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      Community-based HIV self-testing: a cluster-randomised trial of supply-side financial incentives and time-trend analysis of linkage to antiretroviral therapy in Zimbabwe

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          Abstract

          Background

          HIV self-testing (HIVST) requires linkage to post-test services to maximise its benefits. We evaluated effect of supply-side incentivisation on linkage following community-based HIVST and evaluated time-trends in facility-based antiretroviral therapy (ART) initiations.

          Methods

          From August 2016 to August 2017 community-based distributors (CBDs) in 38 rural Zimbabwean communities distributed HIVST door-to-door in 19–25 day campaigns. Communities were allocated (1:1) using constrained randomisation to either one-off US$50 remuneration per CBD (non-incentive arm), or US$50 plus US$0.20 incentive per client visiting mobile-outreach services (conditional-incentive arm). The primary outcome, assessed by population survey 6 weeks later, was self-reported uptake of any clinic service, analysed with random-effects logistic regression. Separately, non-randomised difference-in-differences in monthly ART initiations were analysed for three time periods (6 months baseline; HIVST campaign; 3 months after) at public clinics with (40 clinics) and without (124 clinics) HIVST distribution in catchment area.

          Findings

          A total of 445 conditional-incentive CBDs distributed 39 205 HIVST kits (mean/CBD: 88; 95% CI: 85 to 92) and 447 non-incentive CBDs distributed 41 173 kits (mean/CBD: 93; 95% CI: 89 to 96). Survey participation was 7146/8566 (83.4%), with 3593 (50.3%) reporting self-testing including 1305 (18.3%) previously untested individuals. Use of clinic services post-HIVST was similar in conditional-incentive (1062/3698, 28.7%) and non-incentive (1075/3448, 31.2%) arms (adjusted risk ratio (aRR) 0.94, 95% CI: 0.86 to 1.03). Confirmatory testing by newly diagnosed/untreated HIVST+clients was, however, higher (conditional-incentive: 25/33, 75.8% vs non-incentive: 20/40, 50.0%: aRR: 1.59, 95% CI: 1.05 to 2.39). In total, 12 808 ART initiations occurred, with no baseline or postcampaign differences between initiation rates in HIVST versus non-HIVST clinics, but initiation rates increased from 7.31 to 9.59 initiations per month in HIVST clinics during distribution, aRR: 1.27, 95% CI 1.17 to 1.39.

          Conclusions

          Community-based HIVST campaigns achieved high testing uptake, temporally associated with increased demand for ART. Small supply-side incentives did not affect general clinic usage but may have increased confirmatory testing for newly diagnosed HIVST positive participants.

          Trial registration number

          PACTR201607001701788.

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          Most cited references39

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          Using the Margins Command to Estimate and Interpret Adjusted Predictions and Marginal Effects

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            Systematic review and meta-analysis of community and facility-based HIV testing to address linkage to care gaps in sub-Saharan Africa.

            HIV testing and counselling is the first crucial step for linkage to HIV treatment and prevention. However, despite high HIV burden in sub-Saharan Africa, testing coverage is low, particularly among young adults and men. Community-based HIV testing and counselling (testing outside of health facilities) has the potential to reduce coverage gaps, but the relative impact of different modalities is not well assessed. We conducted a systematic review of HIV testing modalities, characterizing community (home, mobile, index, key populations, campaign, workplace and self-testing) and facility approaches by population reached, HIV positivity, CD4 count at diagnosis and linkage. Of 2,520 abstracts screened, 126 met eligibility criteria. Community HIV testing and counselling had high coverage and uptake and identified HIV-positive people at higher CD4 counts than facility testing. Mobile HIV testing reached the highest proportion of men of all modalities examined (50%, 95% confidence interval (CI) = 47-54%) and home with self-testing reached the highest proportion of young adults (66%, 95% CI = 65-67%). Few studies evaluated HIV testing for key populations (commercial sex workers and men who have sex with men), but these interventions yielded high HIV positivity (38%, 95% CI = 19-62%) combined with the highest proportion of first-time testers (78%, 95% CI = 63-88%), indicating service gaps. Community testing with facilitated linkage (for example, counsellor follow-up to support linkage) achieved high linkage to care (95%, 95% CI = 87-98%) and antiretroviral initiation (75%, 95% CI = 68-82%). Expanding home and mobile testing, self-testing and outreach to key populations with facilitated linkage can increase the proportion of men, young adults and high-risk individuals linked to HIV treatment and prevention, and decrease HIV burden.
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              Is Open Access

              Examining the effects of HIV self-testing compared to standard HIV testing services: a systematic review and meta-analysis

