Young people's preferences for HIV self-testing services in Nigeria: a qualitative analysis

HIV, hepatitis, and syphilis self-testing among adolescents and young adults: A systematic review and meta-analysis

BACKGROUND

Adolescents and young adults (AYA) make up a significant share of the world's burden of HIV and other sexually transmitted infections (STI). Self-testing can increase testing coverage and strengthen the uptake of prevention and treatment services. We critically appraised the literature regarding HIV, hepatitis, and syphilis self-testing among AYA (age 10-24 years) and assessed its usability, feasibility, and acceptability.

METHODS

We conducted a systematic review, searching six databases between January 2010 and October 2023. We included all studies on HIV, hepatitis and syphilis self-testing in AYA. We used a random-effects meta-analysis to pool evidence across the three infections as evidence was deemed sufficiently similar. We summarised the uptake, proportion of first-time testers and linkage to care. Qualitative data were narratively synthesised.

FINDINGS

We identified 89 relevant studies. Most were conducted in Africa (57/89, 64 %) and lower-middle-income countries (34/89, 38 %). Our meta-analysis of 27 studies (n = 28,787 individuals) demonstrated that 79 % (95 % CI: 69-87 %, I2 = 99 %) of AYA who were offered HIV or syphilis self-test completed the test. Five studies (n = 4117) demonstrated 62 % (95 % CI: 53-71 %, I2 = 83 %) were first-time testers. No studies reported completion rates for hepatitis self-testing. In general, AYA were highly accepting of self-testing and found it easy to use.

INTERPRETATION

Self-testing is a safe, acceptable and effective way to increase access to HIV, hepatitis and syphilis testing in AYA. Given these features of self-testing, policies to increase its use should significantly improve testing and maximise their public health impact.

Female sex workers' perceptions, concerns and acceptability of OraQuick HIV self-test in Woldia town, North Wollo, Ethiopia: a qualitative study

OBJECTIVE

To explore female sex workers' perception, concern and acceptability of OraQuick HIV self-test (HIVST) in Woldia town, North Wollo, Ethiopia, in 2024.

DESIGN

The study used a phenomenological design and the Integrated Behaviour Model as a theoretical framework.

SETTING

Woldia town, Ethiopia, is the capital city of North Wollo Zone.

PARTICIPANTS

Twenty female sex workers and 18 key informants in Woldia town were involved.

RESULTS

Most participants had a positive attitude towards testing with these devices and anticipated positive consequences, such as enhanced privacy, decreased waiting time, reduced transportation costs, increased accessibility for immobile individuals, elevated utility in index case screening and testing programmes and the provision of confidential, trustworthy and reliable test results. Most female sex workers perceived that significant people in their social environment approved and used OraQuick HIVST. The facilitators to uptake of OraQuick HIVST among female sex workers included privacy, ease of use and nonrequierement for trained healthcare providers when testing. Thus, most female sex workers were confident in their ability to test themselves and interpret their test result using OraQuick HIVST.To optimise uptake of testing using OraQuick, female sex workers proposed supplying kits in an easily accessible manner, increasing awareness about the kit and advocating for and promoting that the kits are strategies to facilitate HIVST uptake and maximise individuals' self-efficacy. The perceived possible concerns or barriers to the uptake of OraQuick HIVST included a shortage of kits, doubts about reliability prior to education, absence of policies or guidelines for HIVST, lack of post-test counselling and immediate treatment for positive individuals, potential psychological trauma such as suicidal ideation or attempts, lack of linkage to care for those with reactive results and inaccurate reporting of positive results or result concealment.

CONCLUSION

This finding suggests that OraQuick HIVST was acceptable to female sex workers in the study area, with the majority of female sex workers having a positive attitude, supportive social norms and self-efficacy. Therefore, interventions to increase awareness, advocate for the kit and address perceived concerns or barriers to HIVST are needed to maximise its uptake in the study setting.

Factors Influencing the Acceptability and Uptake of HIV Self-Testing Among Priority Populations in Sub-Saharan Africa: A Scoping Review

Objectives

To identify and synthesize the factors influencing the acceptability and uptake of HIV self-testing (HIVST) among Priority Populations (PPs) in Sub-Saharan Africa (SSA) through a comprehensive scoping review.

Methods

Using Arksey and O'Malley's framework refined by Levac, we systematically reviewed the literature on factors affecting HIVST uptake and acceptability among PPs in SSA. The review included searches in six databases (Embase, Medline (via Ovid), PubMed, PsycINFO, Web of Science, WHO Global Health Library), as well as grey literature, including (Google Scholar and OpenGrey), limiting publications to 2010-2023.

Results

The review found evidence indicating that HIVST is widely accepted and considered convenient among priority groups. Key challenges include limited post-test counseling and linkage to care, which hinder effective implementation. Peer-led and digital distribution strategies show the potential to increase uptake. However, user errors and economic constraints pose significant barriers to scaling HIVST, underscoring the need for targeted interventions to address these implementation challenges for optimal impact.

Conclusion

While HIVST can boost testing rates among PPs in SSA, overcoming access and utilization barriers is crucial. Interventions addressing economic, educational, and systemic challenges are essential for successful HIVST integration into broader HIV prevention and care efforts.

Feasibility of HIV self-test implementation among Mizo youths: a field investigation from Northeast India bordering Myanmar

Introduction

This study investigated the potential of HIV self-test (HIVST) to reach individuals who otherwise might not access testing or antiretroviral therapy (ART). The study had two main objectives: (a) to develop an HIV self-test implementation plan based on the findings from qualitative inquiries with local stakeholders and (b) to examine HIVST uptake among youths in the urban setting of Aizawl district in Mizoram.

Methodology

In the first phase, qualitative in-depth interviews (IDI) were conducted with HIV program officials, religious leaders, community influencers, youths, and key population groups. These inquiries guided the planning of strategic communication, community engagement, HIVST delivery, and linkages with HIV confirmatory testing services in phase two. Factors associated with the non-uptake of HIV confirmatory tests by youths following HIVST were analyzed quantitatively. Additionally, secondary data collected from attendees of the "Integrated Counselling and Testing Centre" (ICTC) were also analyzed.

Results

The in-depth interviews underscored the need to introduce HIVST among Mizo youths. The respondents emphasized the importance of diverse outreach approaches and communication strategies, including the use of social media platforms, as critical components for successful HIVST implementation. They also provided valuable insights on the optimal locations and methods for making HIVST kits accessible. Among the youths who used HIVST, the majority were first-time testers (1,772/2,101; 84.3%). Those diagnosed with an undiagnosed HIV infection were started on ART. The preference for the blood-based HIVST format (1,162/2101; 55%) was noted to be slightly higher than the saliva-based format. Confirmatory test uptake was significantly higher among those with sero-reactive HIVST results (χ 2 23.89; p < 0.001). Factors independently associated with (adjusted odds ratio; AOR with 95% CI) "no-show for HIV confirmatory tests," which hold significant programmatic implications, included "age > 20 years (1.47; 1.18-1.82)," "gender (men)" (1.25; 1.01-1.55), "education below 10th standard" (5.16; 2.66-10.01), "no prior HIV testing experience" (2.12; 1.61-2.81), and "unwillingness to undergo HIV confirmatory testing" (2.85; 2.05-3.96). Individuals who opted for the blood-based HIVST were 23% less likely (AOR 0.77; 95% CI; 0.62-0.96) to drop out of the HIV confirmatory testing process. Additionally, only 1% of respondents perceived HIVST as having self-harm potential.

Conclusion

Sustained community engagement, effective networking with HIV program officials, and strategic communication were three critical pillars supporting the successful implementation of HIVST. There was a significant increase in HIVST uptake among young first-time testers.

