Insufficient education is a key factor of incorrect interpretation of HIV self-test results by female sex workers in Democratic Republic of the Congo: A multicenter cross-sectional study

Self-care interventions for sexual and reproductive health in humanitarian and fragile settings: a scoping review

BACKGROUND

Self-care is the ability of individuals, families, and communities to promote health, prevent disease, maintain health, and manage illness and disability with or without a health care provider. In resource-constrained settings with disrupted sexual and reproductive health (SRH) service coverage and access, SRH self-care could play a critical role. Despite SRH conditions being among the leading causes of mortality and morbidity among women of reproductive age in humanitarian and fragile settings, there are currently no reviews of self-care interventions in these contexts to guide policy and practice.

METHODS

We undertook a scoping review to identify the design, implementation, and outcomes of self-care interventions for SRH in humanitarian and fragile settings. We defined settings of interest as locations with appeals for international humanitarian assistance or identified as fragile and conflict-affected situations by the World Bank. SRH self-care interventions were described according to those aligned with the Minimum Initial Services Package for Reproductive Health in Crises. We searched six databases for records using keywords guided by the PRISMA statement. The findings of each included paper were analysed using an a priori framework to identify information concerning effectiveness, acceptability and feasibility of the self-care intervention, places where self-care interventions were accessed and factors relating to the environment that enabled the delivery and uptake of the interventions.

RESULTS

We identified 25 publications on SRH self-care implemented in humanitarian and fragile settings including ten publications on maternal and newborn health, nine on HIV/STI interventions, two on contraception, two on safe abortion care, one on gender-based violence, and one on health service provider perspectives on multiple interventions. Overall, the findings show that well-supported self-care interventions have the potential to increase access to quality SRH for crisis-affected communities. However, descriptions of interventions, study settings, and factors impacting implementation offer limited insight into how practical considerations for SRH self-care interventions differ in stable, fragile, and crisis-affected settings.

CONCLUSION

It is time to invest in self-care implementation research in humanitarian settings to inform policies and practices that are adapted to the needs of crisis-affected communities and tailored to the specific health system challenges encountered in such contexts.

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

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

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

INTRODUCTION

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

METHODS

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

RESULTS AND DISCUSSION

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

CONCLUSIONS

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

Self-testing for HIV, HBV, and HCV using finger-stick whole-blood multiplex immunochromatographic rapid test: A pilot feasibility study in sub-Saharan Africa

Background

The burden of HIV, HBV, and HCV infections remains disproportionately high in sub-Saharan Africa, with high rates of co-infections. Multiplex rapid diagnostic tests for HIV, HBV and HCV serological testing with high analytical performances may improve the “cascade of screening” and quite possibly the linkage-to-care with reduced cost. Based on our previous field experience of HIV self-testing, we herein aimed at evaluating the practicability and acceptability of a prototype finger-stick whole-blood Triplex HIV/HCV/HBsAg self-test as a simultaneous serological screening tool for HIV, HBV, and HCV in the Democratic Republic of the Congo (DRC).

Methods

A cross-sectional multicentric study consisting of face-to-face, paper-based, and semi-structured questionnaires with a home-based and facility-based recruitment of untrained adult volunteers at risk of HIV, HBV, and HCV infections recruited from the general public was conducted in 2020 in urban and rural areas in the DRC. The practicability of the Triplex self-test was assessed by 3 substudies on the observation of self-test manipulation including the understanding of the instructions for use (IFU), on the interpretation of Triplex self-test results and on its acceptability.

Results

A total of 251 volunteers (mean age, 28 years; range, 18–49; 154 males) were included, from urban [160 (63.7%)] and rural [91 (36.3%)] areas. Overall, 242 (96.4%) participants performed the Triplex self-test and succeeded in obtaining a valid test result with an overall usability index of 89.2%. The correct use of the Triplex self-test was higher in urban areas than rural areas (51.2% versus 16.5%; aOR: 6.9). The use of video IFU in addition to paper-based IFU increased the correct manipulation and interpretation of the Triplex self-test. A total of 197 (78.5%) participants correctly interpreted the Triplex self-test results, whereas 54 (21.5%) misinterpreted their results, mainly the positive test results harboring low-intensity band (30/251; 12.0%), and preferentially the HBsAg band (12/44; 27.3%). The rates of acceptability of reuse, distribution of the Triplex self-test to third parties (partner, friend, or family member), linkage to the health care facility for confirmation of results and treatment, and confidence in the self-test results were very high, especially among participants from urban areas.

Conclusions

This pilot study shows evidence for the first time in sub-Saharan Africa on good practicability and high acceptability of a prototype Triplex HIV/HCV/HBsAg self-test for simultaneous diagnosis of three highly prevalent chronic viral infections, providing the rational basis of using self-test harboring four bands of interest, i.e. the control, HIV, HCV, and HBsAg bands. The relatively frequent misinterpretation of the Triplex self-test points however the necessity to improve the delivery of this prototype Triplex self-test probably in a supervised setting. Finally, these observations lay the foundations for the potential large-scale use of the Triplex self-test in populations living in sub-Saharan Africa at high risk for HIV, HBV, and HCV infections.

