1
|
Lippman SA, Grignon JS, Ditshwane B, West RL, Gilmore HJ, Mazibuko S, Mongwe LG, Neilands TB, Gutin SA, O’Connor C, Santana MA, Majam M. Results of the Sukuma Ndoda ("Stand up, Man") HIV Self-Screening and Assisted Linkage to Care Project in Johannesburg: A Quasi-Experimental Pre-Post Evaluation. J Acquir Immune Defic Syndr 2024; 96:367-375. [PMID: 38916430 PMCID: PMC11195924 DOI: 10.1097/qai.0000000000003442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 04/11/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND HIV testing rates among South African men lag behind rates for women and national targets. Community-based HIV self-screening (HIVSS) distribution and follow-up by community health workers (CHWs) is a scalable option to increase testing coverage, diagnosis, and treatment initiation. We provided HIVSS and assisted linkage to care to men not recently tested (within the past 12 months) residing in high-HIV-burden areas of Johannesburg. METHODS CHWs distributed HIVSS in 6 clinic catchment areas. Follow-up to encourage confirmatory testing and antiretroviral therapy initiation was conducted through personal support (PS) or an automated short message service (SMS) follow-up and linkage system in 3 clinic areas each. Using a quasi-experimental pre-post design, we compared differences in the proportion of men testing in the clinic catchment areas during the HIVSS campaign (June-August 2019) to the 3 months prior (March-May 2019) and compared treatment initiations by assisted linkage strategy. RESULTS Among 4793 participants accepting HIVSS, 62% had never tested. Among 3993 participants with follow-up data, 90.6% reported using their HIVSS kit. Testing coverage among men increased by 156%, from under 4% when only clinic-based HIV testing services were available to 9.5% when HIVSS and HIV testing services were available (z = -11.6; P < 0.01). Reported test use was higher for men followed through PS (99% vs. 68% in SMS); however, significantly more men reported reactive self-test results in the SMS group compared with PS (6.4% vs. 2.0%), resulting in more antiretroviral therapy initiations in the SMS group compared with PS (23 vs. 9; P < 0.01). CONCLUSIONS CHW HIVSS distribution significantly increases testing among men. While PS enabled personalized follow-up, reporting differences indicate SMS is more acceptable and better aligned with expectations of privacy associated with HIVSS.
Collapse
Affiliation(s)
- Sheri A. Lippman
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Jessica S. Grignon
- International Training and Education Center for Health (I-TECH), Pretoria, South Africa
- Department of Global Health, University of Washington, Seattle, WA
| | - Boitumelo Ditshwane
- International Training and Education Center for Health (I-TECH), Pretoria, South Africa
| | - Rebecca L. West
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Hailey J. Gilmore
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Sipho Mazibuko
- International Training and Education Center for Health (I-TECH), Pretoria, South Africa
| | - Livhuwani G. Mongwe
- International Training and Education Center for Health (I-TECH), Pretoria, South Africa
| | - Torsten B. Neilands
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Sarah A. Gutin
- Department of Medicine, University of California, San Francisco, San Francisco, CA
- School of Nursing, University of California, San Francisco, San Francisco, CA
| | | | - Maideline A. Santana
- Gauteng Department of Health, Johannesburg District, Johannesburg, South Africa; and
| | - Mohammed Majam
- Ezintsha, University of Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
2
|
Nguyen VTT, Dunkley Y, Son VH, Choko AT, Huong PTT, Manh PD, Truong TM, Truc HM, Giang DT, Tung LT, Hoa VD, Baggaley R, Johnson C. Investigating the effectiveness of web-based HIV self-test distribution and linkage to HIV treatment and PrEP among groups at elevated risk of HIV in Viet Nam provinces: a mixed-methods analysis of implementation from pilot to scale-up. J Int AIDS Soc 2024; 27 Suppl 1:e26264. [PMID: 38965974 DOI: 10.1002/jia2.26264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 04/19/2024] [Indexed: 07/06/2024] Open
Abstract