Factors associated with HIV self-testing and PrEP use among Nigerian youth: Baseline outcomes of a pragmatic, stepped-wedge, cluster-randomized controlled trial

INTRODUCTION

Adolescents and young adults (AYA, 14-24 years) bear a disproportionate burden of new HIV infections in Nigeria and are more likely to have worse HIV outcomes compared to other age groups. However, little is known about their access to recommended sexual health care services, including HIV self-testing (HIVST), sexually transmitted infections (STI) testing, sexual behavior patterns, awareness and or access to pre-exposure prophylaxis (PrEP), and overall risk for HIV.

METHODS

We present a baseline analysis of the 4 Youth by Youth randomized controlled trial aimed to evaluate the uptake and sustainability of crowdsourced HIVST strategies led by and for young people across 14 states in Nigeria. None of the participants had received intervention at the time of completing this self-reported behavioral survey. We conducted a descriptive analysis to summarize participants' characteristics, sexual behavior, HIV testing, STI testing, and knowledge of PrEP and use across the study sample of the AYAs. We conducted a chi-square test, and the level of significance was set at ≤0.05.

RESULTS

A total of 1551 participants completed the baseline survey comprising males (777, 50.1 %) and females (774, 49.9 %). The majority (77 %) of the participants were students at enrollment. Very few of the participants had ever tested for syphilis, 47 (3.1 %), gonorrhea, 49 (3.2 %), chlamydia, 31 (2.0 %), and hepatitis B, 106 (6.9 %). 678 (43.8 %) of the participants reported to be sexually active at the time of enrolment into the study, of which about 38 % of them engaged in condomless sex. Paying for sex, alcohol use, and drug use are all significant sexual behaviors (p < 0.01). Only 14 (1 %) have ever used PrEP. 481 (31.4 %) have ever tested for HIV, and 104 (6.8 %) have ever used an HIV self-testing kit at baseline. 457 (38.6 %) were eligible for PrEP.

CONCLUSIONS

HIVST and STI uptake were low at baseline among the AYA in this study. Most AYAs also do not receive recommended sexual health care services, including STI testing services. This underlines the need for interventions to increase the uptake of HIV/STI prevention services among Nigerian AYA.

Evaluating the effectiveness of oral HIV self testing according to distribution models in Cameroon

Innovative strategies such as HIV self-testing (HIVST) are useful for identifying hard-to-reach people living with HIV/AIDS (PLHIV), especially in developing settings where considerable gaps still exist in reaching the first 95% UNAIDS target. We evaluated the effectiveness of HIVST in Cameroon using several distribution models and investigated the predictors of HIV seropositivity among self-testers. The study was conducted from 2021 to 2022 in three regions in Cameroon. HIVST kits were distributed according to 5 distribution models: antenatal, postnatal, maternal and child clinics (ANC/PNC/MCH); partners of PLHIV; workplace; community and HIV-testing services (HTS). Overall, 42,687 people received oral HIVST kits, among whom 15.6% were HIV first-testers. Approximately 85% reported on the test outcome; 2.3% (n = 825) were reactive, and 75.8% came for test confirmation. After the confirmation test, a concordance of 85% was found with the national algorithm. Overall, the HIV seroprevalence was 1.5% [95% CI: 1.4-1.6]; ANC/PNC/MCHC: 1.9%, partners of PLHIV: 6.9%, workplace: 0.5%, community: 0.1% and HTS: 7.0%, p < 0.001. The positivity rate among first-testers was 1.2%. Youths < 25 years had a lower seroprevalence (0.4%) than older people (2.6% and 2.7% for those aged 25-39 and those aged ≥ 40 years, respectively), p < 0.001. Seropositivity was negatively associated with secondary distribution, workplace model, community model and age < 25 years. On the other hand, partners of PLHIV model, HTS model, female sex and first-time-testers were positively associated with seropositivity. In Cameroon, oral HIVST is an effective approach for identifying undiagnosed PLHIV, especially when using ANC/PNC/MCHC, partners of PLHIV and HTS distribution models. However, to ensure the successful scale-up of HIVST in Cameroon, guidelines should be revised to fine-tune the target populations for HIVST and optimize the use of resources.

Preferences for attributes of an artificial intelligence-based risk assessment tool for HIV and sexually transmitted infections: a discrete choice experiment

INTRODUCTION

Early detection and treatment of HIV and sexually transmitted infections (STIs) are crucial for effective control. We previously developed MySTIRisk, an artificial intelligence-based risk tool that predicts the risk of HIV and STIs. We examined the attributes that encourage potential users to use it.

METHODS

Between January and March 2024, we sent text message invitations to the Melbourne Sexual Health Centre (MSHC) attendees to participate in an online survey. We also advertised the survey on social media, the clinic's website, and posters in affiliated general practice clinics. This anonymous survey used a discrete choice experiment (DCE) to examine which MySTIRisk attributes would encourage potential users. We analysed the data using random parameters logit (RPL) and latent class analysis (LCA) models.

RESULTS

The median age of 415 participants was 31 years (interquartile range, 26-38 years), with a minority of participants identifying as straight or heterosexual (31.8%, n = 132). The choice to use MySTIRisk was most influenced by two attributes: cost and accuracy, followed by the availability of a pathology request form, level of anonymity, speed of receiving results, and whether the tool was a web or mobile application. LCA revealed two classes: "The Precisionists" (66.0% of respondents), who demanded high accuracy and "The Economists" (34.0% of respondents), who prioritised low cost. Simulations predicted a high uptake (97.7%) for a tool designed with the most preferred attribute levels, contrasting with lower uptake (22.3%) for the least preferred design.

CONCLUSIONS

Participants were more likely to use MySTIRisk if it was free, highly accurate, and could send pathology request forms. Tailoring the tool to distinct user segments could enhance its uptake and effectiveness in promoting early detection and prevention of HIV and STIs.

Acceptability and use of HIV self-testing among young people in sub-Saharan Africa: a mixed methods systematic review

BACKGROUND

Young people (YP) are disproportionately affected by the HIV pandemic in sub-Saharan Africa (SSA), but testing rates remain low despite global targets of testing 95% of people with HIV infection by 2030. HIV self-testing (HIVST) has been recently introduced to reach high-risk population groups such as these. Thus, synthesis of emerging evidence on the acceptability and use of HIVST among YP in SSA is needed so that comprehensive information can be generated to inform policy and practice.

METHODS

We employed a mixed methods systematic review of quantitative and qualitative literature reporting on HIVST among YP involving any design and published in English by 31st of October 2023. The review synthesized quantitative evidence on acceptability and use of HIVST, and qualitative evidence on perspectives of YP about HIVST. We searched databases of published articles (e.g. MEDLINE, CINAHL) and Gray literature sources (e.g. Google, Google Scholar). The concepts for the search included self-testing, HIV/AIDS, and countries in SSA. Two authors independently screened, retrieved full-text, and assessed quality of the studies.

RESULTS

A total of 4150 studies were retrieved and 32 studies were finally included in the review. Acceptability of HIVST computed from a single item asking YP on their preference or willingness or demand for HIVST was moderate (34-67%) to high (≥ 67%) among YP in SSA. Nine of the fourteen studies that reported on acceptability found high acceptability of HIVST. Use of HIVST ranged from 0.8 to 100% while in most studies the use rate was below 50%. Key barriers to HIVST use were coping with a positive test in the absence of counselling and support, physical discomfort, and cost of kits. Perceived enablers included perceptions of HIVST as promoting personal empowerment and autonomy; privacy and confidentiality; and convenience in location, time, and skill.

CONCLUSIONS

HIVST was highly accepted but not well utilized among YP in SSA. YP showed diversified needs with mixed preferences for location, and modalities of service provision. Overall, the review identified heterogeneous evidence in terms of methods, population, outcome measures, and results. The review was registered in the International Prospective Registry of Systematic Reviews (PROSPERO: ID = CRD42021278919).

