Acceptability and feasibility of HIV self-testing among transgender people in Larkana, Pakistan: Results from a pilot project

Abstract

Background HIV self-testing (HIVST) is an innovative HIV testing approach that effectively reaches those who do not otherwise test, including key populations (KPs). Despite potential benefits, HIVST is not currently implemented in Pakistan. The high risk of HIV among transgender (TGs) persons is among the highest risk group for HIV in Pakistan, yet knowledge of HIV status remains low in this key population group. We conducted a pilot project to assess the acceptability and feasibility of distributing HIVST to TGs in Larkana. Methods Eligible participants were 18 years or above and self-identified as transgender (“hijra”). One oral fluid HIVST kit per person was distributed free of cost in the community by trained transgender peer outreach workers (ORW). Participants could request a demonstration of the HIVST procedure before performing self-testing which was provided by the trained ORW. Demographic characteristics of participants were collected. The ORW followed up with phone calls two days later to record if HIVST kits were used, the results, and whether assistance was required. Results Between November 2020 and February 2021, 150 HIVST kits were distributed to eligible TGs. The average age of participants was 25.5 years (standard deviation: 7.0). Over a third (52, 34.7%) had no formal education, while (16, 10.6%) had attended at least five years of schooling. Over one-third (58, 38.6%) of participants were first-time testers. One hundred and thirty-nine (92.7%) participants reported their results within two days. For the remaining 11 participants, ORWs had to contact them. All participants reported using HIVST kits within three days. A majority (141, 94%) used the kit in their homes, and the remaining nine (6%) used it at the community-based organization’s office. Overall, a small proportion (11, 7.3%) of participants requested a demonstration of the test procedure before performing HIVST. Four (2.7%) participants who had performed unsupervised self-tests reported reactive HIVST results; all were linked to treatment within five working days once their HIV result was confirmed. The majority (136, 90.6%) of participants felt that self-testing was easy to perform independently, and 143 (95%) reported that they would recommend HIVST to their peers. Conclusion HIVST is acceptable among TGs and identified by first-time testers as undiagnosed infections. Peer-led distribution appears to be a feasible approach for implementation in this setting. HIVST should be considered for routine implementation and scale up to reduce testing gaps among Pakistan’s key population, particularly TGs.

Alarming rise in HIV cases in Pakistan: Challenges and future recommendations at hand

“…22 A total of 5.5% HIV prevalence was estimated in the transgender community of Pakistan in 2020. 23 Healthcare workers are also exposed to the infection due to the lack of guidelines and proper safety equipment. 24 Poor literacy rates, widespread poverty, and hazardous blood transfusions made Pakistan more assailable to HIV.…”

“…The unsafe and unlawful sex in prostitution also results in transmission of HIV 22 . A total of 5.5% HIV prevalence was estimated in the transgender community of Pakistan in 2020 23 . Healthcare workers are also exposed to the infection due to the lack of guidelines and proper safety equipment 24 …”

HIV in Pakistan: Challenges, efforts and recommendations

“…Along with female prostitutes, the districts are home to male transvestites known as “Hijras”, and the fact that most males engaging in male-to-male sexual activity in Pakistan are married, highlights their ability to serve as a conduit to the broader community [ 21 , 22 ]. In 2020, the prevalence of HIV amongst the transgender community was estimated to be 5.5%, making them among the highest risk groups for HIV [ 23 ]. Healthcare workers (HCW) are more susceptible to infections because of non-adherence to WHO guidelines, such as careless handling of contaminated needles, reuse of needles that weren't properly sterilized, improper disposal of potentially dangerous waste, and overcrowding in patient care areas, which may occur as a consequence of not having a suitable reporting channel or a suitable process for reporting workplace accidents [ 24 ].…”