INTRODUCTION In Viet Nam, key populations (KPs) face barriers accessing HIV services. Virtual platforms can be leveraged to increase access for KPs, including for HIV self-testing (HIVST). This study compares reach and effectiveness of a web-based HIVST intervention from pilot to scale-up in Viet Nam. METHODS A mixed-methods explanatory sequential design used cross-sectional and thematic analysis. The pilot launched in Can Tho in November 2020, followed by Hanoi and Nghe An in April 2021. Scale-up included Can Tho and Nghe An, with 21 novel provinces from April to December 2022. After risk assessment, participants registered on the website, receiving HIVST (OraQuick®) by courier, peer educator or self-pick-up. Test result reporting and completing satisfaction surveys were encouraged. Intervention reach was measured through numbers accessing the testing, disaggregated by demographics, and proportion of individuals reporting self-testing post-registration. Effectiveness was measured through numbers reporting self-test results, testing positive and linking to care, and testing negative and using HIVST to manage pre-exposure prophylaxis (PrEP) use. Thematic content analysis of free-text responses from the satisfaction survey synthesized quantitative outcomes. RESULTS In total, 17,589 participants registered on the HIVST website; 11,332 individuals ordered 13,334 tests. Participants were generally young, aged <25 years (4309/11,332, 38.0%), male (9418/11,332, 83.1%) and men who have sex with men (6437/11,332, 56.8%). Nearly half were first-time testers (5069/11,332, 44.9%). Scale-up participants were two times more likely to be assigned female at birth (scale-up; 1595/8436, 18.9% compared to pilot; 392/3727, 10.5%, p < 0.001). Fewer test results were reported in scale-up compared with pilot (pilot: 3129/4140, 75.6%, scale-up: 5811/9194, 63.2%, p < 0.001). 6.3% of all tests were reactive (pilot: 176/3129, 5.6% reactive compared to scale-up: 385/5811, 6.6% reactive, p = 0.063); of which most linked to care (509/522, 97.5%). One-fifth of participants with a negative test initiated or continued PrEP (pilot; 19.8%, scale-up; 18.5%, p = 0.124). Thematic analysis suggested that community delivery models increased programmatic reach. Live chat may also be a suitable proxy for staff support to increase result reporting. CONCLUSIONS Web-based self-testing in Viet Nam reached people at elevated risk of HIV, facilitating uptake of anti-retroviral treatment and direct linkage to PrEP initiations. Further innovations such as the use of social-network testing services and incorporating features powered by artificial intelligence could increase the effectiveness and efficiency of the approach.
Collapse
Affiliation(s)
| | - Yasmin Dunkley
- London School of Hygiene and Tropical Medicine, London, UK
| | - Vo Hai Son
- Viet Nam Administration for HIV/AIDS Prevention and Control, Ministry of Health, Hanoi, Viet Nam
| | - Augustine T Choko
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Department of International Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Phan Thi Thu Huong
- Viet Nam Administration for HIV/AIDS Prevention and Control, Ministry of Health, Hanoi, Viet Nam
| | - Pham Duc Manh
- Viet Nam Administration for HIV/AIDS Prevention and Control, Ministry of Health, Hanoi, Viet Nam
| | | | | | | | - Le Thanh Tung
- Minh Phat Social Enterprise for Community development, Nghe An, Viet Nam
| | | | - Rachel Baggaley
- Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Cheryl Johnson
- Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| |
Collapse
|
3
|
Tran A, Tran N, Tapa J, Tieosapjaroen W, Fairley CK, Chow EPF, Zhang L, Baggaley RC, Johnson CC, Jamil MS, Ong JJ. A typology of HIV self-testing support systems: a scoping review. Sex Health 2024; 21:SH24037. [PMID: 38950142 DOI: 10.1071/sh24037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 06/04/2024] [Indexed: 07/03/2024]
Abstract
To maximise the benefits of HIV self-testing (HIVST), it is critical to support self-testers in the testing process and ensure that they access appropriate prevention and care. To summarise systems and tools supporting HIVST (hereafter, 'support systems') and categorise them for future analysis, we synthesised the global data on HIVST support systems and proposed a typology. We searched five databases for articles reporting on one or more HIVST support systems and included 314 publications from 224 studies. Across 189 studies, there were 539 reports of systems supporting HIVST use; while across 115 studies, there were 171 reports of systems supporting result interpretation. Most commonly, these were pictorial instructions, followed by in-person demonstrations and in-person assistance while self-testing or reading self-test results. Less commonly, virtual interventions were also identified, including online video conferencing and smartphone apps. Smartphone-based automated result readers have been used in the USA, China, and South Africa. Across 173 studies, there were 987 reports of systems supporting post-test linkage to care; most commonly, these were in-person referrals/counselling, written referrals, and phone helplines. In the USA, Bluetooth beacons have been trialled to monitor self-test use and facilitate follow-up. We found that, globally, HIVST support systems use a range of methods, including static media, virtual tools, and in-person engagement. In-person and printed approaches were more common than virtual tools. Other considerations, such as linguistic and cultural appropriateness, may also be important in the development of effective HIVST programs.