Determinants and acceptability of HIV self-testing among vulnerable groups in sub-Saharan Africa: A scoping review protocol

INTRODUCTION

HIV self-testing (HIVST) is where individuals collect their specimens and perform the HIV test privately. HIVST has improved testing uptake and coverage, especially among vulnerable groups of sub-Saharan Africa (SSA). Vulnerable groups include key populations such as men who have sex with men, sex workers, people who inject drugs, lesbian, gay, bisexual and transgender persons and young women. However, little is known about the determinants and acceptability of HIVST among these groups in SSA. Therefore, this scoping review aims to explore the determinants and acceptability of HIVST among vulnerable groups in SSA.

METHODS

A scoping review will be conducted using the Arksey and O'Malley framework and further refined by Levac framework. The review will follow a six-step approach: (1) identifying the research question, (2) identifying relevant studies, (3) study selection eligibility, (4) charting the data, (5) collating, summarising and reporting the results and (6) consultation. A comprehensive search strategy will be developed, and the following electronic databases will be searched: MEDLINE, Embase, Global Health and the Cochrane Library. Grey literature will also be searched, including conference abstracts and reports. Eligibility criteria will include studies conducted in SSA, published between 2010 and 2023, focusing on vulnerable groups and exploring the determinants and acceptability of HIVST. Two independent reviewers will screen identified studies' titles, abstracts and full texts. Any disagreements will be resolved through discussion or consultation with a third reviewer. Data extraction will be conducted using a standardised form.

ETHICS AND DISSEMINATION

This review, not requiring ethical approval, aims to inform policy and intervention design to boost HIV testing adoption within vulnerable communities. We plan to disseminate our findings via a peer-reviewed journal, policy briefs, conference presentations and stakeholder engagement.

HIV self-testing acceptability among injured persons seeking emergency care in Nairobi, Kenya

BACKGROUND

Emergency department-based HIV self-testing (ED-HIVST) could increase HIV-testing services to high-risk, under-reached populations.

OBJECTIVES

This study sought to understand the injury patient acceptability of ED-HIVST.

METHODS

Injury patients presenting to the Kenyatta National Hospital Accident and Emergency Department were enrolled from March to May 2021. Likert item data on HIVST assessing domains of general acceptability, personal acceptability, and acceptability to distribute to social and/or sexual networks were collected. Ordinal regression was performed yielding adjusted odds ratios (aOR) to identify characteristics associated with high HIVST acceptability across domains.

RESULTS

Of 600 participants, 88.7% were male, and the median age was 29. Half reported having primary care providers (PCPs) and 86.2% reported prior HIV testing. For each Likert item, an average of 63.5% of the participants reported they 'Agree Completely' with positive statements about ED-HIVST in general, for themselves, and for others. In adjusted analysis for general acceptability, those <25 (aOR = 1.67, 95%CI:1.36-2.08) and with prior HIV testing (aOR = 1.68, 95%CI:1.27-2.21) had greater odds of agreeing completely. For personal acceptability, those with a PCP (aOR = 3.31, 95%CI:2.72-4.03) and prior HIV testing (aOR = 1.83, 95%CI:1.41-2.38) had greater odds of agreeing completely. For distribution acceptability, participants with a PCP (aOR = 2.42, 95%CI:2.01-2.92) and prior HIV testing (aOR = 1.79, 95%CI: 1.38-2.33) had greater odds of agreeing completely.

CONCLUSIONS

ED-HIVST is perceived as highly acceptable, and young people with prior testing and PCPs had significantly greater favourability. These data provide a foundation for ED-HIVST programme development in Kenya.

Adolescents and young adults are the most undiagnosed of HIV and virally unsuppressed in Eastern and Southern Africa: Pooled analyses from five population-based surveys

Age and gender disparities within the HIV cascade of care are critical to focus interventions efficiently. We assessed gender-age groups at the highest probability of unfavorable outcomes in the HIV cascade in five HIV prevalent settings. We performed pooled data analyses from population-based surveys conducted in Kenya, South Africa, Malawi and Zimbabwe between 2012 and 2016. Individuals aged 15-59 years were eligible. Participants were tested for HIV and viral load was measured. The HIV cascade outcomes and the probability of being undiagnosed, untreated among those diagnosed, and virally unsuppressed (≥1,000 copies/mL) among those treated were assessed for several age-gender groups. Among 26,743 participants, 5,221 (19.5%) were HIV-positive (69.9% women, median age 36 years). Of them, 72.8% were previously diagnosed and 56.7% virally suppressed (88.5% among those treated). Among individuals 15-24 years, 51.5% were diagnosed vs 83.0% among 45-59 years, p<0.001. Among 15-24 years diagnosed, 60.6% were treated vs 86.5% among 45-59 years, p<0.001. Among 15-24 years treated, 77.9% were virally suppressed vs 92.0% among 45-59 years, p<0.001. Among all HIV-positive, viral suppression was 32.9% in 15-24 years, 47.9% in 25-34 years, 64.9% in 35-44 years, 70.6% in 45-59 years. Men were less diagnosed than women (65.2% vs 76.0%, p <0.001). Treatment among diagnosed and viral suppression among treated was not different by gender. Compared to women 45-59 years, young people had a higher probability of being undiagnosed (men 15-24 years OR: 37.9, women 15-24 years OR: 12.2), untreated (men 15-24 years OR:2.2, women 15-24 years OR: 5.7) and virally unsuppressed (men 15-24 years OR: 1.6, women 15-24 years OR: 6.6). In these five Eastern and Southern Africa settings, adolescents and young adults had the largest gaps in the HIV cascade. They were less diagnosed, treated, and virally suppressed, than older counterparts. Targeted preventive, testing and treating interventions should be scaled-up.

An Unstructured Supplementary Service Data System to Verify HIV Self-Testing Among Nigerian Youths: Mixed Methods Analysis of Usability and Feasibility

BACKGROUND

Mobile health (mHealth) interventions among adolescents and young adults (AYAs) are increasingly available in African low- and middle-income countries (LMICs). For example, the unstructured supplementary service data (USSD) could be used to verify HIV self-testing (HIVST) among AYAs with poor bandwidth.

OBJECTIVE

The aim of this study is to describe the creation of an USSD platform and determine its feasibility and usability to promote the verification of HIVST results among AYAs in Nigeria.

METHODS

We developed and evaluated a USSD platform to verify HIVST results using a user-centered approach. The USSD platform guided AYAs in performing HIVST, interpreting the result, and providing linkage to care after the test. Following the usability assessment, the USSD platform was piloted. We used a mixed methods study to assess the platform's usability through a process of quantitative heuristic assessment, a qualitative think-aloud method, and an exit interview. Descriptive statistics of quantitative data and inductive thematic analysis of qualitative variables were organized.

RESULTS

A total of 19 AYAs participated in the usability test, with a median age of 19 (IQR 16-23) years. There were 11 females, 8 males, and 0 nonbinary individuals. All individuals were out-of-school AYAs. Seven of the 10 Nielsen usability heuristics assessed yielded positive results. The participants found the USSD platform easy to use, preferred the simplicity of the system, felt no need for a major improvement in the design of the platform, and were happy the system provided linkage to care following the interpretation of the HIVST results. The pilot field test of the platform enrolled 164 out-of-school AYAs, mostly young girls and women (101, 61.6%). The mean age was 17.5 (SD 3.18) years, and 92.1% (151/164) of the participants reported that they were heterosexual, while 7.9% (13/164) reported that they were gay. All the participants in the pilot study were able to conduct HIVST, interpret their results, and use the linkage to care feature of the USSD platform without any challenge. A total of 7.9% (13/164) of the AYAs had positive HIV results (reactive to the OraQuick kit).

