encourage the authorities to consider the possibility of offering it for self-testing, as it can improve early diagnosis and prevention of future transmissions. However, further research is needed to understand how to best disseminate RHST among MSM who wish to use it and to offer support and linkage to care for those who test HIV-positive.

A prospective multicentre study of healthcare provider preference in rapid HIV testing kits: Determine versus INSTI

Rapid HIV testing may circumvent the practical barriers to HIV testing in several settings. User preference of the testing kits available has been relatively underexplored. We examined healthcare provider (HCP) ratings of two validated rapid testing kits in clinical practice. From 1 July to 1 December 2012 we prospectively recruited HCPs (clinic nurses) from three outpatient clinics linked to Lausanne University Hospital, Lausanne, Switzerland. The HCPs had experience in taking blood samples but varying experience in rapid HIV testing. Participating HCPs performed rapid HIV testing using Determine™ Combo (DETE) or INSTI™ (INSTI), according to a predefined randomization sequence, and rated practical aspects of each test using a Likert scale. Seventeen HCPs of 23 approached (74%) were eligible and agreed to participate, performing a total of 336 HIV tests. Globally, the testing procedure was rated as easy or very easy by 97% (DETE) to 99% (INSTI) of tests performed. Among experienced HCPs, DETE was rated easier than INSTI for kit storage (p < 0.001) and blood collection ( P = 0.012) while INSTI was rated easier than DETE for blood application ( P = 0.001) and test interpretation ( P = 0.005). Among less experienced HCPs, both tests performed equally with the exception of test interpretation ( P < 0.001) and overall ease of use ( P = 0.05) in favour of INSTI. Of all HCPs, 94% stated they would recommend INSTI over DETE based on the time to result, ease of test interpretation and overall ease of use. Rapid HIV testing was considered easy to perform, even by inexperienced nursing staff. Whilst both tests were considered easy to use, the HCPs in this study preferred INSTI to DETE overall, due to rapid time to result, ease of test interpretation and general ease of use.

Accuracy and Acceptability of Oral Fluid HIV Self-Testing in a General Adult Population in Kenya

We evaluated performance, accuracy, and acceptability parameters of unsupervised oral fluid (OF) HIV self-testing (HIVST) in a general population in western Kenya. In a prospective validation design, we enrolled 240 adults to perform rapid OF HIVST and compared results to staff administered OF and rapid fingerstick tests. All reactive, discrepant, and a proportion of negative results were confirmed with lab ELISA. Twenty participants were video-recorded conducting self-testing. All participants completed a staff administered survey before and after HIVST to assess attitudes towards OF HIVST acceptability. HIV prevalence was 14.6 %. Thirty-six of the 239 HIVSTs were invalid (15.1 %; 95 % CI 11.1-20.1 %), with males twice as likely to have invalid results as females. HIVST sensitivity was 89.7 % (95 % CI 73-98 %) and specificity was 98 % (95 % CI 89-99 %). Although sensitivity was somewhat lower than expected, there is clear interest in, and high acceptability (94 %) of OF HIV self-testing.

Longitudinal Study of Hepatitis A Infection by Saliva Sampling: The Kinetics of HAV Markers in Saliva Revealed the Application of Saliva Tests for Hepatitis A Study