Collapse
Affiliation(s)
- Arron Tran
- Melbourne Medical School, Faculty of Medicine Dentistry and Health Sciences, The University of Melbourne, Melbourne, Vic, Australia; and Melbourne Sexual Health Centre, Alfred Health, Melbourne, Vic, Australia
| | - Nghiep Tran
- Melbourne Medical School, Faculty of Medicine Dentistry and Health Sciences, The University of Melbourne, Melbourne, Vic, Australia
| | - James Tapa
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Vic, Australia
| | - Warittha Tieosapjaroen
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Vic, Australia; and Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic, Australia
| | - Christopher K Fairley
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Vic, Australia; and Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic, Australia
| | - Eric P F Chow
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Vic, Australia; and Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic, Australia; and Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Vic, Australia
| | - Lei Zhang
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Vic, Australia; and Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic, Australia
| | - Rachel C Baggaley
- Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Cheryl C Johnson
- Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Muhammad S Jamil
- Department of Communicable Diseases, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt
| | - Jason J Ong
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Vic, Australia; and Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic, Australia; and Department of Communicable Diseases, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt
| |
Collapse
|
4
|
Olum R, Geng EH, Kitutu FE, Musoke PM. Feasibility, acceptability and preliminary effect of a community-led HIV self-testing model among adolescent girls and young women in Rural Northern Uganda: a quasi-experimental study protocol. Implement Sci Commun 2024; 5:56. [PMID: 38773505 PMCID: PMC11110295 DOI: 10.1186/s43058-024-00596-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 05/13/2024] [Indexed: 05/23/2024] Open
Abstract
BACKGROUND Adolescent girls and young women (AGYW) in sub-Saharan Africa face a disproportionately higher HIV/AIDS burden despite the global decline in incidence. Existing interventions often fail to adequately address their unique social, economic, and cultural challenges, limiting access to essential HIV/AIDS services, including HIV testing. Emerging evidence indicates that HIV self-testing, a user-friendly and confidential method, enhances HIV diagnosis and linkage to care by targeting these barriers. This study aims to assess the feasibility, acceptability, and preliminary impact of a peer-delivered, community-health worker (CHW)-facilitated HIV self-testing intervention for AGYW in Northern Uganda. METHODS This mixed-methods quasi-experimental implementation science study will employ a three-fold approach. Firstly, we will conduct baseline formative qualitative research with 50 AGYW, 50 parents/partners to AGYW, 30 CHWs, 15 community leaders, and the district health office to inform the design of a peer-delivered CHW-facilitated HIV self-testing intervention tailored to AGYW's needs in Northern Uganda. Secondly, we will implement a mixed-methods pilot study to assess the intervention's feasibility and acceptability, involving 415 AGYW, 30 AGYW peer leaders, and 10 CHWs in selected parishes and villages in Omoro district, Northern Uganda. Lastly, we will evaluate the implementation outcomes and preliminary impact of the intervention on HIV self-testing rates and linkage to care by collecting and analyzing quantitative data pre- and post-intervention, laying the groundwork for a future robust randomized controlled trial. DISCUSSION Our intervention combines CHWs and peer-led strategies to address the unique challenges of AGYW in Northern Uganda, leveraging community resilience and peer influence. Successful completion of this project will provide a scalable model to be evaluated in a randomized trial and replicated in similar contexts. TRIAL REGISTRATION NUMBER PACTR202404851907736. Registered with the Pan-African Clinical Trials Registry on April 22, 2024.