Double-Antigen Lateral Flow Immunoassay for the Detection of Anti-HIV-1 and -2 Antibodies Using Upconverting Nanoparticle Reporters

Rapid diagnostic tests (RDTs) are often used for the detection of anti-human immunodeficiency virus (HIV) antibodies in remote locations in low- and middle-income countries (LMIC) with low or limited access to central laboratories. The typical format of an RDT is a lateral flow assay (LFA) with visual interpretation prone to subjectivity. This risk of misinterpretation can be overcome with luminescent upconverting nanoparticle reporters (UCNPs) measured with a miniaturized easy-to-use reader instrument. An LFA with UCNPs for anti-HIV-1/2 antibodies was developed and the assay performance was evaluated extensively with challenging patient sample panels. Sensitivity (n = 145) of the UCNP-LFA was 96.6% (95% CI: 92.1–98.8%) and specificity (n = 309) was 98.7% (95% CI: 96.7–99.7%). Another set of samples (n = 200) was used for a comparison between the UCNP-LFA and a conventional visual RDT. In this comparison, the sensitivities for HIV-1 were 96.4% (95% CI: 89.8–99.3%) and 97.6% (95% CI: 91.6–99.7%), for the UCNP-LFA and conventional RDT, respectively. The specificity was 100% (95% CI: 96.4–100%) for both assays. The developed UCNP-LFA demonstrates the applicability of UCNPs for the detection of anti-HIV antibodies. The signal measurement is done by a reader instrument, which may facilitate automated result interpretation, archiving and transfer of data from de-centralized locations.

Comparison of practicability and effectiveness between unassisted HIV self-testing and directly assisted HIV self-testing in the Democratic Republic of the Congo: a randomized feasibility trial

Background

HIV self-testing (HIVST) can be performed using directly assisted and unassisted approaches in facilities or communities to reach different populations. The aim of this study was to compare the practicability and effectiveness of the two delivery approaches for HIVST, unassisted HIVST (UH) and directly assisted HIVST (DAH), in the field setting of Kisangani, the Democratic Republic of the Congo (DRC).

Methods

A randomized (1:1), non-blinded, non-inferiority trial using a blood-based and facility-based HIVST method was carried out in four facilities in Kisangani, the DRC, targeting populations at high risk for HIV infection. The primary outcome was the difference in the practicability of the HIV self-test between the two arms. Practicability was defined as successfully performing the test and correctly interpreting the result. Requests for assistance, positivity rate, linkage to care, and willingness to buy an HIV self-test kit constituted the secondary outcomes for HIVST effectiveness. The adjusted risk ratios (aRRs) were calculated using Poisson regression.

Results

The rate of successfully performing the test was same (93.2%) in the UH and DAH arms. The rate of correctly interpreting the results was 86.9% in the UH arm versus 93.2% in the DAH arm, for a difference of − 6.3%. After the follow-up 72 h later, participants in the UH arm had a significantly lower chance of correctly interpreting the test results than those in the DAH arm (aRR: 0.60; P = 0.019). Although the positivity rate was 3.4% among the participants in the DAH arm and 1.7% among those in the UH arm, no significant differences were found between the two arms in the positivity rate, requests for assistance, and linkage to care. Willingness to buy an HIV self-test was higher in the UH arm than in the DAH arm (92.3% versus 74.1%; aRR: 4.20; P < 0.001).

Conclusion

The results of this study indicate that UH is as practicable and effective as DAH among individuals at high risk for HIV infection in Kisangani, the DRC. However, additional support tools need to be assessed to improve the interpretation of the self-test results when using the UH approach.

Trial registration

PACTR201904546865585. Registered 03 April 2019 - Retrospectively registered, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=6032

Capillary whole-blood IgG-IgM COVID-19 self-test as a serological screening tool for SARS-CoV-2 infection adapted to the general public

The practicability of a prototype capillary whole-blood IgG-IgM COVID-19 self-test (Exacto® COVID-19 self-test, Biosynex Swiss SA, Freiburg, Switzerland) as a serological screening tool for SARS-CoV-2 infection adapted to the general public was evaluated in a cross-sectional, general adult population study performed between April and May 2020 in Strasbourg, France, consisting of face-to-face, paper-based, semi-structured, and self-administrated questionnaires. Practicability was defined as the correct use of the self-test and the correct interpretation of the result. The correct use of self-test was conditioned by the presence of the control band after 15-min of migration. The correct interpretation of the tests was defined by the percent agreement between the tests results read and interpret by the participants compared to the expected results coded by the numbers and verified by trained observers. A total of 167 participants (52.7% female; median age, 35.8 years; 82% with post-graduate level) were enrolled, including 83 and 84 for usability and test results interpretation substudies, respectively. All participants (100%; 95% CI: 95.6-100) correctly used the self-test. However, 12 (14.5%; 95% CI: 8.5-23.6) asked for verbal help. The percent agreement between the tests results read and interpret by the participants compared to the expected results was 98.5% (95% CI: 96.5-99.4). However, misinterpretation occurred in only 2.3% of positive and 1.2% of invalid test results. Finally, all (100%) participants found that performing the COVID-19 self-test was easy; and 98.8% found the interpretation of the self-test results easy. Taken together, these pilot observations demonstrated for the first-time, high practicability and satisfaction of COVID-19 self-testing for serological IgG and IgM immune status, indicating its potential for use by the general public to complete the arsenal of available SARS-CoV-2 serological assays in the urgent context of the COVID-19 epidemic.

