HIV SELF-TESTING AFRICA

HIV Self-Testing: breaking the barriers to uptake of testing among men and adolescents in sub-Saharan Africa, experiences from STAR demonstration

projects in Malawi, Zambia andZimbabwe

Karin Hatzold, Stephano Gudukeya, Miriam Mutseta, Richard Chilongosi, Mutinta Nalubamba, Chiwawa Nkhoma, Hambweka Munkombwe, Malvern Munjoma, Phillip Mkandawire, Varaidzo Mabhunu, Gina Smith, Ngonidzashe Madidi, Hussein Ahmed, Taurai Kambeu, Petra Stankard, Cheryl Johnson and Elizabeth L Corbett.

Introduction

• Low HIV testing, knowledge of status, and suboptimal treatment and prevention coverage among men and young people (15 to 24 years) in sub-Saharan Africa

• PHIA in Zimbabwe, Malawi and Zambia• Men less likely to know their status than

HIV positive women • <50% of youth aged 15 to 24 years with HIV

knew their status,

• Poor utilization of public sector health facilities

• Social Norms, Masculinity

• Higher opportunity and indirect costs

• HIV related stigma

• Lack of youth friendly services prevent young people from taking up services

Methods

• HIVST distribution data from Malawi, Zambia and Zimbabwe

• Kit distributors collected individual-level age, sex and testing history from all clients; five distribution models: • Community-based distribution• Workplace distribution • Integration with HIV testing services • Public health facilities • Demand creation for voluntary male medical

circumcision

• Used kits were collected and re-read from CBD and IHTS recipients.

• Data were aggregated and presented by distribution model

HIVST IMPACT Model of distribution/linkage

Improving access and reaching people with high HIV risk and vulnerability who have not tested

• Community based distribution• Distribution at workplaces and tertiary institutions• Distribution through key population networks

Creating demand for HIV prevention and increasing efficiencies for those who test HIV-negative

HIVST distribution linked to: • Voluntary Medical Male Circumcision • Pre-exposure prophylaxis, • Screening and treatment of sexually transmitted

infections

Integration of HIVST in clinical services, replacing steps in testing process

Integration with provider initiated testing services (public sector)

Integration with client initiated testing services( HTS services, mobile, community outreach, fixed sites)

Facilitating partner testing • Index testing • aPN, • Sexual partners of pregnant/lactating

mothers

HIVST increases HIV testing coverage

0

50,000

100,000

150,000

200,000

250,000

300,000

Malawi Zimbabwe Zambia

N=628,705 work place

key populations

NewStart/TUNZA

Public Sector

VMMC Staticsites

VMMC IPC

Communitybaseddistribution

44%

52%

36%

67%73% 71%

61%67%

49%

83%

72%77%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Malawi Zambia Zimbabwe

Baseline men Midline men

Baseline female Midline female

HIVST kit distribution by country, age and sex M alawi Zambia Zimbabwe Total

All distribution models 172,830 100.0% 190,784 100.0% 265,091 100.0% 628,705 100.0%

Community-based Distributors 163,300 94.5% 156,806 82.2% 199,552 75.3% 519,658 82.7%