Collapse
Affiliation(s)
- Ronald Olum
- Makerere University School of Public Health, Kampala, Uganda.
| | - Elvin H Geng
- Division of Infectious Diseases, Department of Medicine, Washington University in St Louis, MO, St Louis, USA
| | - Freddy E Kitutu
- Department of Pharmacy, School of Health Sciences, Makerere University, Kampala, Uganda
| | - Philippa M Musoke
- Department of Pediatrics and Child Health, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- Makerere University-John Hopkins University (MU-JHU) Collaboration, Kampala, Uganda
| |
Collapse
|
5
|
Empringham B, Karellis A, Kashkary A, D’Silva O, Carmona S, Suarez MF, Addae A, Pai NP, Zwerling AA. How much does HIV self-testing cost in low and middle income countries? A systematic review of evidence from economic studies. Front Public Health 2023; 11:1135425. [PMID: 38026397 PMCID: PMC10679730 DOI: 10.3389/fpubh.2023.1135425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 09/27/2023] [Indexed: 12/01/2023] Open
Abstract
Objectives HIV self-testing (HIVST) has been proposed as an innovative strategy to diagnose human immunodeficiency virus (HIV). While HIVST offers the potential to broaden accessibility of early HIV diagnosis and treatment initiation, this testing strategy incurs additional cost and requires confirmatory testing and treatment. We have conducted the first systematic review to summarize the current economic literature for HIVST in low- and middle-income countries (LMICs). Design A search strategy was developed including key terms for HIV, self-testing and cost-effectiveness and was conducted in Medline and Embase databases. Studies were included that reported costs per outcome and included both cost-effectiveness and cost-utility outcome measures. The search strategy identified publications up until August 15, 2023 were included. Abstract and full text screening was conducted and a standardized data abstraction form was used for included studies. Costs are reported in USD, 2020. Results Our search strategy identified 536 total titles from the search strategy, which were screened down to 25 relevant studies that provided both cost and outcome data on HIVST. There was significant heterogeneity in the HIVST intervention, study population, costs and outcomes reported among included studies. Cost per person tested ranged from $1.09-155. Cost per case diagnosed ranged from $20-1,277. Cost-utility estimates ranged from cost-saving to $1846 per DALY averted. Higher cost-effectiveness estimates were associated with more expensive testing algorithms with increased support for linkage to care and post-test counseling. Conclusion All studies considered HIVST cost-effective although major drivers were identified included underlying HIV prevalence, testing cost and linkage to care. HIVST is likely to be cost-effective in a LMIC context, however policy makers should be aware of the drivers of cost-effectiveness when implementing HIVST programs as these underlying factors can impact the overall cost-effectiveness of HIVST.
Collapse
Affiliation(s)
- Brianna Empringham
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Angela Karellis
- Division of Clinical Epidemiology & Experimental Medicine, McGill University, Montreal, QC, Canada
| | - Abdulhameed Kashkary
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Public Health Authority, Riyadh, Saudi Arabia
| | - Olivia D’Silva
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Sergio Carmona
- Foundation for Innovative New Diagnostics, Geneva, Switzerland
| | | | - Angelina Addae
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Nitika Pant Pai
- Division of Clinical Epidemiology & Experimental Medicine, McGill University, Montreal, QC, Canada
| | - Alice Anne Zwerling
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| |
Collapse
|
6
|
Maierhofer CN, Powers KA, Matoga MM, Chen JS, Jere E, Massa C, Mmodzi P, Bhushan NL, Phiri S, Hoffman IF, Lancaster KE, Miller WC, Rutstein SE. Characterizing Network-Based HIV Testing Interventions to Guide HIV Testing and Contact Tracing at STI Clinics in Lilongwe, Malawi. J Acquir Immune Defic Syndr 2023; 94:151-159. [PMID: 37345996 PMCID: PMC10528029 DOI: 10.1097/qai.0000000000003240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/12/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND Understanding heterogeneity across patients in effectiveness of network-based HIV testing interventions may optimize testing and contact tracing strategies, expediting linkage to therapy or prevention for contacts of persons with HIV (PWH). SETTING We analyzed data from a randomized controlled trial of a combination intervention comprising acute HIV testing, contract partner notification (cPN), and social contact referral conducted among PWH at 2 STI clinics in Lilongwe, Malawi, between 2015 and 2019. METHODS We used binomial regression to estimate the effect of the combination intervention vs. passive PN (pPN) on having any (1) contact, (2) newly HIV-diagnosed contact, and (3) HIV-negative contact present to the clinic, overall and by referring participant characteristics. We repeated analyses comparing cPN alone with pPN. RESULTS The combination intervention effect on having any presenting contact was greater among referring women than men [prevalence difference (PD): 0.17 vs. 0.10] and among previously vs. newly HIV-diagnosed referring persons (PD: 0.20 vs. 0.11). Differences by sex and HIV diagnosis status were similar in cPN vs. pPN analyses. There were no notable differences in the intervention effect on newly HIV-diagnosed referrals by referring participant characteristics. Intervention impact on having HIV-negative presenting contacts was greater among younger vs. older referring persons and among those with >1 vs. ≤1 recent sex partner. Effect differences by age were similar for cPN vs. pPN. CONCLUSION Our intervention package may be particularly efficacious in eliciting referrals from women and previously diagnosed persons. When the combination intervention is infeasible, cPN alone may be beneficial for these populations.
