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      HIV self‐testing: breaking the barriers to uptake of testing among men and adolescents in sub‐Saharan Africa, experiences from STAR demonstration projects in Malawi, Zambia and Zimbabwe

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          Abstract

          Introduction

          Social, structural and systems barriers inhibit uptake of HIV testing. HIV self‐testing ( HIVST) has shown promising uptake by otherwise underserved priority groups including men, young people and first‐time testers. Here, we use characteristics of HIVST kit recipients to investigate delivery to these priority groups during HIVST scale‐up in three African countries.

          Methods

          Kit distributors collected individual‐level age, sex and testing history from all clients. These data were aggregated and analysed by country (Malawi, Zambia and Zimbabwe) for five distribution models: local community‐based distributor ( CBD: door‐to‐door, street and local venues), workplace distribution ( WD), integration into HIV testing services ( IHTS), or public health facilities ( IPHF) and during demand creation for voluntary male medical circumcision ( VMMC). Used kits were collected and re‐read from CBD and IHTS recipients.

          Results

          Between May 2015 and July 2017, 628,705 HIVST kits were distributed in Malawi (172,830), Zambia (190,787) and Zimbabwe (265,091). Community‐based models, the first to be established, accounted for 519,658 (82.7%) of kits distributed, with 275,419 (53.0%) used kits returned. Subsequent model diversification delivered 54,453 (8.7%) test‐kits through IHTS, 23,561 (3.7%) through VMMC, 21,183 (3.4%) through IPHF and 9850 (1.7%) through WD. Men took 294,508 (48.2%) kits, and 263,073 (43.1%) went to young people (16 to 24 years). A higher proportion of male self‐testers (65,577; 22.3%) were first‐time testers than women (54,096; 17.1%) with this apparent in Zimbabwe (16.2% vs. 11.4%), Zambia (25.4% vs. 17.7%) and Malawi (27.9% vs. 25.9%). The highest proportions of first‐time testers were in young (16 to 24 years) and older (>50 years) men (country‐ranges: 18.7% to 35.9% and 13.8% to 26.8% respectively). Most IHTS clients opted for HIVST in preference to standard HTS in each of 12 delivery sites, with those selecting HIVST having lower HIV prevalence, potentially due to self‐selection.

          Conclusions

          HIVST delivered at scale using several different models reached a high proportion of men, young people and first‐time testers in Malawi, Zambia and Zimbabwe, some of whom may not have tested otherwise. As men and young people have limited uptake under standard facility‐and community‐based HIV testing, innovative male‐ and youth‐sensitive approaches like HIVST may be essential to reaching UNAIDS fast‐track targets for 2020.

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          Most cited references13

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          ‘I will choose when to test, where I want to test’: investigating young people's preferences for HIV self-testing in Malawi and Zimbabwe

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            Scaling up HIV self-testing in sub-Saharan Africa: a review of technology, policy and evidence

            Purpose of review HIV self-testing (HIVST) can provide complementary coverage to existing HIV testing services and improve knowledge of status among HIV-infected individuals. This review summarizes the current technology, policy and evidence landscape in sub-Saharan Africa and priorities within a rapidly evolving field. Recent findings HIVST is moving towards scaled implementation, with the release of WHO guidelines, WHO prequalification of the first HIVST product, price reductions of HIVST products and a growing product pipeline. Multicountry evidence from southern and eastern Africa confirms high feasibility, acceptability and accuracy across many delivery models and populations, with minimal harms. Evidence on the effectiveness of HIVST on increased testing coverage is strong, while evidence on demand generation for follow-on HIV prevention and treatment services and cost-effective delivery is emerging. Despite these developments, HIVST delivery remains limited outside of pilot implementation. Summary Important technology gaps include increasing availability of more sensitive HIVST products in low and middle-income countries. Regulatory and postmarket surveillance systems for HIVST also require further development. Randomized trials evaluating the effectiveness and cost-effectiveness under multiple distribution models, including unrestricted delivery and with a focus on linkage to HIV prevention and treatment, remain priorities. Diversification of studies from west and central Africa and around blood-based products should be addressed.
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              Men and antiretroviral therapy in Africa: our blind spot.

              Most antiretroviral therapy (ART)-related policies remain blind to men's treatment needs. Global and national programmes need to address this blindness urgently, to ensure equitable access to ART in Africa. © 2011 Blackwell Publishing Ltd.
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                Author and article information

                Contributors
                khatzold@psi.org
                Journal
                J Int AIDS Soc
                J Int AIDS Soc
                10.1002/(ISSN)1758-2652
                JIA2
                Journal of the International AIDS Society
                John Wiley and Sons Inc. (Hoboken )
                1758-2652
                25 March 2019
                March 2019
                : 22
                : Suppl Suppl 1 , Realizing the potential of HIV self‐testing for Africa: lessons learned from the STAR project, Guest Editors: Vincent J Wong, Nathan Ford, Kawango Agot ( doiID: 10.1002/jia2.2019.22.issue-S1 )
                : e25244
                Affiliations
                [ 1 ] Population Services International (PSI) Washington DC USA
                [ 2 ] Population Services International Harare Zimbabwe
                [ 3 ] Population Services International Blantyre Malawi
                [ 4 ] Society for Family Health Lusaka Zambia
                [ 5 ] Department of HIV World Health Organization Geneva Switzerland
                [ 6 ] Faculty of Infectious and Tropical Diseases London School of Hygiene and Tropical Medicine London United Kingdom
                [ 7 ] Malawi‐Liverpool Wellcome Trust Blantyre Malawi
                Author notes
                [*] [* ] Corresponding author: Karin Hatzold, Population Services International, 1120, 19th Street North West, 20036 Washington, District of Columbia, United States; STAR office South Africa, 70, 7th Avenue, Rosebank, Johannesburg, South Africa. Tel: +27712623849. ( khatzold@ 123456psi.org )
                Article
                JIA225244
                10.1002/jia2.25244
                6432104
                30907505
                82b3b428-2325-43cc-a814-3457d44c3d76
                © 2019 World Health Organization; licensed by IAS.

                This is an open access article distributed under the terms of the Creative Commons Attribution IGO License https://creativecommons.org/licenses/by/3.0/igo/legalcode which permits unrestricted use, distribution and reproduction in any medium, provided that the original work is properly cited. In any reproduction of this article there should not be any suggestion that WHO or the 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 URL.

                History
                : 30 May 2018
                : 18 January 2019
                Page count
                Figures: 0, Tables: 5, Pages: 10, Words: 8721
                Funding
                Funded by: Unitaid
                Categories
                Research Article
                Research Articles
                Custom metadata
                2.0
                jia225244
                March 2019
                Converter:WILEY_ML3GV2_TO_NLMPMC version:5.6.1 mode:remove_FC converted:25.03.2019

                Infectious disease & Microbiology
                hiv self‐testing,hiv testing,men,adolescents,stigma,malawi,zambia,zimbabwe
                Infectious disease & Microbiology
                hiv self‐testing, hiv testing, men, adolescents, stigma, malawi, zambia, zimbabwe

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