Examining the effects of HIV self-testing compared to standard HIV testing services in the general population: A systematic review and meta-analysis

In December 2019, China reported the emergence of a pneumonia of unknown cause in Wuhan [1]. By 7 January 2020, the etiology of the pneumonia was attributed to a virus of the coronavirus family, and later on the disease was named coronavirus disease (COVID-19) on 11 February 2020 by the WHO [2, 3]. The symptoms of COVID-19 appear after an average incubation period of 5.2 days [1]. The median period from the onset of the disease to death is 14 days (range 6 to 41) [3]. Transmission of the virus is human to human through direct contact, or air droplets from infected persons spread by coughing or sneezing. The infection droplets can also contaminate surfaces, and the virus can remain infectious for several days in the environment, providing a reservoir for the infection [4]. The majority of infections go into remission without intervention, while approximately 15% will require hospitalization, with approximately 5% of these requiring intensive care [3, 4]. Unmitigated spread of COVID-19 creates pressure on health systems, and diverts resources that could have otherwise been better utilized for other health conditions. Sub-Saharan Africa health systems are already strained and are characterized by poor health outcomes with high mortality rates linked to the triple burden of disease (HIV, tuberculosis, and non-communicable diseases) and out of pocket healthcare. In response to the epidemic China imposed restriction such as quarantine (lockdown) of the whole city of Wuhan. This model proved efficacious, resulting in some Sub-Saharan Africa countries implementing the same. The lockdown measures are in no way aimed at ending the pandemic but seek to protect the health systems of countries from being overwhelmed by flood of infected and sick patients needing medical care. However, the restrictions come with unintended consequences, such as widening inequalities, mental health problems, and exacerbating poor medical outcomes that are not COVID-19-related. Of particular interest to this paper, The Joint United Nations Programme on HIV and AIDS (UNAIDS) and the World Health Organization (WHO) have announced that the number of AIDS-related deaths in Sub-Saharan Africa could double if access to healthcare for people living with HIV (PLWH) is interrupted during the COVID-19 pandemic. While interruption to the supply of ARV drugs would have by far the largest impact of any potential disruptions [5], suspension of HIV testing would also have significant population impact.

/pdf/covid-19-lockdowns-impact-on-facility-based-hiv-testing-and-4v3r3lnfa8.pdf

COVID-19 Lockdowns: Impact on Facility-Based HIV Testing and the Case for the Scaling Up of Home-Based Testing Services in Sub-Saharan Africa.

Introduction: HIV self-testing (HIVST) provides couples and individuals with a discreet, convenient and empowering testing
option. As with all HIV testing, potential harms must be anticipated and mitigated to optimize individual and public health benefits.
Here, we describe social harms (SHs) reported during HIVST implementation in Malawi, and propose a framework for
grading and responding to harms, according to their severity.
Methods: We report findings from six HIVST implementation studies in Malawi (2011 to 2017) that included substudies
investigating SH reports. Qualitative methods included focus group discussions, in-depth interviews and critical incident interviews.
Earlier studies used intensive quantitative methods (post-test questionnaires for intimate partner violence, household
surveys, investigation of all deaths in HIVST communities). Later studies used post-marketing reporting with/without community
engagement. Pharmacovigilance methodology (whereby potentially life-threatening/changing events are defined as “serious”)
was used to grade SH severity, assuming more complete passive reporting for serious events.
Results: During distribution of 175,683 HIVST kits, predominantly under passive SH reporting, 25 serious SHs were reported
from 19 (0.011%) self-testers, including 15 partners in eight couples with newly identified HIV discordancy, and one perinatally
infected adolescent. There were no deaths or suicides. Marriage break-up was the most commonly reported serious SH (sixteen
individuals; eight couples), particularly among serodiscordant couples. Among new concordant HIV-positive couples, blame
and frustration was common but rarely (one episode) led to serious SHs. Among concordant HIV-negative couples, increased
trust and stronger relationships were reported. Coercion to test or disclose was generally considered “well-intentioned” within
established couples. Women felt empowered and were assertive when offering HIVST test kits to their partners. Some women
who persuaded their partner to test, however, did report SHs, including verbal or physical abuse and economic hardship.
Conclusions: After more than six years of large-scale HIVST implementation and in-depth investigation of SHs in Malawi, we
identified approximately one serious reported SH per 10,000 HIVST kits distributed, predominantly break-up of married
serodiscordant couples. Both “active” and “passive” reporting systems identified serious SH events, although with more complete
capture by “active” systems. As HIVST is scaled-up, efforts to support and further optimize community-led SH monitoring
should be prioritized alongside HIVST distribution.
Keywords: HIV/AIDS; HIV self-test; HIV testing; social harms; Malawi

https://onlinelibrary.wiley.com/doi/pdf/10.1002/jia2.25251

Exploring social harms during distribution of HIV self-testing kits using mixed-methods approaches in Malawi.

