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      Feasibility of community-based HIV self-screening in South Africa: a demonstration project

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          Abstract

          Background

          HIV diagnosis is a critical step in linking HIV-infected individuals to care and treatment and linking HIV-uninfected persons to prevention services. However, the uptake of HIV testing remains low in many countries. HIV self-screening (HIVSS) is acceptable to adults, but there is limited data on HIVSS feasibility in community programmes. This study aimed to evaluate the feasibility of HIVSS in South Africa.

          Methods

          We conducted a prospective study that enrolled participants through mobile site, homebased, workplace and sex worker programmes in two townships from May to November 2017. Following an information session on HIVSS, interested participants were offered one of three methods of HIVSS testing: supervised, semi-supervised, and unsupervised. Participants who opted for unsupervised testing and those who tested HIV positive after semi- or supervised HIVSS were followed up telephonically or with a home visit one week after receipt of the test kit to confirm results and linkages to care. Follow-up visits were concluded when the participant indicated that they had used the kit or had accessed a confirmatory HIV test.

          Results

          Of the 2061 people approached, 88.2% (1818/2061) received HIV testing information. Of this group, 89% (1618/1818) were enrolled in the study and 70.0% (1133/1618) were tested for HIV with the kit. The median age was 28 (IQR:23–33) years with an even gender distribution. Of those enrolled, 43.0% (696/1618) were identified through homebased outreach, 42.5% (687/1618) through mobile sites, 7.3% (118/1618) at their workplace and 7.2% (117/1618) from sex worker programmes. A total of 68.7% (1110/1616) selected unsupervised HIVSS, whereas 6.3% (101/1616) opted for semi-supervised and 25.0% ((405/1616) chose supervised HIVSS. Overall, the HIV prevalence using the HIVSS test was 8.2% (93/1129). Of those newly diagnosed with HIV, 16% (12/75) were initiated on ART. Almost half (48.0%; 543/1131) of those tested were linked to a primary HIV test as follows: supervised (85.2%; 336/394); semi-supervised (93.8%; 91/97) and unsupervised (18.1%; 116/640).

          Conclusion

          Unsupervised HIVSS was by far the most selected and utilised HIVSS method. Linkages to primary and confirmatory testing for the unsupervised HIVSS and further care were low, despite home visits and telephonic reminders.

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          Most cited references5

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          Accuracy and User-Acceptability of HIV Self-Testing Using an Oral Fluid-Based HIV Rapid Test

          Background The United States FDA approved an over-the-counter HIV self-test, to facilitate increased HIV testing and earlier linkage to care. We assessed the accuracy of self-testing by untrained participants compared to healthcare worker (HCW) testing, participants’ ability to interpret sample results and user-acceptability of self-tests in Singapore. Methodology/Principal Findings A cross-sectional study, involving 200 known HIV-positive patients and 794 unknown HIV status at-risk participants was conducted. Participants (all without prior self-test experience) performed self-testing guided solely by visual instructions, followed by HCW testing, both using the OraQuick ADVANCE Rapid HIV 1/2 Antibody Test, with both results interpreted by the HCW. To assess ability to interpret results, participants were provided 3 sample results (positive, negative, and invalid) to interpret. Of 192 participants who tested positive on HCW testing, self-testing was positive in 186 (96.9%), negative in 5 (2.6%), and invalid in 1 (0.5%). Of 794 participants who tested negative on HCW testing, self-testing was negative in 791 (99.6%), positive in 1 (0.1%), and invalid in 2 (0.3%). Excluding invalid tests, self-testing had sensitivity of 97.4% (95% CI 95.1% to 99.7%) and specificity of 99.9% (95% CI: 99.6% to 100%). When interpreting results, 96%, 93.1% and 95.2% correctly read the positive, negative and invalid respectively. There were no significant demographic predictors for false negative self-testing or wrongly interpreting positive or invalid sample results as negative. Eighty-seven percent would purchase the kit over-the-counter; 89% preferred to take HIV tests in private. 72.5% and 74.9% felt the need for pre- and post-test counseling respectively. Only 28% would pay at least USD15 for the test. Conclusions/Significance Self-testing was associated with high specificity, and a small but significant number of false negatives. Incorrectly identifying model results as invalid was a major reason for incorrect result interpretation. Survey responses were supportive of making self-testing available.
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            Acceptability of HIV Self-Testing in Sub-Saharan Africa: Scoping Study.

            Several HIV testing models have been implemented in sub-Saharan Africa (SSA) to improve access to HIV testing, but uptake remains poor. HIV Self-Testing (HIVST) is now available, and may serve to overcome barriers of current testing models which include stigma, discrimination and non-confidential testing environments. A scoping study was conducted to provide an overview of the current literature in SSA, as well as identify future research needs to scale-up HIVST and increase HIV testing uptake. The outcome of the review indicated only 11 reported studies to date, showing variable acceptability (22.3-94%) of HIVST, with acceptability of HIVST higher among men than women in SSA. We conclude that research around HIVST in SSA is still in its infancy, and further implementation research and interventions are required to improve acceptability of HIVST among diverse study populations, failing which policy adoption and scale-up may be hindered.
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              Facilitators and barriers in HIV linkage to care interventions: a qualitative evidence review.

              To synthesize qualitative evidence on linkage to care interventions for people living with HIV.
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                Author and article information

                Contributors
                lebinal@phru.co.za
                Journal
                BMC Public Health
                BMC Public Health
                BMC Public Health
                BioMed Central (London )
                1471-2458
                8 July 2019
                8 July 2019
                2019
                : 19
                : 898
                Affiliations
                [1 ]ISNI 0000 0004 1937 1135, GRID grid.11951.3d, Perinatal HIV Research Unit (PHRU), SA MRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, , Faculty of Health Sciences, University of the Witwatersrand, ; Johannesburg, South Africa
                [2 ]Society for Family Health, Johannesburg, South Africa
                [3 ]GRID grid.442327.4, Foundation for Professional Development, ; Tshwane, South Africa
                [4 ]GRID grid.437959.5, HIV and AIDS and STI Cluster, National Department of Health, ; Pretoria, South Africa
                [5 ]ISNI 0000 0004 0630 4574, GRID grid.416657.7, Centre for HIV and STIs, National Institute for Communicable Diseases, ; Johannesburg, South Africa
                [6 ]ISNI 0000 0004 1937 1135, GRID grid.11951.3d, School of Public Health, , University of Witwatersrand, ; Johannesburg, South Africa
                [7 ]ISNI 0000 0004 1937 1135, GRID grid.11951.3d, Division of Virology, School of Pathology, , University of the Witwatersrand, ; Johannesburg, South Africa
                [8 ]ISNI 0000 0001 2171 9311, GRID grid.21107.35, Center for TB Research, Johns Hopkins University, ; Baltimore, MD USA
                Author information
                http://orcid.org/0000-0001-6825-0573
                Article
                7122
                10.1186/s12889-019-7122-5
                6615295
                31286953
                27e4c378-19a2-43f3-9615-4c5dac52d7ad
                © The Author(s). 2019

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 13 July 2018
                : 7 June 2019
                Funding
                Funded by: USAID
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2019

                Public health
                hiv self-test,high risk populations,hiv,demonstration project
                Public health
                hiv self-test, high risk populations, hiv, demonstration project

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