Community based distribution of oral HIV self-testing kits in Zambia: a cluster-randomised trial nested in four HPTN 071 (PopART) intervention communities

Abstract

SummaryBackgroundThe HPTN 071 (PopART) cluster-randomised trial provided door-to-door HIV testing services to a large proportion of individuals residing in 21 intervention communities in Zambia and South Africa from 2014 to 2017 and reached the UNAIDS first 90 target among women in Zambia, yet gaps remained among men and young adults. This cluster-randomised study nested in the HPTN 071 (PopART) trial sought to increase knowledge of HIV status across all groups by offering the choice of oral HIV self-testing in addition to routine door-to-door HIV testing services.MethodsWe nested this cluster-randomised trial in four HTPN 071 (PopART) intervention communities in northern Zambia. 66 zones (clusters) in these communities were randomly allocated (1:1) to either oral HIV self-testing plus routine door-to-door HIV testing services (HIV self-testing group) or the PopART standard of care of door-to-door HIV testing services alone (non- HIV self-testing group) over a 3-month period. All individuals aged 16 years or older were eligible for HIV testing. Randomisation was achieved by randomly selecting one allocation from a list of 10 000 possible allocations during a public ceremony. In HIV self-testing zones, trained lay-counsellors (known as community HIV care providers) visited households and offered eligible individuals the choice of HIV testing using HIV self-testing or routine door-to-door HIV testing services. For individuals aged 18 years or older whose partner was absent during the household visit, an HIV self-test kit could be left for secondary distribution to the absent partner. The primary outcome was knowledge of HIV status (defined as self-reporting HIV positive to the community HIV care providers or accepting an offer of HIV testing services). Outcomes were measured among households that were first visited, and individuals first enumerated as a household member during the HIV self-testing intervention period. We analysed data at the individual level using population-average logistic regression models, accounting for clustering of outcomes by zone, to estimate the effect of the intervention. This trial is registered with ClinicalTrials.gov, number NCT02994329.FindingsBetween Feb 1, and April 30, 2017, the community HIV care providers enumerated 13 267 eligible individuals in the HIV self-testing group and 13 706 in the non-HIV self-testing group. After intervention implementation, 9027 (68%) of 13 267 in the HIV self-testing group had knowledge of HIV status compared with 8952 (65%) of 13 706 in the non-HIV self-testing group (adjusted odds ratio 1·30, 95% CI 1·03–1·65; p=0·03). The effect differed by sex (pinteraction=0·01). Among men, knowledge of HIV status was higher in the HIV self-testing group than in the non-HIV self-testing group (3843 [60%] of 6368 vs 3571 [55%] of 6486; adjusted odds ratio 1·31, 95% CI 1·07–1·60; p=0·01). There was no evidence of a between-group difference among female participants.InterpretationProviding a choice of HIV self-testing during delivery of door-to-door HIV testing ser...

HIV testing and treatment coverage achieved after 4 years across 14 urban and peri-urban communities in Zambia and South Africa: An analysis of findings from the HPTN 071 (PopART) trial

“…The "pre-intervention" gap among younger individuals might be reduced by making facility-based services more "youth friendly," and steps toward this were taken during the last year of intervention as part of the nested "PopART-for-Youth" (P-ART-Y) study. The provision of HIV self-testing could also contribute [14,[24][25][26].…”

“…These factors placed an upper limit on the testing and treatment coverage that could be achieved. In the future, it is possible that more service provision in the community outside a household setting and the option of HIV self-testing might reach some previously unreached individuals [14,[24][25][26][27].…”

“…In Zambia in February 2017, the novel option of HIV self-testing was introduced to half of the CHiP zones in 2 Arm A and 2 Arm B communities, in a nested randomised trial. Following evidence that this increased testing uptake among men [14], the option to self-test was rolled out to all CHiP zones in Zambia during July-December 2017. For individuals who had been referred but not yet linked to care, or who had dropped out of care, household follow-up visits and/or phone calls were made to provide additional counselling and to offer to accompany an individual to the clinic.…”

“If it is left, it becomes easy for me to get tested”: Use of oral self‐tests and community health workers to maximize the potential of home‐based HIV testing among adolescents in Lesotho

“…However, to our knowledge, ADORE is among the first studies exploring secondary distribution of HIVST during home‐based HIV testing in AYA. A nested trial within HPTN 071 (PopART) investigated primary as well as secondary HIVST distribution during a door‐to‐door testing campaign [27]. This led to a moderate increase in coverage rates from 65% to 68% overall, and from 70% to 74% among young adults aged 16 to 29 years old.…”

“I would like to be part of the team distributing the kits because I have all the qualities” Formative research to inform the development of a peer-led HIV self-testing intervention to improve HIV testing uptake and linkage to HIV care among young people and adult men in Kasensero fishing community, Rakai, Uganda

“…In another study to assess the effect of peer distribution of HIV self-test kits to men who have sex with men on HIV testing uptake among men with undiagnosed HIV infection in Uganda, Okoboi [30] found that 95% of the MSM who were reached with fellow MSM with HIV self-test kits accepted to test for HIV. Evidence from prior studies [31,32], along with our ndings, suggest that the use of a peer-led HIVST approach can help to improve uptake of HIV testing services in populations that cannot easily access conventional HIV services either due to their mobility, physical location, sexual orientation or other barriers.…”