Despite the increasing numbers of studies investigating hepatitis A diagnostic through saliva, the frequency and the pattern of hepatitis A virus (HAV) markers in this fluid still remains unknown. To address this issue, we carried on a longitudinal study to examine the kinetics of HAV markers in saliva, in comparison with serum samples. The present study followed-up ten patients with acute hepatitis A infection during 180 days post diagnosis (dpd). Total anti-HAV was detected in paired serum and saliva samples until the end of the follow-up, showing a peak titer at 90th. However, total anti-HAV level was higher in serum than in saliva samples. This HAV marker showed a probability of 100% to be detected in both serum and saliva during 180 dpd. The IgM anti-HAV could be detected in saliva up to 150 dpd, showing the highest frequency at 30th, when it was detected in all individuals. During the first month of HAV infection, this acute HAV marker showed a detection probability of 100% in paired samples. The detection of IgM anti-HAV in saliva was not dependent on its level in serum, HAV-RNA detection and/or viral load, since no association was found between IgM anti-HAV positivity in saliva and any of these parameter (p>0.05). Most of the patients (80%) were found to contain HAV-RNA in saliva, mainly at early acute phase (30th day). However, it was possible to demonstrate the HAV RNA presence in paired samples for more than 90 days, even after seroconversion. No significant relationship was observed between salivary HAV-RNA positivity and serum viral load, demonstrating that serum viral load is not predictive of HAV-RNA detection in saliva. Similar viral load was seen in paired samples (on average 104 copies/mL). These data demonstrate that the best diagnostic coverage can be achieved by salivary anti-HAV antibodies and HAV-RNA tests during 30-90 dpd. The long detection and high probability of specific-HAV antibodies positivity in saliva samples make the assessment of salivary antibodies a useful tool for diagnosis and epidemiological studies. The high frequency of HAV-RNA in saliva and the probability of detection of about 50%, during the first 30 dpd, demonstrate that saliva is also useful for molecular investigation of hepatitis A cases, mainly during the early course of infection. Therefore, the collection of saliva may provide a simple, cheap and non-invasive means of diagnosis, epidemiological surveys and monitoring of hepatitis A infection purposes.

Field accuracy of fourth-generation rapid diagnostic tests for acute HIV-1: a systematic review

INTRODUCTION

Fourth-generation HIV-1 rapid diagnostic tests (RDTs) detect HIV-1 p24 antigen to screen for acute HIV-1. However, diagnostic accuracy during clinical use may be suboptimal.

METHODS

Clinical sensitivity and specificity of fourth-generation RDTs for acute HIV-1 were collated from field evaluation studies in adults identified by a systematic literature search.

RESULTS

Four studies with 17 381 participants from Australia, Swaziland, the United Kingdom and Malawi were identified. All reported 0% sensitivity of the HIV-1 p24 component for acute HIV-1 diagnosis; 26 acute infections were missed. Specificity ranged from 98.3 to 99.9%.

CONCLUSION

Fourth-generation RDTs are currently unsuitable for the detection of acute HIV-1.

A review of Human Immunodeficiency Virus (HIV) rapid testing

BACKGROUND

In Canada, it is estimated that 71,300 persons were living with HIV at the end of 2011. Approximately 25% (14,500 to 21,500) of prevalent cases were unaware of their HIV infection. Expanded use of HIV rapid tests may increase the detection of undiagnosed infections, enable earlier treatment and support services and prevent the onward transmission of HIV.

OBJECTIVE

To examine patient acceptability, impact (defined as receipt of test results and linkage to care) and cost-effectiveness of HIV rapid tests.

METHODS

A search was conducted for systematic reviews on HIV rapid testing, with studies from both developed and developing countries, published in English and between 2000 and 2013. The Assessment of Multiple Systematic Review (AMSTAR) tool was used to assess the included systematic reviews for methodological quality. Results were summarized narratively for each of the outcomes.

RESULTS

Eight systematic reviews were included. Acceptability of HIV rapid tests was generally high in medical settings (69% to 98%) especially among pregnant women and youth attending emergency rooms but was lower in non-medical settings (14% to 46%). The percentage of people who obtained their test results was variable. It was high (83% to 93%) in emergency rooms but was low in a rapid care setting with regular business hours (27%). Impact on linkage to care was limited. Only one systematic review examined cost-effectiveness of rapid testing and concluded that HIV rapid tests were cost-effective in comparison to traditional methods; however, results were all based on static models.

CONCLUSION

Overall, HIV rapid tests demonstrated generally high acceptability, variability in receiving test results and limited impact on linkage to care. While these findings suggest that HIV rapid tests may be useful, further research is needed to confirm in whom, when and where they are best used and how to ensure better linkage to care.