HTS integration (7 months) 2,199 1.3% 52,254 19.7% 54,453 8.7%

Work place 6,004 3.5% 298 0.2% 3,548 1.3% 9,850 1.6%

Public Sector 18,588 9.7% 2,595 1.0% 21,183 3.4%

VMMC demand creation 1,327 0.8% 15,092 7.9% 7,142 2.7% 23,561 3.7%

Demographics available* 172,830 172,562 265,091 610,483

Male sex 84,603 49.0% 87,418 50.7% 122,487 46.2% 294,508 48.2%

Age-group16-24 87,744 50.8% 84,437 48.9% 90,892 34.3% 263,073 43.1%

25-34 45,864 26.5% 50,168 29.1% 61,438 23.2% 157,470 25.8%

35-49 29,405 17.0% 28,926 16.8% 55,464 20.9% 113,795 18.6%

50-plus 9,817 5.7% 9,031 5.2% 57,298 21.6% 76,146 12.5%

First time testers 46,402 26.8% 37,232 21.6% 36,039 13.6% 119,673 19.6%

Men 23585 27.9% 22,180 25.4% 19,812 16.2% 65,577 22.3%

Women 22817 25.9% 15,052 17.7% 16,227 11.4% 54,096 17.1%

Reaching first-time testers

• 19.6% First-Time testers• 26.8% in

Malawi• 21.6% in

Zambia• 13.6% in

Zimbabwe

• 22.3% among Male HIVST

• 17.1% among Female HIVST

• Highest among youth and >50 years

Increasing uptake/coverage/case identification: Integration of HIVST in clinical services

HIVST Provider Delivered Testing Total

Tested

HIV

(+)

Rate 11 HIV

Testing sites

Mobile Outreach

Males

Screen

(-)HIVST

Females

Screen

(-) HIVST

Male

s

screen

( +)

HIVST

Female

s

screen(+ )

HIVST

Males

Tested

Female

Tested

Males

confirm

Positive HIVST

Females

confirm

Positive HIVST

Males

PDHTS

Positive

Females

PDHTS

Positive

Total

Positive

TOTALS 47,190 49,307 2,095 3,032 8,808 9,559 745 1,163 859 1,072 3,839 119,991 21%

HIVST used to screen

Provider testing of both HIVST and

non-HIVST

Increased case identification

Increased Positivity

Rate

HIVST impact on uptake of prevention services – VMMC, STAR Zimbabwe

395

315

275 265

70

10 100

50

100

150

200

250

300

350

400

450

Men reachedwith VMMCmoblisation

Men Testedbefore VMMC

Men receiveHIVST before

VMMC

Men testing HIVNegative

Men who tookup VMMC

Men with HIVpositive self-test

HIV positive menstarted on ART

87%

26%

Conclusions

• Men and young people in sub-Saharan Africa contribute disproportionately to the number of PLHIV who are not aware of their status.

• HIVST delivered through targeted distribution models• Reaches people not previously tested • Increase coverage of HIV testing among priority populations • Increase case finding among priority populations• Contribute substantially to comprehensive provider-initiated HTS in high volume and congested

public sector clinics • Increase uptake of HIV prevention services

• HIVST offers clear advantages when provided in addition to existing services, and if scaled-up, can contribute to closing the gap towards the “first 90.”

• HIVST distribution/linkage approaches need to be adapted to epidemiological context and targeted at priority population

Limitations

• Based on programmatic data; Self-reported client data

• Data on HIVST with regards to first-time testers, motivators and barriers to HIVST may have been prone to social desirability bias.

• Some HTS clients may have obtained confirmation of an earlier positive test or self-test

• Results may not be generalizable to other program contexts with less intensity of distribution or different starting attitudes and perceptions by potential HIVST users and HTS providers.

STAR Initiative Way Forward • STAR Initiative expansion to South Africa, Lesotho and Eswatini

• Optimise scalable and sustainable models of distribution, cost-effectiveness• Community led models • Private sector

• Workplace • Open access/Community pharmacies• Community shops and retail outlets

• Facility based HIVST distribution• Index, secondary distribution• ANC, secondary distribution• Direct distribution through OPD

• Blood based RDTs

• Commodity forecasting for operational planning and investment

• Sustainable procurement and supply chain systems

• M&E of HIVST

• Optimise linkages to care and prevention

• Outcome/Impact measurement of HIVST services

All Co-authors: Stephano Gudukeya, Miriam Mutseta, Richard Chilongosi, Mutinta Nalubamba, Chiwawa Nkhoma, Hambweka Munkombwe, Malvern Munjoma, Phillip Mkandawire, Varaidzo Mabhunu, Gina Smith, Ngonidzashe Madidi, Hussein Ahmed,

Taurai Kambeu, Petra Stankard, Cheryl Johnson and Elizabeth L Corbett.

JIAS Editors Guest editors: Vincent J. Wong (USAID), Nathan Ford (WHO) and Kawango Agot (Impact-RDO)UnitaidWHO STAR Consortium Partners

Acknowledgements