How can most-at-risk populations be encouraged to seek HIV testing?

The referral voucher used to track contribution to increased demand for HCT and other health services for MARPs in Kyrgyzstan. Image from the presentation of Djamila Alisheva.
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Peer-mediated HIV counselling resulted in the highest uptake of HIV counselling and testing (HCT) among male most-at-risk populations (M-MARPS), according to a longitudinal analysis of three testing strategies conducted in three states in Nigeria. At the same time, a voucher scheme proved successful in monitoring the effectiveness of a programme to encourage testing among MARPs in Kyrgyzstan, researchers reported at the 7th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2013) in Kuala Lumpur, Malaysia, on Tuesday.

The UNAIDS Investment Framework recommends that focused programmes for key populations at higher risk (particularly sex workers and their clients, men who have sex with men [MSM], and people who inject drugs) are essential to an adequate HIV response and need to be delivered at scale.

“Training...peers to provide HIV counselling and testing (HCT) is a high-impact approach in delivering HCT to male most-at-risk populations." Dr Sylvia Adebajo

Robust evidence of what works in linking most-at-risk populations to HIV counselling, testing, care and treatment is limited, particularly in settings where these populations are stigmatised or where they have not been treated as priority groups for HIV prevention.



A healthcare professional’s recommendation that a person sees another medical specialist or service.


Social attitudes that suggest that having a particular illness or being in a particular situation is something to be ashamed of. Stigma can be questioned and challenged.

key populations

Groups of people who are disproportionately affected by HIV or who are particularly vulnerable to HIV infection. Depending on the context, may include men who have sex with men, transgender people, sex workers, people who inject drugs, adolescent girls, prisoners and migrants.


Short for people who inject drugs.

drug interaction

A risky combination of drugs, when drug A interferes with the functioning of drug B. Blood levels of the drug may be lowered or raised, potentially interfering with effectiveness or making side-effects worse. Also known as a drug-drug interaction.

Two studies, from Nigeria and Kyrgyzstan, presented evidence on how to reach MARPs with large-scale interventions.

Nigeria: reaching men at risk of HIV

The Nigerian study compared facility-based HCT accompanied by a community mobilisation component using key opinion leaders, M-MARPS being referred to nearby mobile HCT teams, and mobile M-MARPS peers conducting the HCT.

A total of 31,609 M-MARPs (including MSM, male sex workers, the male clients of sex workers and males who inject drugs) received HCT between July 2009 and July 2012. In total, 1988 (6.3%) were tested at facilities, 14,726 (46.6%) through referral and 14,895 (47.1%) through the mobile peer-led HCT. The authors noted that this stark difference in those accessing HCT at facilities compared to mobile HCT sites illustrates the need for an increased number of mobile HCT testing sites for MARPs.

M-MARPs are less likely to access HCT and other prevention services because they engage in behaviours that are criminalised, because they fear stigmatising behaviours of healthcare workers, and because there is a lack of M-MARPs-friendly services which meet their specific needs.

M-MARPs make up approximately 1% of the Nigerian population, but M-MARPs and their sexual partners account for a disproportionally high burden of HIV infections in the country at 38%.

The peer-led mobile HCT strategy attracted the highest number of men who were testing for HIV for the first time (90.1%, n=13 313), compared to the referral strategy (84.3%, n=12 079) and the facility-based strategy (87.9%, n=1 646). The HIV prevalence among first-time testers was 8.2, 2.9 and 13.2% respectively in the different strategies (p≤0.001).

“Training M-MARPs peers to provide HCT is a high-impact approach in delivering HCT to M-MARPs. Nigeria’s National Prevention Plan needs to align to WHO’s goal of universal access and promote annual testing for all MARPs in Nigeria through peer-led HCT”, said Dr Sylvia Adebajo, who presented the study.


Use of referral vouchers to measure increased demand of for HIV counselling and testing among MARPs in Kyrgyzstan

The use of referral voucher to track contribution to increased demand for HCT and other health services for MARPs in Kyrgyzstan has been shown to provide strong evidence of the intervention's effectiveness.

A referral voucher system was established in partnership with NGOs, Ministry of Health, AIDS centres and other service providers. To increase service uptake, the project trains providers on the use of the referral system, stigma reduction, and communication skills with key populations.

In all, 17,390 individuals (11,281 people who inject drugs [PWID], 4529 sex workers and 1580 MSM) were reached, with only 4807 people being referred for HCT between 2010 and 2012. Overall, the percentage of people who accessed HCT after receiving a voucher increased from 17.3% in 2010 to 21.7% in 2011 and to 40.5% in 2012.

The percentage of PWID who accessed HCT after receiving a project referral voucher increased from 6.2% in 2010 to 10.5% in 2011 and to 28.2% in 2012. Among sex workers who were reached, use of HCT after referral increased from 17.0 to 18.6 to 22.0% over the three years. Among MSM who were reached, use of HCT after referral increased from 6.6 to 35.1 to 54.3% over the same period.

The referral system uses vouchers with two sections: one section is kept by outreach workers who provide the referral and the second is given to the referred individual and collected by the service provider when HCT is accessed. Unique identifier codes (UIC) on each section are matched to track the uptake of referrals while ensuring confidentiality.

Stigma and discrimination, especially self-stigma of populations fearing disclosure of unsafe behaviours when accessing HTC services, were reduced.  “Clients informally report friendlier interaction with providers when the voucher is presented,” said Djamila Alisheva who presented the study.

While the voucher itself has no financial value, uptake of services using the voucher allowed the individual to overcome obstacles such as absence of passport or registration. In cases where the target individual feared going to a service facility alone, an outreach worker escorted the individual to the health facility.

One of the advantages of the voucher system is that it can be used as a monitoring and evaluation tool which provides evidence to the government's HIV programme of civil society and NGO contributions to reaching national health goals.


Adebajo S Evaluating the effects of three HIV counseling and testing strategies on male most-at-risk-populations. 7th IAS Conference on HIV Pathogenesis, Treatment and Prevention, Kuala Lumpur, abstract TUAD0104, July 2013. View the abstract on the conference website.

 Alisheva D Use of referral vouchers to measure increased demand of HIV counselling and testing among key populations in Kyrgyzstan. 7th IAS Conference on HIV Pathogenesis, Treatment and Prevention, Kuala Lumpur, abstract TUAD0105, July 2013. View the abstract on the conference website.

View details of the conference session, Two Sides of the Same Coin: Demand Creation and Supply Strategies for HIV Services, in which these abstracts were presented, including some presentation slides, on the conference website.