CONCLUSIONS

This study demonstrated the usability and feasibility of using a USSD system as an alternative to mobile phone apps to verify HIVST results among Nigerian youth without smartphone access. Therefore, the use of a USSD platform has implications for the verification of HIVST in areas with low internet bandwidth. Further pragmatic trials are needed to scale up this approach.

Feasibility and Usability of Mobile Technology to Assist HIV Self-Testing in Youth in Zimbabwe: A Mixed-Methods Study

PURPOSE

Mobile technology is increasingly being used to widen access to and support the delivery of public health interventions. Human immunodeficiency viruses (HIV) self-testing (HIVST) enables individuals to have autonomy. We evaluated the feasibility of a novel application called ITHAKA to support HIVST among youth aged 16-24 years in Zimbabwe.

METHODS

This study was nested within a trial of community-based delivery of integrated HIV and sexual and reproductive health services called CHIEDZA. Youth accessing CHIEDZA were offered provider-delivered HIV testing or HIVST supported by ITHAKA, either on a tablet on-site at a community centre or on their mobile phone off-site. ITHAKA incorporated pre and post-test counselling, and instructions for conducting the test and the appropriate actions to take depending on test result, including reporting HIV test results to health providers. The outcome was completion of the testing journey. Semistructured interviews with CHIEDZA providers explored the perceptions of and experiences with the application.

RESULTS

Between April and September 2019, of the 2,181 youth who accepted HIV testing in CHIEDZA, 128 (5.8%) initiated HIVST (the remainder opting for provider-delivered testing) using ITHAKA. Nearly all who performed HIVST on-site (108/109 (99.1%)) compared to only 9/19 (47.4%) who tested off-site completed their testing journey. Low digital literacy, lack of agency, erratic network coverage, lack of dedicated phone ownership, the limited functionality of smartphones challenged implementation of ITHAKA.

DISCUSSION

Digitally supported HIVST had low uptake among youth. The feasibility and usability of digital interventions should be carefully assessed before implementation, paying careful attention to digital literacy, network availability, and access to devices.

Acceptability and strategies for enhancing uptake of human immunodeficiency virus self-testing in Nigeria

BACKGROUND

In 2019, the Nigerian Ministry of Health published the first operational guidelines for human immunodeficiency virus self-testing (HIVST) to improve access to human immunodeficiency virus (HIV) testing services among undertested populations in the country. Also, as part of the campaign to increase HIV testing services in Nigeria, the Nigerian Ministry of Health developed standard operating procedures for using HIVST kits.

AIM

To systematically review the acceptability and strategies for enhancing the uptake of HIVST in Nigeria.

METHODS

The systematic review was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Different databases were searched to get the necessary materials needed for this review. Standardized forms developed by the authors were used for data extraction to minimize the risk of bias and ensure that the articles used for the study were properly screened. Identified articles were first screened using the titles and their abstracts. The full papers were screened, and the similarities of the documents were determined. Qualitative, quantitative, and mixed-method studies were evaluated using the Critical Appraisal Skills Programme and Critical Appraisal Framework criteria.

RESULTS

All the publications reviewed were published between 2015 and 2022, with 33.3% published in 2021. Most (77.8%) of the studies were cross-sectional, 43.3% were conducted in Lagos State, and 26.3% were conducted among young people. The study revealed a high level of acceptability of HIVST. Certain factors, such as gender, sexual activity, and previous testing experience, influence the acceptability of HIV self-testing, with some individuals more likely to opt-out. The cost of the kit was reported as the strongest factor for choosing HIVST services, and this ranged from 200 to 4000 Naira (approximately United States Dollar 0.55-11.07), with the majority willing to pay 500 Naira (approximately United States Dollar 1.38). Privately-owned, registered pharmacies, youth-friendly centres, supermarkets, and online stores were the most cited access locations for HIVST. The least influential attribute was the type of specimen needed for HIVST. Strategies addressing cost and preferred access points and diverse needs for social media promotion, local translation of product use instructions, and HIVST distribution led by key opinion leaders for key populations were found to significantly enhance HIVST uptake and linkage to care.

CONCLUSION

HIVST acceptability is generally high from an intention-to-use perspective. Targeted strategies are required to improve the acceptability of HIV self-testing, especially among males, sexually active individuals, and first-time testers. Identified and proposed uptake-enhancing strategies need to be investigated in controlled settings and among different populations and distribution models in Nigeria.

Preferences for oral- vs blood-based human immunodeficiency virus self-testing: A scoping review of the literature

BACKGROUND

The evidence on preferences for oral- vs blood-based human immunodeficiency virus self-testing (HIVST) has been heterogenous and inconclusive. In addition, most evaluations have relied on hypothetical or stated use cases using discreet choice experiments rather than actual preferences among experienced users, which are more objective and critical for the understanding of product uptake. Direct head-to-head comparison of consumer preferences for oral- versus blood-based HIVST is lacking.

AIM

To examine the existing literature on preferences for oral- vs blood-based HIVST, determine the factors that impact these preferences, and assess the potential implications for HIVST programs.

METHODS

Databases such as PubMed, Medline, Google Scholar, and Web of Science were searched for articles published between January 2011 to October 2022. Articles must address preferences for oral- vs blood-based HIVST. The study used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist to ensure the quality of the study.

RESULTS

The initial search revealed 2424 records, of which 8 studies were finally included in the scoping review. Pooled preference for blood-based HIVST was 48.8% (9%-78.6%), whereas pooled preference for oral HIVST was 59.8% (34.2%-91%) across all studies. However, for male-specific studies, the preference for blood-based HIVST (58%-65.6%) was higher than that for oral (34.2%-41%). The four studies that reported a higher preference for blood-based HIVST were in men. Participants considered blood-based HIVST to be more accurate and rapid, while those with a higher preference for oral HIVST did so because these were considered non-invasive and easy to use.

CONCLUSION

Consistently in the literature, men preferred blood-based HIVST over oral HIVST due to higher risk perception and desire for a test that provides higher accuracy coupled with rapidity, autonomy, privacy, and confidentiality, whereas those with a higher preference for oral HIVST did so because these were considered non-invasive and easy to use. Misinformation and distrust need to be addressed through promotional messaging to maximize the diversity of this new biomedical technology.

Tracking adaptation strategies of an HIV prevention intervention among youth in Nigeria: a theoretically informed case study analysis of the 4 Youth by Youth Project

BACKGROUND

Although many behavioral interventions are adapted, little is known about the reasons for adaptations and the process and outcomes influencing adaptations. To address this gap, we explored the adaptations made to promote HIV prevention services, including HIV self-testing (HIVST), among Nigerian youth.

METHODS

The main objective of this qualitative case study design was to document the adaptations made over time using the Framework for Reporting Adaptations and Modifications - Expanded (FRAME). Between 2018 and 2020, we organized four participatory activities as part of the 4 Youth by Youth project to increase the uptake of HIVST services in Nigeria-an open call, a designathon, a capacity-building bootcamp and a pilot feasibility trial. We also began the process of implementing a final intervention using a pragmatic randomized control trial (RCT). The open call solicited creative strategies to promote HIVST among Nigerian youth and then had experts evaluate them. The designathon brought together youth teams to further develop their HIVST service strategies into implementation protocols. Teams determined to be exceptional were invited to a four-week capacity-building bootcamp. The five teams that emerged from the bootcamp were supported to pilot their HIVST service strategies over a 6-month period. The adapted intervention is currently being evaluated in a pragmatic RCT. We transcribed meeting reports and conducted document reviews of study protocols and training manuals.