HIV self-testing in Nigeria: public opinions and perspectives

Nigeria views the HIV self-test (HIVST) as a possible mechanism to help increase HIV testing uptake and capture otherwise undiagnosed HIV cases. The purpose of this survey was to obtain perspectives of informed members of the Nigerian public on the use of the HIVST. A convenience sample of 1712 researchers, academics, journalists, community advocates, activists and HIV policy-makers and programmers including those working in the development sectors enlisted on the New HIV Vaccine and Microbicide Advocacy Society listserv were sent a brief survey. Respondents were asked to provide a 'yes' or 'no' response to an enquiry if they support the introduction of HIVST into Nigeria. Reasons for their response were also recorded. Information was collected anonymously with no identifiers. Only 157 (9.2%) provided a response. While the majority (54.8%) supported the introduction of HIVST, a significant number of respondents were concerned about possible risk associated with self-testing, especially suicide and partner violence. Others were concerned about poor linkages to care. Introduction of HIVST would need to be paired with intense media campaigns and education about its use. Once Nigeria commences HIVST, efforts should also focus on approaches to reach people in hard to reach areas of the country.

Will an unsupervised self-testing strategy be feasible to operationalize in Canada? Results from a pilot study in students of a large canadian university

Background. A convenient, private, and accessible HIV self-testing strategy stands to complement facility-based conventional testing. Over-the-counter oral HIV self-tests are approved and available in the United States, but not yet in Canada. Canadian data on self-testing is nonexistent. We investigated the feasibility of offering an unsupervised self-testing strategy to Canadian students. Methods. Between September 2011 and May 2012, we recruited 145 students from a student health clinic of a large Canadian university. Feasibility of operationalization (i.e., self-test conduct, acceptability, convenience, and willingness to pay) was evaluated. Self-test conduct was computed with agreement between the self-test performed by the student and the test repeated by a healthcare professional. Other metrics were measured on a survey. Results. Participants were young (median age: 22 years), unmarried (97%), and 47% were out of province or international students. Approximately 52% self-reported a history of unprotected casual sex and sex with multiple partners. Self-test conduct agreement was high (100%), so were acceptability (81%), convenience (99%), and willingness to pay (74%) for self-tests. Concerns included accuracy of self-tests and availability of expedited linkages. Conclusion. An unsupervised self-testing strategy was found to be feasible in Canadian students. Findings call for studies in at-risk populations to inform Canadian policy.

Acceptability of HIV self-testing: a systematic literature review

Background

The uptake of HIV testing and counselling services remains low in risk groups around the world. Fear of stigmatisation, discrimination and breach of confidentiality results in low service usage among risk groups. HIV self-testing (HST) is a confidential HIV testing option that enables people to find out their status in the privacy of their homes. We evaluated the acceptability of HST and the benefits and challenges linked to the introduction of HST.

Methods

A literature review was conducted on the acceptability of HST in projects in which HST was offered to study participants. Besides acceptability rates of HST, accuracy rates of self-testing, referral rates of HIV-positive individuals into medical care, disclosure rates and rates of first-time testers were assessed. In addition, the utilisation rate of a telephone hotline for counselling issues and clients` attitudes towards HST were extracted.

Results

Eleven studies met the inclusion criteria (HST had been offered effectively to study participants and had been administered by participants themselves) and demonstrated universally high acceptability of HST among study populations. Studies included populations from resource poor settings (Kenya and Malawi) and from high-income countries (USA, Spain and Singapore). The majority of study participants were able to perform HST accurately with no or little support from trained staff. Participants appreciated the confidentiality and privacy but felt that the provision of adequate counselling services was inadequate.

Conclusions

The review demonstrates that HST is an acceptable testing alternative for risk groups and can be performed accurately by the majority of self-testers. Clients especially value the privacy and confidentiality of HST. Linkage to counselling as well as to treatment and care services remain major challenges.

Saliva specimen sampling: a noninvasive method for diagnosis and basic investigation of viral hepatitis A, B and C

Saliva is a biological fluid that is easy to collect and manipulate. Collection of saliva samples is less expensive, noninvasive and painless compared with blood collection. Due to these advantages, saliva has been investigated as an alternative fluid to serum for diagnostic and epidemiological purposes. The aim of this article was to the review research on salivary biomarkers of viral hepatitis A, B and C, highlighting their current use, collection devices, and potential applications for diagnosis and epidemiological studies. This paper also explores recent findings of saliva as a possible source of viral hepatitis transmission.