Collapse
Affiliation(s)
- Courtney N. Maierhofer
- Department of Epidemiology, Gillings School of Global
Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North
Carolina, USA
| | - Kimberly A. Powers
- Department of Epidemiology, Gillings School of Global
Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North
Carolina, USA
| | | | - Jane S. Chen
- Department of Epidemiology, Gillings School of Global
Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North
Carolina, USA
| | | | | | | | | | | | - Irving F. Hoffman
- Institute of Global Health and Infectious Disease,
University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- UNC Project Malawi, Lilongwe, Malawi
| | - Kathryn E. Lancaster
- Division of Epidemiology, College of Public Health, The
Ohio State University, Columbus, Ohio, USA
| | - William C. Miller
- Division of Epidemiology, College of Public Health, The
Ohio State University, Columbus, Ohio, USA
| | - Sarah E. Rutstein
- Institute of Global Health and Infectious Disease,
University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| |
Collapse
|
7
|
Wagner AD, Njuguna IN, Neary J, Lawley KA, Louden DKN, Tiwari R, Jiang W, Kalu N, Burke RM, Mangale D, Obermeyer C, Escudero JN, Bulterys MA, Waters C, Mollo B, Han H, Barr-DiChiara M, Baggaley R, Jamil MS, Shah P, Wong VJ, Drake AL, Johnson CC. Demand creation for HIV testing services: A systematic review and meta-analysis. PLoS Med 2023; 20:e1004169. [PMID: 36943831 PMCID: PMC10030044 DOI: 10.1371/journal.pmed.1004169] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 01/05/2023] [Indexed: 03/23/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Anjuli D. Wagner
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Irene N. Njuguna
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Jillian Neary
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Kendall A. Lawley
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Diana K. N. Louden
- University Libraries, University of Washington, Seattle, Washington, United States of America
| | - Ruchi Tiwari
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Wenwen Jiang
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Ngozi Kalu
- Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Rachael M. Burke
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Malawi Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Dorothy Mangale
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Chris Obermeyer
- The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland
| | - Jaclyn N. Escudero
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Michelle A. Bulterys
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Chloe Waters
- Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Center, Seattle, Washington, United States of America
| | - Bastien Mollo
- Infectious and Tropical Diseases Department, Bichat-Claude Bernard Hospital, AP-HP, Paris, France
| | - Hannah Han
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
| | | | - Rachel Baggaley
- Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Muhammad S. Jamil
- Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Purvi Shah
- Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
- UNAIDS, Asia Pacific, Regional Support Team, Bangkok, Thailand
| | - Vincent J. Wong
- USAID, Division of HIV Prevention, Care and Treatment, Office of HIV/AIDS, Washington DC, United States of America
| | - Alison L. Drake
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Cheryl C. Johnson
- Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| |
Collapse
|
8
|
Rosen JG, Stone EM, Mbizvo MT. Age-of-consent requirements and adolescent HIV testing in low-and middle-income countries: multinational insights from 51 population-based surveys. Int J STD AIDS 2023; 34:168-174. [PMID: 36524432 PMCID: PMC9928845 DOI: 10.1177/09564624221142372] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
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.
