The effects of HIV testing advocacy messages on test acceptance: a randomized clinical trial

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

BACKGROUND

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

METHODS AND FINDINGS

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

CONCLUSIONS

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

Factors Associated With the Intention to Receive the COVID-19 Vaccine: Cross-sectional National Study

BACKGROUND

The COVID-19 pandemic is an unprecedented public health crisis, and vaccines are the most effective means of preventing severe consequences of this disease. Hesitancy regarding vaccines persists among adults in the United States, despite overwhelming scientific evidence of safety and efficacy.

OBJECTIVE

The purpose of this study was to use the Health Belief Model (HBM) and reasoned action approach (RAA) to examine COVID-19 vaccine hesitancy by comparing those who had already received 1 vaccine to those who had received none.

METHODS

This study examined demographic and theory-based factors associated with vaccine uptake and intention among 1643 adults in the United States who completed an online survey during February and March 2021. Survey items included demographic variables (eg, age, sex, political ideology), attitudes, and health belief variables (eg, perceived self-efficacy, perceived susceptibility). Hierarchical logistic regression analyses were used for vaccine uptake/intent. The first model included demographic variables. The second model added theory-based factors to examine the association of health beliefs and vaccine uptake above and beyond the associations explained by demographic characteristics alone.

RESULTS

The majority of participants were male (n=974, 59.3%), White (n=1347, 82.0%), and non-Hispanic (n=1518, 92.4%) and reported they had already received a COVID-19 vaccine or definitely would when it was available to them (n=1306, 79.5%). Demographic variables significantly associated with vaccine uptake/intent included age (adjusted odds ratio [AOR] 1.05, 95% CI 1.04-1.06), other race (AOR 0.47, 95% CI 0.27-0.83 vs White), and political ideology (AOR 15.77, 95% CI 7.03-35.35 very liberal vs very conservative). The theory-based factors most strongly associated with uptake/intention were attitudes (AOR 3.72, 95% CI 2.42-5.73), self-efficacy (AOR 1.75, 95% CI 1.34-2.29), and concerns about side effects (AOR 0.59, 95% CI 0.46-0.76). Although race and political ideology were significant in the model of demographic characteristics, they were not significant when controlling for attitudes and beliefs.

CONCLUSIONS

Vaccination represents one of the best tools to combat the COVID-19 pandemic, as well as other possible pandemics in the future. This study showed that older age, attitudes, injunctive norms, descriptive norms, and self-efficacy are positively associated with vaccine uptake and intent, whereas perceived side effects and lack of trust in the vaccine are associated with lower uptake and intent. Race and political ideology were not significant predictors when attitudes and beliefs were considered. Before vaccine hesitancy can be addressed, researchers and clinicians must understand the basis of vaccine hesitancy and which populations may show higher hesitancy to the vaccination so that interventions can be adequately targeted.

The effects of message framing and healthcare provider recommendation on adult hepatitis B vaccination: A randomized controlled trial

Many adults in the U.S. do not receive recommended vaccines, and the research literature remains inconclusive on the best communication strategies for increasing this behavior. This study examined the association of message framing (gained-framed vs. loss-framed vs. control), and healthcare provider (HCP) recommendation (offered vs. recommended) on uptake of adult hepatitis B virus (HBV) vaccination in a high risk population using a 3 × 2 block design randomized controlled trial. Fear of shots, fear of vaccines, and perceived message framing were examined in secondary analyses. Of the 1747 participants, 47.7% (n = 833) received 0 doses of HBV vaccine, 27.8% (n = 485) received 1 dose, 10.4% received 2 doses, and 14.1% received all 3 recommended doses. There was not a significant interaction between message framing and HCP recommendation (p = .59). Mean number of doses received by the gain-framed group (m = 0.96) was not significantly different from the loss-framed group (m = 0.97, RR = 0.99, 95% CI = 0.88-1.12). However, those receiving any framing message received significantly more doses (m = 0.96) than those in the control condition (m = 0.81, RR = 1.17, 95%CI = 1.06-1.31). Participants who received a HCP recommendation received significantly more vaccine doses (m = 0.95) than those in the vaccine-offered condition (mean = 0.82, RR = 1.16, 95%CI = 1.05-1.28). These results suggest there is no difference in vaccine uptake between gain-frame and loss-frame messages, but both are better than a control message. These results also support advising HCP to provide a strong recommendation for vaccinations beyond merely offering it to patients. This study has implications for vaccine uptake beyond HBV, and can inform future research on effective vaccine communication research. Clinicaltrials.gov Identifier: NCT00739752. Registration date: August 20, 2008.

