Effect of index HIV self-testing for sexual partners of clients enrolled in antiretroviral therapy (ART) programs in Malawi: A randomized controlled trial

Abstract

Background HIV testing among the sexual partners of HIV–positive clients is critical for case identification and reduced transmission in southern and eastern Africa. HIV self-testing (HIVST) may improve uptake of HIV services among sexual partners of antiretroviral therapy (ART) clients, but the impact of HIVST on partner testing and subsequent ART initiation remains unclear. Methods and findings We conducted an individually randomized, unblinded trial to assess if an index HIVST intervention targeting the partners of ART clients improves uptake of testing and treatment services in Malawi. The trial was conducted at 3 high-burden facilities in central and southern Malawi. ART clients attending HIV treatment clinics were randomized using simple randomization 1:2·5 to: (1) standard partner referral slip (PRS) whereby ART clients were given facility referral slips to distribute to their primary sexual partners; or (2) index HIVST whereby ART clients were given HIVST kits + HIVST instructions and facility referral slips to distribute to their primary sexual partners. Inclusion criteria for ART clients were: ≥15 years of age, primary partner with unknown HIV status, no history of interpersonal violence (IPV) with partner, and partner lives in facility catchment area. The primary outcome was partner testing 4-weeks after enrollment, reported by ART clients using endline surveys. Medical chart reviews and tracing activities with partners with a reactive HIV test measured ART initiation at 12 months. Analyses were conducted based on modified intention-to-treat principles, whereby we excluded individuals who did not have complete endline data (i.e., were loss to follow up from the study). Adjusted models controlled for the effects of age and marital status. A total of 4,237 ART clients were screened and 484 were eligible and enrolled (77% female) between March 28, 2018 and January 5, 2020. A total of 365 participants completed an endline survey (257/34 index HIVST arm; 107/13 PRS arm) and were included in the final analysis (78% female). Testing coverage among sexual partners was 71% (183/257) in the index HIVST arm and 25% (27/107) in the PRS arm (aRR: 2·77, 95% CI [2·56 to 3·00], p ≤ 0.001). Reported HIV positivity rates did not significantly differ by arm (16% (30/183) in HIVST versus 15% (4/27) in PRS; p = 0.99). ART initiation at 12 months was 47% (14/30) in HIVST versus 75% (3/4) in PRS arms; however, index HIVST still resulted in a 94% increase in the proportion of all partners initiating ART due to higher HIV testing rates in the HIVST arm (5% partners initiated ART in HVIST versus 3% in PRS). Adverse events including IPV and termination of the relationship did not vary by arm (IPV: 3/257 index HIVST versus 4/10 PRS; p = 0.57). Limitations include reliance on secondary report by ART clients, potential social desirability bias, and not powered for sex disaggregated analyses. Conclusions Index HIVST significantly increased HIV testing and the absolute number of partners initiating ART in Malawi, without increased risk of adverse events. Additional research is needed to improve linkage to HIV treatment services after HIVST use. Trial registration ClinicalTrials.gov, NCT03271307, and Pan African Clinical Trials, PACTR201711002697316.

Effectiveness of HIV self‐testing when offered within assisted partner services in Western Kenya (APS‐HIVST Study): a cluster randomized controlled trial

“…Those receiving HIVST do not have immediate post‐testing counselling but rather must contact a provider or wait for study follow‐up to report their results. Though lower linkage to care among those receiving HIVST is a concern, 86.6% is relatively high compared to other settings [14, 27–30]. Furthermore, linkage within the intervention arm for those who opted for HIVST and provider‐delivered testing was similar.…”

Social network strategies to distribute HIV self‐testing kits: a global systematic review and network meta‐analysis

“…Six studies were from high‐income countries, 24 in middle‐income countries and nine in low‐income countries. The included studies were conducted in eight countries from 2010 to 2021, seven in China [ 25 , 26 , 27 , 28 , 29 , 30 , 31 ], six in South Africa [ 32 , 33 , 34 , 35 , 36 , 37 ], six in the United States [ 38 , 39 , 40 , 41 , 42 , 43 ], six in Uganda [ 44 , 45 , 46 , 47 , 48 , 49 ], eight in Kenya [ 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 ], three in Malawi [ 58 , 59 , 60 ], two in Vietnam [ 61 , 62 ] and one in Zambia [ 63 ].…”

Interventions to improve men’s engagement in HIV and other key services in sub-Saharan Africa: a scoping review

“…One intervention for TB-HIV co-infection found that community-based TB screening increased screening efforts but decreased presumed TB and TB positive cases identified. 45 There were a total of 39 community service interventions focused on HIV testing -17 interventions distributed HIVST to men (primary or secondary distribution), [46][47][48][49][50][51][52][53][54][55][56][57][58] 15 provided community/workforce testing (non-HIVST), 52,53,55,[59][60][61][62][63][64][65][66][67][68][69][70][71] and 11 provided home-based HIV testing services. 46,54,61,69,[72][73][74][75] Community services outperformed standard of care facility services 48,52,60,61,65,67,72,73 and mobile and targeted venue testing such as work were more cost...…”

“…63,64,68 Primary distribution of HIVST increased reach testing. 48,52,53,55 Secondary HIVST distribution increased testing among men when given to female partners living with HIV as part of index testing, 47,58 ANC clients, [49][50][51]57 young women, 56 and when HIVST was left for male adults and adolescents who were not home during door-to-door distribution. 48,54 Only one community service intervention examined the impact on linkage for men.…”