RESULTS

Sixteen adaptations were identified and categorized into three domains: (1) modifications to the content of the intervention (i.e. photo verification system and/or Unstructured Supplementary Service Data (USSD) system to verify HIVST); (2) modifications to the delivery the intervention (i.e. implement participatory learning community sessions to provide supportive supervision and technical support); (3) modifications to the evaluation processes (i.e. economic evaluation to estimate the cost of implementing intervention on a larger scale). Frequent reasons for adaptation included increasing intervention reach, modifying interventions to enhance their appropriateness and fit with the recipient, and increasing the intervention's feasibility and acceptability. Most adaptations were planned and reactive, and the need for modifications was determined by the youths, 4YBY program staff, and advisory group.

CONCLUSIONS

Findings suggest that the nature of adaptations made throughout the implementation process reflects the necessity of evaluating services in context while adjusting to specific challenges as they are identified. Further research is needed to understand the effect of these adaptations on the overall intervention effect as well as the quality of youth engagement.

Exploring Determinants of HIV/AIDS Self-Testing Uptake in South Africa Using Generalised Linear Poisson and Geographically Weighted Poisson Regression

Increased HIV/AIDS testing is of paramount importance in controlling the HIV/AIDS pandemic and subsequently saving lives. Despite progress in HIV/AIDS testing programmes, most people are still reluctant to test and thus are still unaware of their status. Understanding the factors associated with uptake levels of HIV/AIDS self-testing requires knowledge of people's perceptions and attitudes, thus informing evidence-based decision making. Using the South African National HIV Prevalence, HIV Incidence, Behaviour and Communication Survey of 2017 (SABSSM V), this study assessed the efficacy of Generalised Linear Poisson Regression (GLPR) and Geographically Weighted Poisson Regression (GWPR) in modelling the spatial dependence and non-stationary relationships of HIV/AIDS self-testing uptake and covariates. The models were calibrated at the district level across South Africa. Results showed a slightly better performance of GWPR (pseudo R² = 0.91 and AICc = 390) compared to GLPR (pseudo R² = 0.88 and AICc = 2552). Estimates of local intercepts derived from GWPR exhibited differences in HIV/AIDS self-testing uptake. Overall, the output of this study displays interesting findings on the levels of spatial heterogeneity of factors associated with HIV/AIDS self-testing uptake across South Africa, which calls for district-specific policies to increase awareness of the need for HIV/AIDS self-testing.

Preferences for an HIV Self-Testing Program Among Women who Engage in sex Work and use Drugs in Kazakhstan, Central Asia

Purpose

Women engaged in sex work (WESW) who use drugs face barriers to HIV testing. HIV self-testing (HST) may empower sex workers to learn their HIV status; however, it is not scaled up among WESW in Kazakhstan. This study aimed to explore barriers and facilitators to traditional HIV testing and HST among this population.

Method

We conducted 30 in-depth interviews (IDIs) and four focus groups (FGs) with Kazakhstani WESW who use drugs. Pragmatic analysis was used to explore key themes from qualitative data.

Results

Participants welcomed HST due to its potential to overcome logistical challenges by accessing HIV testing, as well as the stigma that WESW faces in traditional HIV testing. Participants desired emotional and social support for HST, and for linkage to HIV care and other services.

Discussion

HST among women who exchange sex and use drugs can be successfully implemented to mitigate stigma and barriers to HIV testing.

Age-of-consent requirements and adolescent HIV testing in low-and middle-income countries: multinational insights from 51 population-based surveys

BACKGROUND

Pervasive social and structural barriers-including national policies-inhibit HIV testing uptake among priority populations, including adolescents. We assessed the relationship between age-of-consent policies for HIV testing and adolescent HIV testing coverage in 51 low- and middle-income countries.

METHODS

We pooled data from household surveys (2010-2020) and calculated the weighted country-level prevalence of lifetime HIV testing separately for adolescent girls and boys (ages 15-19). We then abstracted age-of-consent requirements for HIV testing across countries. Using multivariable linear regression, we estimated the average difference in national HIV testing coverage estimates for adolescent girls and boys by age-of-consent restrictions for HIV testing.

RESULTS

National HIV testing coverage estimates ranged from 0.7% to 72.5% among girls (median: 18.0%) and 0% to 73.2% among boys (median: 7.5%) in Pakistan and Lesotho, respectively. In adjusted models, HIV testing coverage in countries requiring parental consent for individuals <18 years was, on average, 9.4 percentage-points (pp) lower (95% confidence interval [95%CI] -17.9pp to -0.9pp) among girls and 9.3pp lower (95%CI: -17.3pp to -1.2pp) among boys, relative to countries with less restrictive policies (age-of-consent: ≤16 years). Compared to countries with less restrictive (age-of-consent: ≤14 years) policies, HIV testing prevalence was significantly lower among girls (β -10.5pp, 95%CI: -19.7pp to -1.3pp) and boys (β -10.5pp, 95%CI -19.2pp to -1.8pp) in countries with more restrictive (age-of-consent: 18 years) parental consent requirements.

CONCLUSIONS

Age-of-consent policies are persistent obstacles to adolescent HIV testing. Repealing parental consent requirements for HIV testing is needed to expand coverage and accelerate progress towards global HIV treatment and prevention targets.

Preferences, beliefs, and attitudes about oral fluid and blood-based HIV self-testing among truck drivers in Kenya choosing not to test for HIV

Introduction

Clinical trials in sub-Saharan Africa support that HIV self-testing (HIVST) can increase testing rates in difficult-to-reach populations. However, trials mostly evaluate oral fluid HIVST only. We describe preferences for oral fluid vs. blood-based HIVST to elucidate prior trial results and inform testing programs.

Methods

Participants were recruited from a HIVST randomized controlled trial in Nakuru County, Kenya, which aimed to test the effect of choice between oral HIVST and facility-based testing compared to standard-of-care on HIV testing among truck drivers. We conducted in-depth interviews (IDIs) with purposively sampled trial participants who declined HIV testing at baseline or who were offered access to oral fluid HIVST and chose not to pick up the kit during follow-up. IDIs were conducted with all consenting participants. We first describe IDI participants compared to the other study participants, assessing the statistical significance of differences in characteristics between the two samples and then describe preferences, beliefs, and attitudes about HIVST biospecimen type expressed in the IDIs.

Results

The final sample consisted of 16 men who refused HIV testing at baseline and 8 men who did not test during follow-up. All IDI participants had tested prior to study participation; mean number of years since last HIV test was 1.55, vs. 0.98 among non-IDI participants (p = 0.093). Of the 14 participants who answered the question about preferred type of HIVST, nine preferred blood-based HIVST, and five, oral HIVST. Preference varied by study arm with four of five participants who answered this question in the Choice arm and five of nine in the SOC arm preferring blood-based HIVST. Six key themes characterized truckers' views about test type: (1) Rapidity of return of test results. (2) Pain and fear associated with finger prick. (3) Ease of use. (4) Trust in test results; (5) fear of infection by contamination; and (6) Concerns about HIVST kit storage and disposal.

Conclusion

We found no general pattern in the themes for preference for oral or blood-based HIVST, but if blood-based HIVST had been offered, some participants in the Choice arm might have chosen to self-test. Offering choices for HIVST could increase testing uptake.