The Effectiveness of Social Marketing Interventions to Improve HIV Testing Among Gay, Bisexual and Other Men Who Have Sex with Men: A Systematic Review

HIV testing is central to biomedical HIV prevention, but testing among men who have sex with men remains suboptimal. We evaluated effectiveness of mass media and communication interventions to increase HIV testing and explored patterns between study type, internal validity and intervention effectiveness for the first time. Five databases were searched for articles published between 2009 and 2016 using standard MeSH terms. Eligible studies were quality appraised using standard checklists for risk of bias. Data were extracted and synthesised narratively. Nineteen studies met inclusion criteria; 11 were cross-sectional/non-comparative studies, four were pre/post or interrupted time series, three were randomised controlled trials (RCTs) and one was a case study. Risk of bias was high. Five cross-sectional (two graded as high internal validity, one medium and two low) and one RCT (medium validity) reported increased HIV testing. Further work is required to develop and evaluate interventions to increase frequency and maintenance of HIV testing.

A need for implementation science to optimise the use of evidence-based interventions in HIV care: A systematic literature review

To improve health outcomes in people living with HIV, adoption of evidence-based interventions (EBIs) using effective and transferable implementation strategies to optimise the delivery of healthcare is needed. ViiV Healthcare's Positive Pathways initiative was established to support the UNAIDS 90-90-90 goals. A compendium of EBIs was developed to address gaps within the HIV care continuum, yet it was unknown whether efforts existed to adapt and implement these EBIs across diverse clinical contexts. Therefore, this review sought to report on the use of implementation science in adapting HIV continuum of care EBIs. A systematic literature review was undertaken to summarise the evaluation of implementation and effectiveness outcomes, and report on the use of implementation science in HIV care. Ten databases were reviewed to identify studies (time-period: 2013-2018; geographic scope: United States, United Kingdom, France, Germany, Italy, Spain, Canada, Australia and Europe; English only publications). Studies were included if they reported on people living with HIV or those at risk of acquiring HIV and used interventions consistent with the EBIs. A broad range of study designs and methods were searched, including hybrid designs. Overall, 118 publications covering 225 interventions consistent with the EBIs were identified. These interventions were evaluated on implementation (N = 183), effectiveness (N = 81), or both outcomes (N = 39). High variability in the methodological approaches was observed. Implementation outcomes were frequently evaluated but use of theoretical frameworks was limited (N = 13). Evaluations undertaken to assess effectiveness were inconsistent, resulting in a range of measures. This review revealed extensive reporting on implementation science as defined using evaluation outcomes. However, high variability was observed in how implementation outcomes and effectiveness were defined, quantified, and reported. A more specific and consistent approach to conducting and reporting on implementation science in HIV could facilitate achievement of UNAIDS 90-90-90 targets.

Behavior and health beliefs as predictors of HIV testing among women: a prospective study of observed HIV testing

Much of the research examining predictors of HIV testing has used retrospective self-report to assess HIV testing.

FINDINGS

therefore, may be subject to recall bias and to difficulties determining the direction of associations. In this prospective study, we administered surveys to women in community clinics to identify predictors of subsequent observed HIV testing, overcoming these limitations. Eighty-three percent were tested. In the adjusted multivariable model, being born in the U.S., perceived benefits of testing, worries about being infected with HIV, having had more than 15 lifetime sexual partners, and having had one or more casual sexual partners in the previous three months predicted acceptance of testing. Perceived obstacles to testing predicted non-acceptance. Those who had never been tested for HIV and those tested two to five years previously had greater odds of test acceptance than those who had been tested within the last year. The findings from this study with observed testing as the outcome, confirm some of the results from retrospective, self-report studies. Participants made largely rational decisions about testing, reflecting assessments of their risk and their history of HIV testing. Health beliefs are potentially modifiable through behavioral intervention, and such interventions might result in greater acceptance of testing.

ABBREVIATIONS

HIV: human immunodeficiency virus; AIDS: acquired immune deficiency syndrome; CDC: Centers for Disease Control and Prevention; ACASI: audio computer-assisted self-interview; TRA: theory of reasoned action; HBM: Health Belief Model; STI: sexually transmitted infection; STD: Sexually Transmitted Disease; AOR: adjusted odds ratio; CI: confidence interval.

College students and HIV testing: cognitive, emotional self-efficacy, motivational and communication factors

Most college students have never been tested for HIV, even though they regularly have unprotected sex and multiple sex partners. Theory-based research addressing factors influencing HIV testing among college students is limited. This study explored this topic via a conceptual framework that integrates the health belief model with emotion and communication factors. Data was collected with a sample of four focus group panels, including two male and two female groups (N = 52). Transcripts for the seven discussion questions were produced based on the audio recordings of group sessions. Two research assistants reviewed, summarized and cross-validated the discussion content to address each of the four research questions under study. Students believe HIV to be a severe health threat, but feel 'invincible' about contracting the virus. Their low emotional self-efficacy is a barrier for adopting HIV testing. Gaining social approval and emotional support for making a testing decision can help them overcome the perceived fear, stigma and lack of response efficacy associated with taking the test. Students are open to receiving cues to action via confidential HIV-testing related communication from health professionals or important others as well as media messaging from various sources. Bridging the perceptual-emotional gap between perceived invulnerability and fear can help increase emotional self-efficacy in coping with HIV testing. Normalizing HIV testing as a primary care routine for harm avoidance/reduction will increase perceived benefits of testing. Communicating cues to action will help reinforce HIV testing as a societally approved and socially supported protective behavioral norm.