              Abstract Introduction: HIV self-testing (HIVST) is a discreet and convenient way to reach people with HIV who do not know their status, including many who may not otherwise test. To inform World Health Organization (WHO) guidance, we assessed the effect of HIVST on uptake and frequency of testing, as well as identification of HIV-positive persons, linkage to care, social harm, and risk behaviour. Methods: We systematically searched for studies comparing HIVST to standard HIV testing until 1 June 2016. Meta-analyses of studies reporting comparable outcomes were conducted using a random-effects model for relative risks (RR) and 95% confidence intervals. The quality of evidence was evaluated using GRADE. Results: After screening 638 citations, we identified five randomized controlled trials (RCTs) comparing HIVST to standard HIV testing services among 4,145 total participants from four countries. All offered free oral-fluid rapid tests for HIVST and were among men. Meta-analysis of three RCTs showed HIVST doubled uptake of testing among men (RR = 2.12; 95% CI: 1.51, 2.98). Meta-analysis of two RCTs among men who have sex with men showed frequency of testing nearly doubled (Rate ratio = 1.88; 95% CI: 1.17; 3.01), resulting in two more tests in a 12–15-month period (Mean difference = 2.13; 95% CI: 1.59, 2.66). Meta-analysis of two RCTs showed HIVST also doubled the likelihood of an HIV-positive diagnosis (RR = 2.02; 95% CI: 0.37, 10.76, 5.32). Across all RCTs, there was no indication of harm attributable to HIVST and potential increases in risk-taking behaviour appeared to be minimal. Conclusions: HIVST is associated with increased uptake and frequency of testing in RCTs. Such increases, particularly among those at risk who may not otherwise test, will likely identify more HIV-positive individuals as compared to standard testing services alone. However, further research on how to support linkage to confirmatory testing, prevention, treatment and care services is needed. WHO now recommends HIVST as an additional HIV testing approach.
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                Author and article information

                Journal
                BMJ Glob Health
                BMJ Glob Health
                bmjgh
                bmjgh
                BMJ Global Health
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2059-7908
                2021
                18 July 2021
                : 6
                : Suppl 4
                : e003866
                Affiliations
                [1 ]CeSHHAR Zimbabwe , Harare, Zimbabwe
                [2 ]departmentDepartment of International Public Health , Liverpool School of Tropical Medicine , Liverpool, UK
                [3 ]departmentMRC Tropical Epidemiology Group , London School of Hygiene & Tropical Medicine , London, UK
                [4 ]departmentHIV and Tuberculosis , Population Services International Global , Washington, DC, USA
                [5 ]departmentDepartment of Sexual Reproductive Health Rights and Innovations , Population Services International Zimbabwe , Harare, Zimbabwe
                [6 ]departmentWomen’s Global Health Imperative , RTI International , Berkeley, California, USA
                [7 ]departmentHIV and TB Unit , Ministry of Health and Child Care , Harare, Zimbabwe
                [8 ]departmentDepartment of Global Health and Development, Faculty of Public Health and Policy , London School of Hygiene and Tropical Medicine , London, UK
                [9 ]departmentHIV Department , Geneva, Switzerland
                [10 ]departmentDepartment of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health , London School of Hygiene & Tropical Medicine , London, UK
                [11 ]departmentDepartment of Clinical Research, Faculty of Infectious and Tropical Diseases , London School of Hygiene and Tropical Medicine Faculty of Epidemiology and Public Health , London, UK
                [12 ]Malawi-Liverpool Wellcome Trust Clinical Research Programme , Blantyre, Malawi
                Author notes
                [Correspondence to ] Euphemia Lindelwe Sibanda; euphemia@ 123456ceshhar.co.zw
                Author information
                http://orcid.org/0000-0003-1754-1076
                http://orcid.org/0000-0002-8870-6504
                http://orcid.org/0000-0002-0733-0622
                http://orcid.org/0000-0003-3087-4422
                Article
                bmjgh-2020-003866
                10.1136/bmjgh-2020-003866
                8287602
                34275865
                06c176e4-d287-48c5-b5c4-87826020fca5
                ©World Health Organization 2021. Licensee BMJ.

                This is an open access article distributed under the terms of the Creative Commons Attribution-Non commercial IGO License (CC BY-NC 3.0 IGO), which permits use, distribution, and reproduction for non-commercial purposes in any medium, provided the original work is properly cited. In any reproduction of this article there should not be any suggestion that WHO or this article endorse any specific organization or products. The use of the WHO logo is not permitted. This notice should be preserved along with the article's original URL.

                History
                : 03 September 2020
                : 10 February 2021
                : 18 February 2021
                Funding
                Funded by: Unitaid;
                Award ID: STAR Project Sub agreement number 4214-CeSHHAR
                Categories
                Original Research
                1506
                Custom metadata
                unlocked

                epidemiology,hiv,community-based survey,cluster randomised trial,public health

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