Supervised and unsupervised self-testing for HIV in high- and low-risk populations: a systematic review

BACKGROUND

Stigma, discrimination, lack of privacy, and long waiting times partly explain why six out of ten individuals living with HIV do not access facility-based testing. By circumventing these barriers, self-testing offers potential for more people to know their sero-status. Recent approval of an in-home HIV self test in the US has sparked self-testing initiatives, yet data on acceptability, feasibility, and linkages to care are limited. We systematically reviewed evidence on supervised (self-testing and counselling aided by a health care professional) and unsupervised (performed by self-tester with access to phone/internet counselling) self-testing strategies.

METHODS AND FINDINGS

Seven databases (Medline [via PubMed], Biosis, PsycINFO, Cinahl, African Medicus, LILACS, and EMBASE) and conference abstracts of six major HIV/sexually transmitted infections conferences were searched from 1st January 2000-30th October 2012. 1,221 citations were identified and 21 studies included for review. Seven studies evaluated an unsupervised strategy and 14 evaluated a supervised strategy. For both strategies, data on acceptability (range: 74%-96%), preference (range: 61%-91%), and partner self-testing (range: 80%-97%) were high. A high specificity (range: 99.8%-100%) was observed for both strategies, while a lower sensitivity was reported in the unsupervised (range: 92.9%-100%; one study) versus supervised (range: 97.4%-97.9%; three studies) strategy. Regarding feasibility of linkage to counselling and care, 96% (n = 102/106) of individuals testing positive for HIV stated they would seek post-test counselling (unsupervised strategy, one study). No extreme adverse events were noted. The majority of data (n = 11,019/12,402 individuals, 89%) were from high-income settings and 71% (n = 15/21) of studies were cross-sectional in design, thus limiting our analysis.

CONCLUSIONS

Both supervised and unsupervised testing strategies were highly acceptable, preferred, and more likely to result in partner self-testing. However, no studies evaluated post-test linkage with counselling and treatment outcomes and reporting quality was poor. Thus, controlled trials of high quality from diverse settings are warranted to confirm and extend these findings. Please see later in the article for the Editors' Summary.

Are participants in a street-based HIV testing program able to perform their own rapid test and interpret the results?

Objective

Availability of over-the-counter rapid HIV tests could improve access to testing those reluctant or unable to use current services. We aimed to evaluate the feasibility of HIV self-testing using a finger-stick whole-blood rapid test (Determine™ HIV Combo) to detect both antigen and antibody.

Methods

Before being tested, 313 participants in a street-based testing program were given adapted instructions and a test kit, and performed the self-test without supervision. These participants, together with another 207 who performed supervised self-testing, received additional instructions on how to interpret the test results shown in six colour photos and filled out a questionnaire. Logistic regression and generalized estimating equations (GEE) were used in the statistical analysis.

Results

About 8.0% (95%CI:4.8%–11.2%) obtained an invalid self-test. An invalid result was inversely associated with male participants who had sex with men (OR = 0.3;95%CI:0.1–1.0). Of the 3111 photos interpreted,4.9% (95%CI:4.1–5.7) were incorrect. Only 1.1% (95%CI:0.3–1.8) of the positive results were interpreted as negative. Age 30 or older (OR = 2.1; 95%CI:1.2–3.7), having been born in Latin America (OR = 1.6; 95%CI:1.1–2.2),and not having university education (OR = 2.1;95%CI:1.2–3.7) were associated with misinterpreting test results in the GEE. Participant's perceptions of both their proficiency when conducting the test and interpretation were related with actual outcomes. Most participants (83.9%) were more motivated than before to use the self-test in the future, and 51.7% would pay >10 Euros for the test if it was sold in pharmacies.

Conclusions

This is the first study showing that blood-based self-testing with current technology is feasible in HIV-negative participants demanding the test and without prior training or supervision. Bearing in mind that it was conducted under difficult weather conditions and using a complex kit, over-the-counter tests could be a feasible option to complement current diagnostic strategies. More studies are needed to accommodate technology, minimise interpretation mistakes and provide on-line support.