Collapse
Affiliation(s)
- Joseph G Rosen
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Elizabeth M Stone
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | |
Collapse
|
9
|
Endalamaw A, Gilks CF, Ambaw F, Habtewold TD, Assefa Y. Universal Health Coverage for Antiretroviral Treatment: A Review. Infect Dis Rep 2022; 15:1-15. [PMID: 36648855 PMCID: PMC9844463 DOI: 10.3390/idr15010001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/16/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Universal health coverage is essential for the progress to end threats of the acquired immunodeficiency syndrome epidemic. The current review assesses the publication rate, strategies and barriers for antiretroviral therapy (ART) coverage, equity, quality of care, and financial protection. We searched Web of Science, PubMed, and Google Scholar. Of the available articles, 43.13% were on ART coverage, 40.28% were on financial protection, 10.43% were on quality of care, and 6.16% were on equity. A lack of ART, fear of unwanted disclosure, lack of transportation, unaffordable health care costs, long waiting time to receive care, and poverty were barriers to ART coverage. Catastrophic health care costs were higher among individuals who were living in rural settings, walked greater distances to reach health care institutions, had a lower socioeconomic status, and were immunocompromised. There were challenges to the provision of quality of care, including health care providers' inadequate salary, high workload and inadequate health workforce, inappropriate infrastructure, lack of training opportunities, unclear division of responsibility, and the presence of strict auditing. In conclusion, ART coverage was below the global average, and key populations were disproportionally less covered with ART in most countries. Huge catastrophic health expenditures were observed. UHC contexts of ART will be improved by reaching people with poor socioeconomic status, delivering appropriate services, establishing a proper health workforce and service stewardship.
Collapse
Affiliation(s)
- Aklilu Endalamaw
- School of Public Health, The University of Queensland, Brisbane, QLD 4072, Australia
- College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar P.O. Box 79, Ethiopia
- Correspondence: ; Tel.: +61-424-690-121
| | - Charles F Gilks
- School of Public Health, The University of Queensland, Brisbane, QLD 4072, Australia
| | - Fentie Ambaw
- School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar P.O. Box 79, Ethiopia
| | - Tesfa Dejenie Habtewold
- Branch of Epidemiology, Division of Population Health Research, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, 9712 CP Groningen, The Netherlands
| | - Yibeltal Assefa
- School of Public Health, The University of Queensland, Brisbane, QLD 4072, Australia
| |
Collapse
|
10
|
Indravudh PP, Terris-Prestholt F, Neuman M, Kumwenda MK, Chilongosi R, Johnson CC, Hatzold K, Corbett EL, Fielding K. Understanding mechanisms of impact from community-led delivery of HIV self-testing: Mediation analysis of a cluster-randomised trial in Malawi. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0001129. [PMID: 36962622 PMCID: PMC10021599 DOI: 10.1371/journal.pgph.0001129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 09/08/2022] [Indexed: 11/05/2022]
Abstract
Community HIV strategies are important for early diagnosis and treatment, with new self-care technologies expanding the types of services that can be led by communities. We evaluated mechanisms underlying the impact of community-led delivery of HIV self-testing (HIVST) using mediation analysis. We conducted a cluster-randomised trial allocating 30 group village heads and their catchment areas to the community-led HIVST intervention in addition to the standard of care (SOC) or the SOC alone. The intervention used participatory approaches to engage established community health groups to lead the design and implementation of HIVST campaigns. Potential mediators (individual perceptions of social cohesion, shared HIV concern, critical consciousness, community HIV stigma) and the outcome (HIV testing in the last 3 months) were measured through a post-intervention survey. Analysis used regression-based models to test (i) intervention-mediator effects, (ii) mediator-outcome effects, and (iii) direct and indirect effects. The survey included 972 and 924 participants in the community-led HIVST and SOC clusters, respectively. The community-led HIVST intervention increased uptake of recent HIV testing, with no evidence of indirect effects from changes in hypothesised mediators. However, standardised scores for community cohesion (adjusted mean difference [MD] 0.15, 95% CI -0.03 to 0.32, p = 0.10) and shared concern for HIV (adjusted MD 0.13, 95% CI -0.02 to 0.29, p = 0.09) were slightly higher in the community-led HIVST arm than the SOC arm. Social cohesion, community concern, and critical consciousness also apparently had a quadratic association with recent testing in the community-led HIVST arm, with a positive relationship indicated at lower ranges of each score. We found no evidence of intervention effects on community HIV stigma and its association with recent testing. We conclude that the intervention effect mostly operated directly through community-driven service delivery of a novel HIV technology rather than through intermediate effects on perceived community mobilisation and HIV stigma.
