Post on 08-Mar-2021
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