Understanding factors that promote uptake of HIV self-testing among young people in Nigeria: Framing youth narratives using the PEN-3 cultural model

It is important to understand how to frame the formats for promoting HIV self-testing to increase uptake among young people. In this study, we used a culture-centered model to understand the narratives of HIV self-testing preferences among young people in Nigeria. We conducted a crowdsourcing contest to solicit ideas surrounding HIV self-testing promotion among young people (10–24 years) in Nigeria from October to November 2018 as part of the 2018 World AIDS Day event. We received 903 submissions and employed thematic content analysis to evaluate 769 eligible youth narratives. Thematic content analysis of the statements from the youth narratives was guided by the PEN-3 cultural model to examine the positive, existential, and negative perceptions (beliefs and values), enablers (resources), and nurturers (roles of friends and family) of HIV self-testing promotion among young people in Nigeria. Several themes emerged as factors that influence the uptake of HIV self-testing among young people in Nigeria. Specifically, seven themes emerged as perceptions: HIV testing accessibility, stigma reduction, and autonomy (positive); HIV self-testing kit packaging and advertisements (existential); lack of knowledge and increased stigma (negative). Seven themes emerged as enablers: social media, school, and government promotion (positive); gamification and animation (existential); high cost and access to linkage to care services (negative); And seven themes emerged as nurturers: peer, families, and faith-based communities (positive); parents and family-centered approach (existential); and partners and family (negative). Our data suggests that increased awareness around HIV self-testing on current youth-friendly platforms, de-stigmatization of HIV and HIV self-testing, decreased prices for HIV self-testing kits, reliability of testing kits, increased linkage to care services, and promotion of self-testing among family members and the community will be beneficial for HIV self-testing scale-up measures among young people in Nigeria.

Utilizing a Designathon to develop HIV self-testing intervention to improve linkage to care among youth in Nigeria (Preprint)

BACKGROUND

UNAIDS (Joint United Nations Programme on HIV and AIDS) and the Nigeria National HIV/AIDS Strategic Framework recommend HIV self-testing and youth-friendly services to enhance HIV testing, linkage to health services, and prevention. However, the voices of youths are seldom incorporated into interventions. We examined qualitative data generated from a series of participatory events in partnership with Nigerian youths focused on enhancing linkage to care.

OBJECTIVE

The aim of this study was to assess youth-initiated interventions developed during a designathon to improve linkage to care and sexually transmitted infection services.

METHODS

This study conducted a designathon informed by crowdsourcing principles and the participatory research action framework. A designathon is a multistage process including an open call, a sprint event, and follow-up activities. The open call solicited Nigerian youths (14-24 years old) to develop intervention strategies for linkage to care and youth-friendly health services. A total of 79 entries were received; from this, a subset of 13 teams responded to the open call and was invited to participate in a sprint event over 72 hours. Narratives from the open-call proposals were analyzed using grounded theory to identify emergent themes focused on youth-proposed interventions for linkage to care and youth-friendly services.

RESULTS

A total of 79 entries (through the web=26; offline=53) were submitted. Women or girls submitted 40 of the 79 (51%) submissions. The average age of participants was 17 (SD 2.7) years, and 64 of 79 (81%) participants had secondary education or less. Two main themes highlighted strategies for enhancing youths' HIV linkage to care: digital interventions and collaboration with youth influencers. A total of 76 participants suggested digital interventions that would facilitate anonymous web-based counseling, text prompt referrals, and related services. In addition, 16 participants noted that collaboration with youth influencers would be useful. This could involve working in partnership with celebrities, gatekeepers, or others who have a large youth audience to enhance the promotion of messages on HIV self-testing and linkage. The facilitators of youths' linkage included health facility restructuring, dedicated space for youths, youth-trained staff, youth-friendly amenities, and subsidized fees. Barriers to HIV linkage to care among youths included a lack of privacy at clinics and concerns about the potential for breaching confidentiality.

CONCLUSIONS

Our data suggest specific strategies that may be useful for enhancing HIV linkage to care for Nigerian youths, but further research is needed to assess the feasibility and implementation of these strategies. Designathons are an effective way to generate ideas from youths.

Effects of a multimedia campaign on HIV self-testing and PrEP outcomes among young people in South Africa: a mixed-methods impact evaluation of 'MTV Shuga Down South'

Introduction

Innovative HIV technologies can help to reduce HIV incidence, yet uptake of such tools is relatively low among young people. To create awareness and demand among adolescents and young adults, a new campaign of the pan-African MTV Shuga series (‘Down South 2’; DS2), featured storylines and messages about HIV self-testing (HIVST) and pre-exposure prophylaxis (PrEP) through television, radio and accompanying multimedia activities in 2019–2020.

Methods

We conducted a mixed-methods evaluation of the new MTV Shuga series among 15–24 years old in Eastern Cape, South Africa, in 2020. Quantitative and qualitative methods were used to investigate complementary evaluations questions, namely, whether and how the DS2 campaign works. A web-based survey, promoted via social media platforms of schools, universities and communities, assessed exposure to MTV Shuga and knowledge of HIV status; secondary outcomes included awareness and uptake of HIVST and PrEP. We used multivariable logistic regression to estimate associations between exposure to DS2 and each outcome, adjusting for sociodemographic factors, media assets and exposure to other media campaigns. An embedded qualitative evaluation explored mechanisms of DS2’s impact through deductive and inductive thematic analysis of in-depth individual and group interviews.

Results

Among 3431 online survey participants, 43% had engaged with MTV Shuga and 24% with DS2 specifically. Knowledge of HIV status was higher among those exposed to DS2 (71%) vs those who were not (39%; adjusted OR=2.26 (95% CI 1.78 to 2.87)). Exposure was also associated with increased awareness of HIVST (60% vs 28%; aOR=1.99 (1.61 to 2.47)) and use of HIVST (29% vs 10%; aOR=2.49 (1.95 to 3.19)). One-third of respondents were aware of PrEP, with higher proportions among those exposed versus non-exposed to DS2 (52% vs 27%; aOR=1.90 (1.53 to 2.35)). Qualitative insights identified mechanisms by which DS2 increased awareness, confidence and motivation to use HIVST and PrEP, but had less influence on service access.

Conclusions

We found evidence consistent with a positive causal impact of the MTV Shuga DS2 campaign on HIV prevention outcomes among young people in a high-prevalence setting. As diverse testing and PrEP technologies become accessible, an immersive edutainment campaign can help to expand HIV prevention choices and close age and gender gaps in HIV testing and prevention goals.

Analyses of Kaposi Sarcoma trends among adults establishing initial outpatient HIV care in Nigeria: 2006-2017

Background

The incidence of Human Immunodeficiency Virus (HIV)-associated Kaposi Sarcoma (KS) in the pre-antiretroviral therapy (ART) population remains high in several countries in sub-Saharan Africa. We examined trends of KS prevalence in adults, establishing initial outpatient HIV care from 2006 to 2017 in Nigeria.

Methods

We analyzed data of 16,431 adults (age ≥ 18 years) enrolled for HIV care from January 1, 2006, to December 31, 2017, in a large clinic in Jos, Nigeria. KS at enrollment was defined as KS recorded in the electronic health record within 30 days of clinic enrollment. Time trends were compared among four periods: 2006–2008, 2009–2011, 2012–2014, and 2015–2017 using logistic regression models. Annual trends were analyzed using join point regression and restricted splines.

Results

The study population had a mean age 35.1 (standard deviation, SD 9.5) years, and were 65.7% female (n = 10,788). The mean CD4 cell count was 220 (95% CI 117–223). The overall KS prevalence at entry was 0.59% (95% CI 0.48–0.72). Compared to 2006–2008, KS prevalence was significantly higher in 2009–2011 (adjusted odds ratio 5.07 (95% CI 3.12–8.24), p < 0.001), but remained unchanged in subsequent periods. Male sex and low CD4 T-cell count independently increased odds for KS.

Conclusions

Despite ART expansion, KS at enrollment showed no significant decline. The low CD4 cell count, across all periods, indicates delay in enrollment for HIV care, which increases KS risk. Interventions aimed at early HIV diagnosis and linkage to ART is critical to KS risk reduction in this population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13027-022-00424-4.