Collapse
Affiliation(s)
- Pitchaya P. Indravudh
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Fern Terris-Prestholt
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland
| | - Melissa Neuman
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Moses K. Kumwenda
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - Cheryl C. Johnson
- Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organisation, Geneva, Switzerland
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Karin Hatzold
- Population Services International, Washington, District of Columbia, United States of America
| | - Elizabeth L. Corbett
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Katherine Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
11
|
Rotsaert A, Sibanda E, Hatzold K, Johnson C, Corbett E, Neuman M, Cowan F. Did you hear about HIV self-testing? HIV self-testing awareness after community-based HIVST distribution in rural Zimbabwe. BMC Infect Dis 2022; 22:51. [PMID: 35027000 PMCID: PMC8895763 DOI: 10.1186/s12879-022-07027-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 01/03/2022] [Indexed: 12/02/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Anke Rotsaert
- Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, 2000, Antwerp, Belgium.
| | - Euphemia Sibanda
- Centre for Sexual Health and HIV AIDS Research (CeSHHAR), Harare, Zimbabwe
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Karin Hatzold
- Population Services International, Cape Town, South Africa
| | - Cheryl Johnson
- Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
- Department of Clinical Research and Infection Disease, London School of Hygiene and Tropical Medicine, London, UK
| | - Elizabeth Corbett
- Department of Clinical Research and Infection Disease, London School of Hygiene and Tropical Medicine, London, UK
| | - Melissa Neuman
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Frances Cowan
- Centre for Sexual Health and HIV AIDS Research (CeSHHAR), Harare, Zimbabwe
- Liverpool School of Tropical Medicine, Liverpool, UK
| |
Collapse
|
12
|
Neuman M, Fielding KL, Ayles H, Cowan FM, Hensen B, Indravudh PP, Johnson C, Sibanda EL, Hatzold K, Corbett EL. ART initiations following community-based distribution of HIV self-tests: meta-analysis and meta-regression of STAR Initiative data. BMJ Glob Health 2021; 6:e004986. [PMID: 34275871 PMCID: PMC8287607 DOI: 10.1136/bmjgh-2021-004986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 06/24/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Measuring linkage after community-based testing, particularly HIV self-testing (HIVST), is challenging. Here, we use data from studies of community-based HIVST distribution, conducted within the STAR Initiative, to assess initiation of antiretroviral therapy (ART) and factors driving differences in linkage rates. METHODS Five STAR studies evaluated HIVST implementation in Malawi, Zambia and Zimbabwe. New ART initiations during the months of intervention at clinics in HIVST and comparison areas were presented graphically, and study effects combined using meta-analysis. Meta-regression was used to estimate associations between the impact of community-based HIVST distribution and indicators of implementation context, intensity and reach. Effect size estimates used (1) prespecified trial definitions of ART timing and comparator facilities and (2) exploratory definitions accounting for unexpected diffusion of HIVST into comparison areas and periods with less distribution of HIVST than was expected. RESULTS Compared with arms with standard testing only, ART initiations were higher in clinics in HIVST distribution areas in 4/5 studies. The prespecified meta-analysis found positive but variable effects of HIVST on facility ART initiations (RR: 1.14, 95% CI 0.93 to 1.40; p=0.21). The exploratory meta-analysis found a stronger impact of HIVST distribution on ART initiations (RR: 1.29, 95% CI 1.08 to 1.55, p=0.02).ART initiations were higher in studies with greater self-reported population-level intensity of HIVST use (RR: 1.12; 95% CI 1.04 to 1.21; p=0.02.), but did not differ by national-level indicators of ART use among people living with HIV, number of HIVST kits distributed per 1000 population, or self-reported knowledge of how to link to care after a reactive HIVST. CONCLUSION Community-based HIVST distribution has variable effect on ART initiations compared with standard testing service alone. Optimising both support for and approach to measurement of effective and timely linkage or relinkage to HIV care and prevention following HIVST is needed to maximise impact and guide implementation strategies.
