High uptake of HIV self-testing among adolescents

Uptake, accuracy, safety, and linkage into care over two years of promoting annual self-testing for HIV in Blantyre, Malawi: a community-based prospective study.

Choko AT, MacPherson P, Webb EL, Willey BA, Feasy H, Sambakunsi R, Mdolo A, Makombe SD, Desmond N, Hayes R, Maheswaran H, Corbett EL.  PLoS Med. 2015 Sep 8;12(9):e1001873. doi: 10.1371/journal.pmed.1001873. eCollection 2015.

Background: Home-based HIV testing and counselling (HTC) achieves high uptake, but is difficult and expensive to implement and sustain. We investigated a novel alternative based on HIV self-testing (HIVST). The aim was to evaluate the uptake of testing, accuracy, linkage into care, and health outcomes when highly convenient and flexible but supported access to HIVST kits was provided to a well-defined and closely monitored population.

Methods and findings: Following enumeration of 14 neighbourhoods in urban Blantyre, Malawi, trained resident volunteer-counsellors offered oral HIVST kits (OraQuick ADVANCE Rapid HIV-1/2 Antibody Test) to adult (≥16 y old) residents (n = 16 660) and reported community events, with all deaths investigated by verbal autopsy. Written and demonstrated instructions, pre- and post-test counselling, and facilitated HIV care assessment were provided, with a request to return kits and a self-completed questionnaire. Accuracy, residency, and a study-imposed requirement to limit HIVST to one test per year were monitored by home visits in a systematic quality assurance (QA) sample. Overall, 14 004 (crude uptake 83.8%, revised to 76.5% to account for population turnover) residents self-tested during months 1-12, with adolescents (16-19 y) most likely to test. 10 614/14 004 (75.8%) participants shared results with volunteer-counsellors. Of 1257 (11.8%) HIV-positive participants, 26.0% were already on antiretroviral therapy, and 524 (linkage 56.3%) newly accessed care with a median CD4 count of 250 cells/µl (interquartile range 159-426). HIVST uptake in months 13-24 was more rapid (70.9% uptake by 6 mo), with fewer (7.3%, 95% CI 6.8%-7.8%) positive participants. Being "forced to test", usually by a main partner, was reported by 2.9% (95% CI 2.6%-3.2%) of 10 017 questionnaire respondents in months 1-12, but satisfaction with HIVST (94.4%) remained high. No HIVST-related partner violence or suicides were reported. HIVST and repeat HTC results agreed in 1639/1649 systematically selected (1 in 20) QA participants (99.4%), giving a sensitivity of 93.6% (95% CI 88.2%-97.0%) and a specificity of 99.9% (95% CI 99.6%-100%). Key limitations included use of aggregate data to report uptake of HIVST and being unable to adjust for population turnover.

Conclusions: Community-based HIVST achieved high coverage in two successive years and was safe, accurate, and acceptable. Proactive HIVST strategies, supported and monitored by communities, could substantially complement existing approaches to providing early HIV diagnosis and periodic repeat testing to adolescents and adults in high-HIV settings.

Abstract [1]  Full-text [free] access [2]

Editor’s notes: The new global 90–90–90 targets call for 90% of all people with HIV to be diagnosed, 90% of people with HIV diagnosed to receive ART and 90% of people on ART to have a suppressed viral load by 2020. The first 90 (diagnosis of HIV) is essential to the second 90 (initiation of ART among people with HIV) and the ultimate outcome of the third 90 (viral load suppression among people on ART), which improves client outcomes and prevents HIV transmission.

The first 90 is also the most problematic, especially for adolescents, men and key populations, as HIV testing primarily takes place at the health care facility, which is typically underutilised by these groups.

This article reports on a prospective study on community-based oral HIV self-testing (HIVST) among adults (16 years or older) in Blantyre, Malawi. HIVST involves individuals performing and interpreting their own HIV test, in this study by using an oral HIV test kit. The high acceptability and ease of distribution of oral test kits makes HIVST of special interest in settings with high HIV prevalence, where the aim is to achieve affordable universal coverage and regular repeat testing.

The authors found high uptake among men and adolescents (two hard-to-reach groups), and a high accuracy of HIVST, but suboptimal linkage post-testing to ART services: less than 60% of HIV-positive clients not yet on ART were linked to HIV care. However, they attribute these good outcomes partially to the involvement of trained volunteers in their community-based HIV care service delivery model. They suggest re-evaluating accuracy and uptake of post-testing services when using different tests or less supportive models, for example over-the-counter or vending machine sales of oral HIV test kits.

The authors found that 35% of participants had never previously tested. Interestingly they also found that among self-testing participants, HIV prevalence was highest in the age group 40-49 years (with a pooled estimate among men and women of 23%). The authors emphasize that the high acceptability of HIVST services among adolescents and men could facilitate linkage into HIV prevention programmes, such as pre-exposure prophylaxis and voluntary medical male circumcision, as well as ensuring prompt linkage into HIV care. They conclude that HIV self-testing is complementary to existing strategies in providing early HIV diagnosis and periodic repeat testing, and that HIVST has potential to be scaled up in other low-income settings where annual repeat HIV testing is recommended. 

Health care delivery [5], HIV testing [6]
Africa [7]
Malawi [8]
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