The 4 Youth by Youth (4YBY) pragmatic trial to enhance HIV self-testing uptake and sustainability: Study protocol in Nigeria

BACKGROUND

The World Health Organization recommends HIV self-testing (HIVST) as an additional approach to HIV testing and the Nigerian government is supportive of this policy recommendation. However, effectively increasing uptake and sustainability among Nigerian youth is unknown. The goal of this study is to conduct a full-powered type I hybrid effectiveness-implementation trial to test the effectiveness of youth-friendly implementation science strategies in increasing uptake and sustainability of HIVST led by and for Nigerian youth.

METHODS

Our 4 Youth by Youth (4YBY) strategy combines four core elements: 1) HIVST bundle consisting of HIVST kits and photo verification system; 2) a participatory learning community; 3) peer to peer support and technical assistance; and 4) on-site supervision and performance feedback to improve uptake and sustainability of HIVST and enhance linkage to youth-friendly health clinics for confirmatory HIV testing where needed, sexually transmitted infection (STI) testing (i.e. syphilis, gonorrhea, chlamydia, and hepatitis, STI treatment, and PrEP referral. Utilizing a stepped-wedge, cluster-randomized controlled trial, a national cohort of youth aged 14-24 recruited from 32 local government areas across 14 states and four geo-political zones in Nigeria will receive the 4YBY implementation strategy. In addition, an economic evaluation will explore the incremental cost per quality adjusted life year gained.

DISCUSSION

This study will add to the limited "how-to-do it literature" on implementation science strategies in a resource-limited setting targeting youth population traditionally underrepresented in implementation science literature. Study findings will also optimize uptake and sustainability of HIVST led by and for young people themselves.

TRIAL REGISTRATION

This study is registered in ClinicalTrials.govNCT04710784 (on January 15, 2021).

Implementation of a campus-based and peer-delivered HIV self-testing intervention to improve the uptake of HIV testing services among university students in Zimbabwe: the SAYS initiative

Background

The uptake of HIV testing services among adolescents and young adults in Zimbabwe is low due to stigma associated with the risk of mental and social harm. The WHO recommends HIV self-testing (HIVST) as an innovative approach to improve access to HIV testing for this hard-to-reach populations. This study describes the development and implementation of a coordinated multifaceted and multidisciplinary campus-based approach to improve the uptake of HIV testing among university students in Zimbabwe.

Methods

We utilized both quantitative and qualitative methods guided by the Exploration, Preparation, Implementation, and Sustainment Framework. A formative survey, in-depth interviews, and a scoping review were conducted as part of the situation analysis. Implementers (peer educators and health workers) were trained and community dialogue sessions were conducted to ascertain the determinants (enablers and barriers) influencing both the inner and outer contexts. Self-test kits were disbursed over 6 months before a summative evaluation survey was conducted. Qualitative data were analyzed thematically while the chi-squared test was used to analyze quantitative data.

Results

The formative evaluation showed that 66% of students intended to test and 44% of the enrolled students collected HIVST test kits. Giving comprehensive and tailored information about the intervention was imperative to dispel the initial skepticism among students. Youth-friendly and language-specific packaging of program materials accommodated the students. Despite the high acceptability of the HIVST intervention, post-test services were poorly utilized due to the small and isolated nature of the university community. Implementers recommended that the students seek post-test services off-site to ensure that those with reactive results are linked to treatment and care.

Conclusions

Peer-delivered HIVST using trained personnel was acceptable among adolescents and young adults offered the intervention at a campus setting. HIVST could increase the uptake of HIV testing for this population given the stigma associated with facility-based HTS and the need for routine HIV testing for this age group who may not otherwise test. An off-site post-test counseling option is likely to improve the implementation of a campus-based HIVST and close the linkage to treatment and care gap.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07622-1.

Did you hear about HIV self-testing? HIV self-testing awareness after community-based HIVST distribution in rural Zimbabwe

BACKGROUND

Several trials of community-based HIV self-testing (HIVST) provide evidence on the acceptability and feasibility of campaign-style distribution to reach first-time testers, men and adolescents. However, we do not know how many remain unaware of HIVST after distribution campaigns, and who these individuals are. Here we look at factors associated with never having heard of HIVST after community-based campaign-style HIVST distribution in rural Zimbabwe between September 2016 and July 2017.

METHODS

Analysis of representative population-based trial survey data collected from 7146 individuals following community-based HIVST distribution to households was conducted. Factors associated with having never heard of HIVST were determined using multivariable mixed-effects logistic regression adjusted for clustered design.

RESULTS

Among survey participants, 1308 (18.3%) self-reported having never heard of HIVST. Individuals who were between 20 and 60 years old {20-29 years: [aOR = 0.74, 95% CI (0.58-0.95)], 30-39 years: [aOR = 0.56, 95% CI (0.42-0.74)], 40-49 years: [aOR = 0.50, 95% CI (0.36-0.68)], 50-59 years [aOR = 0.58, 95% CI (0.42-0.82)]}, who had attained at least ordinary level education [aOR = 0.51, 95% CI (0.34-0.76)], and who had an HIV test before [aOR = 0.30, 95% CI (0.25-0.37)] were less likely to have never heard of HIVST compared with individuals who were between 16 and 19 years old, who had a lower educational level and who had never tested for HIV before, respectively. In addition, non-household heads or household head representatives [aOR = 1.21, 95% CI (1.01-1.45)] were more likely to report never having heard of HIVST compared to household head and representatives.

CONCLUSIONS

Around one fifth of survey participants remain unaware of HIVST even after an intensive community-based door-to-door HIVST distribution. Of note, those least likely to have heard of self-testing were younger, less educated and less likely to have tested previously. Household heads appear to play an important role in granting or denying access to self-testing to other household members during door-to-door distribution. Differentiated distribution models are needed to ensure access to all. Trial registration PACTR, PACTR201607001701788. Registered 29 June 2016, https://pactr.samrc.ac.za/ PACTR201607001701788.

The 4 Youth By Youth mHealth Photo Verification App for HIV Self-testing in Nigeria: Qualitative Analysis of User Experiences

Background

Despite the global expansion of HIV self-testing (HIVST), many research studies still rely on self-reported outcomes. New HIVST verification methods are needed, especially in resource-limited settings.

Objective

This study aims to evaluate the user experience of a mobile health (mHealth) app to enhance HIVST result reporting and verification.

Methods

Semistructured, in-depth interviews were used to evaluate the user experience of the 4 Youth By Youth mHealth photo verification app for HIVST. We used a think-aloud approach, and participants performed usability tasks and completed a qualitative exit interview. The app included HIV educational resources, step-by-step video instructions for performing HIVST, a 20-minute timer, a guide on interpreting results with linkages to care, an offline version, and a photo verification system. Demographic characteristics were reported by using descriptive statistics. Qualitative data were analyzed by using thematic analysis.

Results

A total of 19 users—12 women and 7 men—with a mean age of 22 years, participated in the study. The users completed the usability tasks and successfully uploaded a photo of their test results by using the app without assistance. Four main themes were identified in the data. First, in terms of user-friendly design, the participants noted the user-friendly features of the offline version and the app’s low data use. However, some wanted the app to work in the background when using their mobile phone, and the font used should be more youth friendly. Second, in terms of ease of use, participants remarked that the app’s self-explanatory nature and instructions that guided them on how to use the app enhanced its use. Third, in terms of a user’s privacy, many participants reinforced the importance of privacy settings and tools that protect confidentiality among users. Finally, in terms of linkage to care, participants noted that the app’s linkage to care features were useful, particularly in relation to referrals to trained counselors upon the completion of the test. All the participants noted that the app provided a convenient and private means of verifying the HIV test results.

Conclusions

Our findings demonstrated the importance of engaging end users in the development phase of health technology innovations that serve youth. Clinical trials are needed to determine the efficacy of using an mHealth app to verify HIVST results among young people.