Collapse
Affiliation(s)
- Melissa Neuman
- Department of Infectious Disease Epidemiology and MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Katherine L Fielding
- Department of Infectious Disease Epidemiology and MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Helen Ayles
- Zambart, Lusaka, Zambia
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Frances M Cowan
- Centre for Sexual Health HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Pitchaya P Indravudh
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK
- TB-HIV Group, Malawi Liverpool Wellcome Trust, Blantyre, Malawi
| | - Cheryl Johnson
- HIV, Hepatitis and STI Department, World Health Organization, Geneva, Switzerland
| | - Euphemia Lindelwe Sibanda
- Centre for Sexual Health HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Karin Hatzold
- Population Services International, Washington, District of Columbia, USA
| | - Elizabeth Lucy Corbett
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
- TB-HIV Group, Malawi Liverpool Wellcome Trust, Blantyre, Malawi
| |
Collapse
|
13
|
Indravudh PP, Fielding K, Sande LA, Maheswaran H, Mphande S, Kumwenda MK, Chilongosi R, Nyirenda R, Johnson CC, Hatzold K, Corbett EL, Terris-Prestholt F. Pragmatic economic evaluation of community-led delivery of HIV self-testing in Malawi. BMJ Glob Health 2021; 6:e004593. [PMID: 34275869 PMCID: PMC8287609 DOI: 10.1136/bmjgh-2020-004593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/27/2021] [Accepted: 04/16/2021] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Community-based strategies can extend coverage of HIV testing and diagnose HIV at earlier stages of infection but can be costly to implement. We evaluated the costs and effects of community-led delivery of HIV self-testing (HIVST) in Mangochi District, Malawi. METHODS This economic evaluation was based within a pragmatic cluster-randomised trial of 30 group village heads and their catchment areas comparing the community-led HIVST intervention in addition to the standard of care (SOC) versus the SOC alone. The intervention involved mobilising community health groups to lead 7-day HIVST campaigns including distribution of HIVST kits. The SOC included facility-based HIV testing services. Primary costings estimated economic costs of the intervention and SOC from the provider perspective, with costs annualised and measured in 2018 US$. A postintervention survey captured individual-level data on HIV testing events, which were combined with unit costs from primary costings, and outcomes. The incremental cost per person tested HIV-positive and associated uncertainty were estimated. RESULTS Overall, the community-led HIVST intervention costed $138 624 or $5.70 per HIVST kit distributed, with test kits and personnel the main contributing costs. The SOC costed $263 400 or $4.57 per person tested. Individual-level provider costs were higher in the community-led HIVST arm than the SOC arm (adjusted mean difference $3.77, 95% CI $2.44 to $5.10; p<0.001), while the intervention effect on HIV positivity varied based on adjustment for previous diagnosis. The incremental cost per person tested HIV positive was $324 but increased to $1312 and $985 when adjusting for previously diagnosed self-testers or self-testers on treatment, respectively. Community-led HIVST demonstrated low probability of being cost-effective against plausible willingness-to-pay values, with HIV positivity a key determinant. CONCLUSION Community-led HIVST can provide HIV testing at a low additional unit cost. However, adding community-led HIVST to the SOC was not likely to be cost-effective, especially in contexts with low prevalence of undiagnosed HIV. TRIAL REGISTRATION NUMBER NCT03541382.
Collapse
Affiliation(s)
- Pitchaya P Indravudh
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Katherine Fielding
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Linda A Sande
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - Saviour Mphande
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Moses K Kumwenda
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - Rose Nyirenda
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - Cheryl C Johnson
- Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, WHO, Geneva, Switzerland
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Karin Hatzold
- Population Services International, Washington, DC, USA
| | - Elizabeth L Corbett
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Fern Terris-Prestholt
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| |
Collapse
|