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Can self-testing engage 'hard to reach' men with HIV testing?
Roger Pebody, 2017-07-25 17:10:00
Adding HIV self-testing as an additional option to a
door-to-door programme offering HIV testing in Zambia boosted the uptake of HIV
testing among men, younger adults and those who had previously refused HIV
testing, Helen Ayles of the London School of Hygiene and Tropical Medicine told
the 9th International AIDS Society Conference on HIV Science (IAS 2017) in
Paris today. It appears that HIV self-testing may have a particular impact on
testing rates in men and could contribute to meeting the 90-90-90 targets in
Ayles emphasised that the effect was seen in communities
which had already been exposed to three years of intensive efforts to offer HIV
testing to all. People who had not already been tested must be considered the
‘hardest to reach’ and the self-testing intervention was notable for having an
impact with these individuals.
The study presented was a substudy of PopART (also known as
HPTN 071), a large community-randomised trial being carried out in
high-prevalence communities in Zambia and South Africa. PopART is aiming to
implement an approach of universal HIV testing and universal access to
immediate HIV treatment for those who need it, in order to reduce new HIV
The main approach to HIV testing used in PopART is home
based HIV testing, in which lay counsellors (known in the study as Community
HIV Care Providers or CHiPs) systematically visit all households in a
geographical area and offer HIV testing and counselling. While this approach is
feasible and acceptable, it is challenging to achieve very high levels of
uptake among men, younger people and mobile individuals (for example, people
travelling for work).
By the end of the second year of PopART, the target of
having tested 90% of people had been achieved for women, in almost all age
groups over 20 years (but not for younger women). But uptake was much lower in
men – in most age groups, between 70 and 85% had tested, with uptake only
surpassing 90% in those over the age of 55.
Supplementary approaches appear to be necessary.
A substudy of PopART therefore aimed to evaluate whether
offering self-testing as an additional option would increase the uptake of HIV
testing. This was a cluster-randomised trial in 66 zones in four communities in
Zambia. In the 33 intervention zones, household members were offered two
options for HIV testing – rapid testing by the lay counsellor or self-testing.
In the 33 zones in the control group, only rapid testing by the lay counsellor
The standard PopART intervention, offered in the control
group, involves lay counsellors making door-to-door visits to households and
offering rapid HIV testing, using a finger prick blood test. The lay
counsellors also test for sexually transmitted infections and tuberculosis, as
well as promoting and making referrals to treatment and male circumcision services.
They also provide support for retention in care and adherence to treatment.
In the arm of the study in which self-testing was an option,
it was chosen by 55% of those who took a test. The vast majority (88%) of those
taking a self-test chose to have the lay counsellor present during the test,
described as ‘supervised’ self-testing by the researchers. The health worker
could help with problems users faced in operating the test or in interpreting
the result. Helen Ayles said that she would expect more self-testing to be
unsupervised in the future, as people become more familiar with the process.
Another testing modality was ‘secondary distribution’ — when a household member was absent, a
self-testing kit could be left with their partner for them to use later.
By the end of a three-month period earlier this year, 60.4%
of adult men in the intervention arm knew their HIV status, compared to 55.1%
in the control arm. A similar effect was not seen in women.
The effect of providing self-testing was also seen in people
of both genders aged 16 to 29 (73.5% in the intervention arm and 70.2% in the
control arm knew their status).
There was also strong evidence that providing self-testing
improved knowledge of status in individuals who were locally resident during
earlier phases of PopART but had previously turned down the offer of testing by
the PopART lay counsellors. Among these individuals, 29.7% knew their status in
the intervention arm, compared to 20.6% in the control arm.
In the control arm, 2.6% of people testing had reactive
results. The figure was similar for people tested by the lay counsellor in the
intervention arm (2.5%), people using self-tests with supervision (2.9%) and
people using self-tests without supervision (3.5%).
However, it was noticeable that in people tested following
secondary distribution (i.e. partners who were absent when the lay counsellor
visited), the numbers with reactive results were higher. In 81 people who
discussed their results with the lay counsellor, 9.9% had a reactive result and
in 242 people whose results were communicated by the partner to the lay
counsellor, 5.4% had a reactive result. Secondary distribution may be
particularly helpful in reducing undiagnosed infection. In many cases, it led
to the couple testing together.
Qualitative findings from in-depth interviews and focus
groups suggested that self-testing was acceptable for people who were worried
about waiting times and stigma in clinics; self-testing had advantages in terms
of confidentiality, control and convenience; and that people felt empowered by
knowing how to test themselves. Self-testing was particularly acceptable for
busy and mobile people, married men, those living with a partner, people of
higher social classes, those in formal employment and members of key
populations (such as sex workers).
Helen Ayles said that HIV self testing is a solution for
engaging ‘hard to reach’ groups such as working men and mobile populations with
HIV testing. She said that even if the increase in testing uptake may be modest
(a few percentage points), this should be considered in the context of a
population that has already been given multiple opportunities to test.