HIV self-testing is feasible and acceptable for men who have sex with men (MSM) and transgender women (TGW), engaging more people than usual testing services, according to the results of a randomised trial in Burma presented to the 25th Conference on Retroviruses and Opportunistic Infections (CROI 2018) in Boston last week.
The confidentiality and privacy of self-testing, in relation to both HIV status and sexual behaviour, may have particular advantages for stigmatised groups. The conference also heard positive results from a programme distributing self-testing kits through peer networks of MSM in South Africa.
The HIV epidemic in Burma disproportionately affects key populations, including MSM and TGW. The HIV prevalence in these populations is estimated to be 12% but may be as high as 27% in Rangoon, the city where the study was done. Only one in five has ever been tested and access to other healthcare services, including HIV treatment, is also poor.
Earlier qualitative research with MSM and TGW in Burma suggested that self-testing would be acceptable because of its confidentiality and privacy. As neither sexual behaviour nor HIV status would need to be disclosed, participants felt it could help them avoid stigma. While self-testing was expected to be convenient, there was some concern that provision would not include counselling and linkage to care.
In the randomised trial, HIV-negative MSM and TGW were recruited by getting the first recruits to refer their social contacts and peers to the study, with those individuals, in turn, referring people they knew and so on (respondent-driven sampling). Participants were randomised to either:
- HIV self-testing, using an Oraquick test kit, or
- Counselling and testing at a community-based organisation that serves MSM and TGW.
Of note, all participants received pre-test counselling and were also asked to return for a second study visit to report test results and receive post-test counselling and referrals, if necessary. This addressed some of the concerns raised in the qualitative research, as well as meaning that this is not an ‘unsupervised’ model of self-testing.
Of the 577 participants, 85 identified as transgender women. Just over half the participants were described as gay or homosexual, whereas 38% were bisexual. However, it’s worth noting that the categories and terms for gender identity and sexual orientation that are used in Burma are complex and do not neatly correlate with Western categories.
Self-reported HIV risk behaviour was high: 30% had engaged in sex work in the last six months; 30% had used condoms the last time they had sex, and 33% had ever been tested for HIV.
The acceptability of both testing methods was high, with some preference for self-testing: 99% in the self-testing arm and 93% in the community organisation arm said the method was easy; 98% and 95% said the method was convenient; 99% in both arms said they trusted the results of their test; and 99% in both arms said that they would recommend their assigned testing method to a partner, friend, or family member.
Those in the self-testing arm were more likely to return for the second study visit (54% vs 46%). More new HIV diagnoses were reported in the self-testing arm (28 vs 16).
In both arms, the majority of participants said that their preference for future HIV testing would be to use a self-test at home. Visiting a government clinic or hospital was the least popular option. Had self-testing been compared to testing at a government clinic (rather than at a community-based organisation), it is likely that its advantages would have been even more apparent.