Augustine Choko and colleagues assess the uptake and acceptability of home-based supervised oral HIV self-testing in Malawi, demonstrating the feasibility of this approach in a high-prevalence, low-income environment.

Summary Background Identifying interventions to increase men’s uptake of HIV testing in sub-Saharan Africa is essential for the success of combination HIV prevention. HIV self-testing is an emerging approach with high acceptability, but limited evidence exists on optimal strategies for distributing self-tests. We explored a novel approach of providing multiple self-tests to women at high risk of HIV acquisition in order to promote partner HIV testing and facilitate safer sexual decision-making. Methods HIV-uninfected women aged 18–39 years were recruited at two sites in Kisumu, Kenya: a health facility with antenatal (ANC) and postpartum (PPC) clinics, and a drop-in center for female sex workers (FSW). Following informed consent and instructions on using the OraQuick Rapid HIV 1/2 Test, index participants (IPs) enrolled at the health facility and drop-in center received 3 and 5 self-tests, respectively. Structured interviews were conducted with IPs at enrollment and over 3 months to determine how self-tests were used. Key outcomes included the number of self-tests distributed by IPs, the proportion of IPs whose sexual partners used a self-test, couples testing, and sexual behavior following self-testing. Findings Between January 14, 2015 and March 13, 2015, 280 IPs were enrolled (61 ANC, 117 PPC, 102 FSW). Follow-up interviews were completed with 265 IPs (96%). Most IPs with a primary sexual partner distributed a self-test to that partner (53/58, 91% ANC; 91/106, 86% PPC; 64/85, 75% FSW). A vast majority of FSW IPs also distributed ≥1 self-tests to commercial sex clients (82/101, 81%). Among self-tests distributed to and used by IPs’ primary sexual partners, couples testing occurred frequently (27/53, 51% ANC; 62/91, 68% PPC; and 53/64; 83% FSW). Among self-tests distributed to and used by IPs’ sexual partners, an HIV-positive result was obtained for 3.8% (2/53), 2.2% (2/91), and 13.8% (41/298) of the tests in the ANC, PPC, and FSW participant groups, respectively. Sexual intercourse was significantly less likely after a sexual partner tested HIV-positive versus HIV-negative (18% vs. 62%, p<0.0001), while condom use was significantly more likely (100% vs. 44%, p=0.0018). Of 265 IPs with follow-up data, four reported intimate partner violence as a result of self-test distribution. No other adverse events were reported. Interpretation Provision of multiple HIV self-tests to women at high risk of HIV infection was successful in promoting HIV testing among their sexual partners and in facilitating safer sexual decisions. This novel strategy warrants further consideration as countries develop self-testing policies and programs.

BackgroundAchieving higher rates of partner HIV testing and couples testing among pregnant and postpartum women in sub-Saharan Africa is essential for the success of combination HIV prevention, including the prevention of mother-to-child transmission. We aimed to determine whether providing multiple HIV self-tests to pregnant and postpartum women for secondary distribution is more effective at promoting partner testing and couples testing than conventional strategies based on invitations to clinic-based testing.Methods and FindingsWe conducted a randomized trial in Kisumu, Kenya, between June 11, 2015, and January 15, 2016. Six hundred antenatal and postpartum women aged 18–39 y were randomized to an HIV self-testing (HIVST) group or a comparison group. Participants in the HIVST group were given two oral-fluid-based HIV test kits, instructed on how to use them, and encouraged to distribute a test kit to their male partner or use both kits for testing as a couple. Participants in the comparison group were given an invitation card for clinic-based HIV testing and encouraged to distribute the card to their male partner, a routine practice in many health clinics. The primary outcome was partner testing within 3 mo of enrollment. Among 570 participants analyzed, partner HIV testing was more likely in the HIVST group (90.8%, 258/284) than the comparison group (51.7%, 148/286; difference = 39.1%, 95% CI 32.4% to 45.8%, p < 0.001). Couples testing was also more likely in the HIVST group than the comparison group (75.4% versus 33.2%, difference = 42.1%, 95% CI 34.7% to 49.6%, p < 0.001). No participants reported intimate partner violence due to HIV testing. This study was limited by self-reported outcomes, a common limitation in many studies involving HIVST due to the private manner in which self-tests are meant to be used.ConclusionsProvision of multiple HIV self-tests to women seeking antenatal and postpartum care was successful in promoting partner testing and couples testing. This approach warrants further consideration as countries develop HIVST policies and seek new ways to increase awareness of HIV status among men and promote couples testing.Trial RegistrationClinicalTrials.gov NCT02386215.

Abstractobjectives To describe the sexual and reproductive behaviour of adolescents in sub-Saharan Africa, particularly 15-to 19-year-olds.methods Using DHS ⁄ AIS data (2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010), nine indicators of adolescent behaviour and one of adult attitudes towards condom education for adolescents were described for 24 countries. Indicators were disaggregated by gender, urban ⁄ rural residency and educational status, and time trends were described.results Up to 25% of 15-to 19-year-olds reported sex before age 15; this proportion shrank over time in many countries. In most countries, ‡5% of females reported marriage before age 15, and >20% had commenced childbearing. Early sexual debut and childbearing were more common among the least educated and ⁄ or rural females. Reporting of multiple sexual partnerships was more common among males than among females, but decreases over time were more common among males. Urban males and females, and females with higher education, were more likely to report multiple partnerships. Urban youth and those with higher education also reported more condom use. Adult support for condom education for 12-to 14-year-olds has increased over time to 60-65%.conclusions Many 15-to 19-year-olds are at risk of HIV ⁄ STIs and unplanned pregnancies because of multiple partnerships and insufficient condom and other contraceptive use. In many countries, trends are moving in a favourable direction. To better inform prevention programmes in this important area, we recommend routine collection of sexual and reproductive behaviour data for adolescents aged <15 years, expanding the data collected for 15-to 19-year-olds to include detailed information on sexual behaviour within partnerships, and disaggregating data according to sociodemographic variables.keywords sexual behaviour, adolescent, Africa ⁄ epidemiology, review