Introduction The HIV epidemic in Vietnam is concentrated in key populations and their partners - people who inject drugs, men who have sex with men, sex workers and partners of people living with HIV. These groups have poor access to and uptake of conventional HIV testing services (HTS). To address this gap, lay provider- and self-testing and assisted partner notification (aPN) were introduced and delivered by the community. We explored the feasibility and effectiveness of implementing aPN as part of community testing services for key populations. Methods Lay provider testing and self-testing was started in January 2017, and targeted key populations and their partners. Since July 2017, aPN was introduced. HTS was offered at drop-in houses or coffee shops in Thai Nguyen and Can Tho provinces. All self-testing was assisted and observed by peer educators. Both in-person and social network methods were used to mobilize key populations to test for HIV and offer HTS to partners of people living with HIV. Client-level data, including demographic information and self-reported risk behaviour, were collected on site by peer educators. Results Between January 2017 and May 2018, 3978 persons from key populations were tested through community-led HTS; 66.7% were first-time testers. Of the 3978 clients, 3086 received HTS from a lay provider and 892 self-tested in the presence of a lay provider. Overall, 245 (6.2% of tested clients) had reactive results, 231 (94.3%) were confirmed to be HIV positive; 215/231 (93.1%) initiated antiretroviral therapy (ART). Of 231 adult HIV-positive clients, 186 (80.5%) were provided voluntary aPN, and 105 of their partners were contacted and received HTS. The ratio of partners who tested for HIV per index client was 0.56. Forty-four (41.9%) partners of index clients receiving HTS were diagnosed with HIV, 97.7% initiated ART during the study period. No social harm was identified or reported. Conclusions Including aPN as part of community-led HTS for key populations and their partners is feasible and effective, particularly for reaching first-time testers and undiagnosed HIV clients. Scale-up of aPN within community-led HTS for key populations is essential for achieving the United Nations 90-90-90 targets in Vietnam.

https://onlinelibrary.wiley.com/doi/epdf/10.1002/jia2.25301

Community-led HIV testing services including HIV self-testing and assisted partner notification services in Vietnam: lessons from a pilot study in a concentrated epidemic setting.

Introduction HIV self-testing (HIV-ST) is an effective means of improving HIV testing rates. Low- and middle-income countries (LMIC) are taking steps to include HIV-ST into their national HIV/AIDS programs but very few reviews have focused on implementation in LMIC. We performed a scoping review to describe and synthesize existing literature on implementation outcomes of HIV-ST in LMIC. Methods We conducted a systematic search of Medline, Embase, Global Health, Web of Science, and Scopus, supplemented by searches in HIVST.org and other grey literature databases (done 23 September 2020) and included articles if they reported at least one of the following eight implementation outcomes: acceptability, appropriateness, adoption, feasibility, fidelity, cost, penetration, or sustainability. Both quantitative and qualitative results were extracted and synthesized in a narrative manner. Results and discussion Most (75%) of the 206 included articles focused on implementation in Africa. HIV-ST was found to be acceptable and appropriate, perceived to be convenient and better at maintaining confidentiality than standard testing. The lack of counselling and linkage to care, however, was concerning to stakeholders. Peer and online distribution were found to be effective in improving adoption. The high occurrence of user errors was a common feasibility issue reported by studies, although, diagnostic accuracy remained high. HIV-ST was associated with higher program costs but can still be cost-effective if kit prices remain low and HIV detection improves. Implementation fidelity was not always reported and there were very few studies on, penetration, and sustainability. Conclusions Evidence supports the acceptability, appropriateness, and feasibility of HIV-ST in the LMIC context. Costs and user error rates are threats to successful implementation. Future research should address equity through measuring penetration and potential barriers to sustainability including distribution, cost, scale-up, and safety.

/pdf/implementation-outcomes-of-hiv-self-testing-in-low-and-3f7fg86786.pdf

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

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Exploring social harms during distribution of HIV self-testing kits using mixed-methods approaches in Malawi.