“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

Abstract

Introduction Home‐based HIV testing fails to reach high coverage among adolescents and young adults (AYA), mainly because they are often absent during the day of home‐based testing. ADORE (ADolescent ORal tEsting) is a mixed‐method nested study among AYA in rural Lesotho, measuring the effect of home‐based secondary distribution of oral HIV self‐tests (HIVST) on coverage, as well as exploring how AYA perceive this HIV self‐testing model. Methods ADORE study was nested in a cluster‐randomized trial. In intervention village‐clusters, oral HIVST were left for household members who were absent or declined testing during a testing campaign. One present household member was trained on HIVST use. Distributed HIVST were followed up by village health workers (VHW). In control clusters no self‐tests were distributed. The quantitative outcome was testing coverage among AYA (age 12 to 24) within 120 days, defined as a confirmed HIV test result or known status, using adjusted random‐effects logistic regression on the intention‐to‐treat population. Qualitatively, we conducted in‐depth interviews among both AYA who used and did not use the distributed HIVST. Results From July 2018 to December 2018, 49 and 57 villages with 1471 and 1620 consenting households and 1236 and 1445 AYA in the control and intervention arm, respectively, were enrolled. On the day of the home‐visit, a testing coverage of 37% (461/1236) and 41% (596/1445) in the control and the intervention arm, respectively, were achieved. During the 120 days follow‐up period, an additional 23 and 490 AYA in control and intervention clusters, respectively, knew their status. This resulted in a testing coverage of 484/1236 (39%) in the control versus 1086/1445 (75%) in the intervention arm (aOR 8.80 [95% CI 5.81 to 13.32]; p < 0.001). 21 interviews were performed. Personal assistance after the secondary distribution emerged as a key theme and VHWs were generally seen as a trusted cadre. Conclusions Secondary distribution of HIVST for AYA absent or refusing to test during home‐based testing in Lesotho resulted in an absolute 36% increase in coverage. Distribution should, however, go along with clear instructions on the use of the HIVST and a possibility to easily access more personal support.

Implementation outcomes of HIV self-testing in low- and middle- income countries: A scoping review

“…"Willingness to use" was the most common way of measuring acceptability and other measures included ease of use, preference over standard tests, and willingness to pay. Sixty-six (66) used a quantitative design [22-87], 37 were qualitative [43,, and 19 were mixed or multi-method studies [20, [124][125][126][127][128][129][130][131][132][133][134][135][136][137][138][139][140][141]. Only the quantitative results are presented in this section; qualitative results are discussed with findings on appropriateness due to similarities in themes and results.…”

“…Interventional studies have focused on evaluating the impact of implementation strategies on HIV-ST uptake or on overall HIV testing rates. The most commonly studied strategy was distribution of self-testing kits through community members, volunteers or peers [44,61,67,74,78,85,124,125,140,146,151,159,162,194] or intimate partners (usually female) [28,47,49,68,144,147,152,156,161,165,166]. All except Tun et al [74] used direct distribution of kits to users.…”

“…In quasi-experimental studies, there was high uptake (�80%) after direct distribution by peers [43,78,146,151] or partners [28,144,152]. Nearly all randomized trials [28, 47,124,144,146,147,156], except for one study in Zimbabwe [67], showed significant positive effects on overall HIV testing rates in the interventions arms. Also, Choko et al [152] noted that in Malawi, distribution via partners with financial incentives can improve actual clinic follow-up by male partners.…”

“…HIV-ST also had potential to reduce stigma and anxiety associated with testing [9, 20, 45, 91, 95, 98, 99, 103, 104, 107, 112, 114, 118-120, 122, 126, 127, 131, 138, 184, 198]. Compared to standard facility-based testing, HIV-ST was perceived to be better in protecting confidentiality [20, 57, 88, 91, 95, 98, 100, 103, 104, 108, 112-116, 118-120, 122, 124, 126, 127, 129, 131, 137-140, 183, 184, 195-197, 199] especially in settings where people doubt the ability of HCW to protect confidentiality [20,57,99,100,104,113,124,126,137]. It was a common belief that HIV-ST would be useful for increasing HIV testing rates in certain populations, such as men or young people [45, 48, 78, 90, 91, 95, 98-100, 102, 106, 116, 118, 120, 137, 139, 184, 190, 191, 196, 199].…”

“…Proper kit design for the target population was often mentioned. Design considerations included the instructional materials [90, 98, 100, 103, 107, 114, 120, 124, 131-133, 187, 190, 201-203] and the type of fluid (blood or oral fluid) [90,92,100,102,104,106,108,110,114,116,119,124,127,131,132,137,139,184,191,196]. Instructions needed to be clear and easy to understand.…”