Field evaluation of capillary blood and oral-fluid HIV self-tests in the Democratic Republic of the Congo

Background

HIV self-testing (HIVST) is an additional approach to increasing uptake of HIV testing services. The practicability and accuracy of and the preference for the capillary blood self-test (Exacto Test HIV) versus the oral fluid self-test (OraQuick HIV self-test) were compared among untrained individuals in the Democratic Republic of the Congo (DRC).

Methods

This multicenter cross-sectional study (2019) used face-to-face, tablet-based, structured questionnaires in a facility-based HIVST approach. Volunteers from the general public who were at high risk of HIV infection, who were between 18 and 49 years of age, and who had signed an informed consent form were eligible for the study. The successful performance and correct interpretation of the self-test results were the main outcomes of the practicability evaluation. The successful performance of the HIV self-test was conditioned by the presence of the control band. The sensitivity and specificity of the participant-interpreted results compared to the laboratory results were estimated for accuracy. Preference for either type of self-test was assessed. Logistic regression models were used to examine factors associated with participants’ preference.

Results

A total of 528 participants were included in this survey. The rate of successful performance of the HIV self-tests was high, with the blood test (99.6%) and the oral-fluid test (99.4%) yielding an absolute difference of 0.2% (95% CI: -1.8 to 1.1; P = 0.568). The rate of correct interpretation of the HIV self-test results was 84.4% with the blood test versus 83.8% with the oral-fluid test (difference = 0.6; 95% CI: -0.2 to 1.7; P = 0.425). Misinterpretation (25.4% for the blood test and 25.6% for the oral-fluid test) and inability to interpret (20.4% for the blood test and 21.1% for the oral-fluid test) test results were significantly more prevalent with invalid tests. The Exacto Test HIV self-test and the OraQuick HIV self-test showed 100% and 99.2% sensitivity, and 98.9% and 98.1% specificity, respectively. Preference for oral-fluid-based HIVST was greater than that for blood-based HIVST (85.6% versus 78.6%; P = 0.008). Preference for the blood test was greater among participants with a university education (86.1%; aOR = 2.4 [95% CI: 1.1 to 4.9]; P = 0.016), a higher risk of HIV infection (88.1%; aOR = 2.3 [95% CI: 1.0 to 5.3]; P = 0.047), and knowledge about the existence of HIVST (89.3%; aOR = 2.2 [95% CI: 1.0 to 5.0]; P = 0.05).

Conclusion

Our field observations demonstrate that blood-based and oral-fluid-based HIVST are both practicable approaches with a high and comparable rate of accuracy in the study setting. Although preference for the oral-fluid test was generally greater, preference for the blood test was greater among participants with a university education, a high risk of HIV infection, and knowledge about the existence of HIVST. Both approaches seem complementary in the sense that users can choose the type of self-test that best suits them for a similar result. Taken together, our observations support the use of the two HIV self-test kits in the DRC.

Strategies to promote the meaningful involvement of sex workers in HIV prevention and care

PURPOSE OF REVIEW

We review the recent evidence regarding strategies for engaging sex workers in HIV prevention and care programs. We searched Pub Med on 19 March 2019 using terms 'Sex Work' And 'HIV infections'. Our search was limited to articles published since 2017.

RECENT FINDINGS

Community empowerment approaches where sex workers work collaboratively to address their specific priorities and concerns, including those beyond HIV, are those most likely to meaningfully engage sex workers. Community-driven programs that combine structural, behavioral and biomedical approaches can facilitate improved HIV outcomes by tackling barriers to uptake and retention of services along all steps in the prevention and care cascades. Microplanning, network-based recruitment and mobile-phone interventions can also help reach and support sex workers to mobilize and to engage with a range of services. Sex worker-led groups and initiatives including economic strengthening and community drug refill groups can both build social cohesion and address structural barriers to HIV outcomes including financial insecurity. Interventions which focus narrowly on increasing uptake of specific steps in prevention and care cascades outside the context of broader community empowerment responses are likely to be less effective.

SUMMARY

Comprehensive, community-driven approaches where sex workers mobilize to address their structural, behavioral and biomedical priorities work across HIV prevention and treatment cascades to increase uptake of and engagement with prevention and care technologies and promote broader health and human rights. These interventions need to be adequately supported and taken to scale.

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

Background

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

Methods

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

Results

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

Conclusions

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