Perspectives of Policymakers on the Introduction and Scale-Up of HIV Self-Testing and Implication for National HIV Programming in Ghana

Background: HIV self-testing (HIVST) has the potential to greatly increase HIV testing uptake, particularly among key populations (KPs) at higher risk for HIV. Studies have shown high acceptability and feasibility of HIVST among various target populations globally. However, less is known about the perspectives of policymakers, who are critical to the success of HIVST implementation. Their views on barriers to the introduction and scale-up of self-testing are critical to understand in order for HIVST to become part of the national HIV guidelines. We sought to understand policymakers' perspectives of challenges and facilitators to the introduction of HIVST at the client and structural levels.

Method: Key informant interviews (KIIs) were conducted with national and regional level policymakers involved in the HIV response. Twenty policymakers were purposively selected from Greater Accra (capital) and Brong-Ahafo (outlying) regions. Qualitative content analysis was used to arrive at the results after the verbatim transcripts were coded.

Results: Client-level challenges included lack of pre-test counseling, the need for confirmatory testing if reactive, potential for poor linkage to care and treatment, and client-level facilitator from policy makers' perspectives included increase testing modality that would increase testing uptake. Structural-level challenges mentioned by policymakers were lack of a national policy and implementation guidelines on HIVST, cost of HIVST kits, supply chain management of HIVST commodities, data monitoring and reporting of positive cases. The structural-level appeal of HIVST to policymakers were the reduced burden on health system and HIVST's contribution to achieving testing targets. Despite the challenges mentioned, policymakers unanimously favored and called for the introduction of HIVST in Ghana.

Conclusions: Findings indicate that a non-conventional HIV testing strategy such as HIVST is highly acceptable to policymakers. However, successful introduction of HIVST hinges on having national guidelines in place and stakeholder consultations to address various individual and structural -level implementation issues.

Multiple Sexual Partners as Major Predictor of Human Immunodeficiency Virus Seropositivity Among Pregnant Women, Osun State, Nigeria

Concerning human immunodeficiency virus (HIV) epidemiology, pregnant women (PW) are particularly vulnerable and severely affected. Nigeria has over 40 years of HIV epidemiology and enlightenments; to suggest control hub, we sought to know extant variables predicting HIV positivity among PW in selected towns in Osun State. Our hypothesis: none of the study PW's variables predicts HIV seropositivity. With ethics approval from UNIOSUN Health Research Ethics Committee, 900 consecutively selected consenting PW attending antenatal care (ANC) facilities in four towns (capital city inclusive) provided relevant sociodemographic/behavioral data with questionnaire forms; each participant was aseptically bled and plasma screened with the Alere Determine^® Rapid HIV-1/2 Kit. The presumptive reactive plasma samples (and some randomly selected nonreactive samples) were confirmed with Genscreen^® ULTRA HIV-1/2 P²⁴ antigen/antibody ELISA. Microsoft Excel and SPSS 16.0 were used for result analysis using t-test, CHI² test, and binary logistic regression. The PW were 15-50 years of age (n = 900; mean: 26.6 years [95% CI: 26.1-26.9 years]); they were predominantly 15-29 years (71.1%), married (90.8%), with one lifetime sexual partner (86.4%). Seropositive PW by screening and confirmatory tests were, respectively, 14 (1.6% [95% CI: 0.9-2.6%]) and 15 (1.7% [95% CI: 0.9-2.7%]). The latter were predominantly 20-30 years (80.0%), married (93.3%), with ≤ secondary school education (86.7%), reportedly never screened for HIV (60.0%), with 86.7% aware HIV is sexually transmitted. Analysis showed only ≥ three lifetime sexual partners was independently associated with HIV seropositivity (p = 0.03; odds ratio (OR) = 17.0). Although educational status was not associated with seropositivity, PW having primary school education had about 6 times higher likelihood of seropositivity (p = 0.06; OR = 5.7 [95% CI: 0.94-35.1]). Also, primigravida had about twice higher likelihood of seropositivity (p = 0.44; OR = 1.5 [95% CI: 0.54-4.17]). HIV seropositivity was relatively low and majorly predicted by ≥ three lifetime sexual partners; suggesting this as prime focus of HIV counseling among PW attending ANC in Osun State, Nigeria.

Strategies for enhancing uptake of HIV self-testing among Nigerian youths: a descriptive analysis of the 4YouthByYouth crowdsourcing contest

INTRODUCTION

Youth are often the intended beneficiaries of HIV programs but are rarely involved in program design. Engaging youth in program design is one potential way of identifying promising approaches for HIV service delivery. The purpose of this study is to examine the feasibility of using a crowdsourcing contest to solicit ideas on ways to promote HIV self-testing (HIVST) services among Nigerian youths.

METHODS

From October-November, 2018 Nigerian youth 10-24 years old submitted ideas to a crowdsourcing contest on how to promote HIVST among their peers. Submissions were scored on feasibility, desirability, and impact, with an integer score of 1 (low) to 3 (high) in each domain. The three-domain scores were added to calculate a total score (3-9). The demographic characteristics of contestants were calculated using descriptive statistics.

RESULTS

Nine-hundred and three entries were received, 831 had unique valid responses, and 769 were eligible for scoring. Youth submitted ideas on paper (44.9%), Google Forms (39.4%), WhatsApp (9.6%), and email (6.1%). Participants' ages were 10-14 years (37%), 15-19 years (44%), and 20-24 years (22%).Approximately half were female (51.2%). Mean scores were 1.4/3.0 (SD=0.6) for feasibility, 1.4/3.0 (SD=0.6) for desirability, 1.2/3.0 (SD=0.5) for impact, and 4.0/9.0 (SD=1.5) overall. Eight percent of submissions had an overall score >7. A disproportionate share of these high-quality submissions came from email and Google submissions.

CONCLUSION

The 4 Youth by Youth crowdsourcing contest engaged a broad audience and is a feasible way to elicit potential strategies to distribute HIVST kits to other youth. Several high-quality ideas require further evaluation.

Designing HIV Testing and Self-Testing Services for Young People in Nigeria: A Discrete Choice Experiment

BACKGROUND AND OBJECTIVE

A third of new human immunodeficiency virus (HIV) infections occur among young people and the majority of young people living with HIV are in sub-Saharan Africa. We examined the strength of Nigerian youth preferences related to HIV testing and HIV self-testing (HIVST).

METHODS

Discrete choice experiments were conducted among Nigerian youth (age 14-24 years). Participants completed one of two discrete choice experiments: (1) preferred qualities of HIV testing (cost, location of test, type of test, person who conducts the test, and availability of HIV medicine at the testing site) and (2) preferred qualities of HIVST kits (cost, test quality, type of test, extra items, and support if tested positive). A random parameter logit model measured the strength of preferences.

RESULTS

A total of 504 youth participated: mean age 21 years (standard deviation 2 years), 38% male, and 35% had a higher than secondary school education. There was a strong preference overall to test given the scenarios presented, although male individuals were less likely to test for HIV or use HIVST kits. Youth preferred HIV testing services (with attributes in order of importance) that are free, blood-based testing, available in private/public hospitals or home, for HIV medications to be available in the same location as testing, and a doctor conducts the test. Participants preferred HIVST kits (with attributes in order of importance) that are available from community health centers, free, approved by the World Health Organization, include other sexually transmitted infection testing, have the option of an online chat, and oral-based HIVST.

CONCLUSIONS

The HIV home testing was equally preferred to testing in a hospital, suggesting a viable market for HIVST if kits account for youth preferences. Male youth were less likely to choose to test for HIV or use HIVST kits, underscoring the need for further efforts to encourage HIV testing among young male individuals.