A study from Malawi has found that short-term campaigns of HIV self-testing, whose design and implementation are led by community groups, can rapidly increase the uptake of HIV testing and antiretroviral therapy among underserved populations. Recently published in PLOS Medicine, the study also reported a lower cost for this intervention than for other testing programmes.
In sub-Saharan Africa, the rate of undiagnosed HIV infection remains high among adolescents, men and older adults, driving ongoing HIV transmission. However, barriers to routine HIV testing are common. Most testing services are provided in healthcare facilities, which some underserved individuals perceive as inconvenient, far away, expensive to get to, and exposing, in terms of HIV stigma and discrimination.
Closer to the population, community-based HIV testing services (for example, through door-to-door outreach) can diagnose people at earlier stages of disease and improve treatment uptake. However, despite these advantages, costs are higher while global funding for community health programmes has been declining.
There is a need for more efficient and scalable community strategies to reach out to HIV-prevalent populations and work towards universal HIV testing. Combining the design and implementation of health services led by community members – which has demonstrated its efficacy in improving health outcomes – and the use of self-testing is a promising approach.
Conducted in 2018-19 by Dr Pitchaya Indravudh from the London School of Hygiene and Tropical Medicine, the study investigated the impact, safety and costs of mobilising community health groups to lead the design and implementation of 7-day self-testing campaigns. These campaigns aimed to increase HIV testing and antiretroviral therapy demand in underserved subgroups from high HIV prevalence areas of Malawi. The study was run in the rural district of Mangochi, where adult HIV prevalence is over 10%.
The investigators randomised thirty groups of villages (clusters) that are serviced by five primary health care centres, to either the standard of care alone or the standard of care, plus the community-led self-testing campaign.
The standard of care was national and included HIV testing, provided by lay counsellors at health facilities and though periodic community-based outreach, and antiretroviral therapy available immediately after an HIV-positive diagnosis.
The community-led intervention involved engaging established community health action groups from fifteen clusters to lead the design and implementation of 7-day self-testing campaigns. The groups planned strategies for distribution of self-testing kits, demand creation, support for linkage to routine HIV care, etc. Community volunteers were trained to support the use and interpretation of self-testing kits, provide information on linkage to HIV services and communicate HIV prevention messages.
The delivery of the self-testing 7-day campaigns (one per cluster) was performed by community volunteers in their area. The study team provided the self-test kits, instructional materials and data collecting tools. Volunteers distributed the OraQuick self-test door-to-door, and from fixed locations (such as schools and mosques) or social hotspots (like fishing docks and sports fields). Linkage to care support included providing phone referrals and funds for transport to clinics in the case of a positive result.
The primary outcome compared the proportion of adolescents (15-19 years old) who self-reported lifetime testing for HIV between the standard of care and the self-testing arms. Lifetime testing is a relevant measure for adolescents since it was anticipated that a high proportion of them would have never tested, with the need for testing among this group highly variable and dependent on the onset of sexual debut and HIV risk. Secondary outcomes were self-reported recent HIV testing among men and among adults aged 40 or more; cumulative incidence of starting antiretroviral therapy per 100,000 population; knowledge of the preventive benefits of the therapy; and measures of HIV testing stigma.
Except for data on the uptake of antiretroviral therapy, which was captured at the five health facilities, outcomes were measured in household surveys eight to twelve weeks after the intervention. Consenting household members over the age of 15 were interviewed on socio-demographics, HIV service use and sexual behaviour.
There were 44,543 and 39,806 residents in fifteen self-testing and other fifteen standard of care village clusters, respectively. Overall, 24,316 oral fluid-based self-test kits were distributed, of which 47% (11,472) were to men.
The survey included 90.2% and 89.2% of listed participants from the self-testing and the standard of care arms, respectively. Adolescent participation rates were similar at 90.2% and 86.4% respectively. Participation was higher amongst women than amongst men.
Most participants had received primary education or below, were married and reported a sexual partner. Characteristics were well balanced by arm, but adolescents showed differences in literacy, religion, ethnicity and self-reported health status.
Community-led delivery of 7-day self-testing campaigns linked to HIV treatment and prevention increased HIV testing in the underserved groups. Lifetime HIV testing among adolescents was 67.1% in the standard of care arm and 84.6% in the self-testing arm. After adjustment for demographic differences between the arms, this amounted to an increase of 15.2%, with more pronounced differences among the younger ones (15-17 years old) and boys (20.5% vs 11.1% among girls).
Other results included:
- Recent HIV testing (in the last three months) increased by 42.1% among older adults and by 40.2% among men.
- Mutual knowledge of HIV status between sexual partners increased by 14.1%.
- No difference was found between the two arms regarding knowledge of the prevention benefits of antiretroviral therapy and measures of HIV testing stigma.
- Cumulative 6-month incidence of starting antiretroviral therapy per 100,000 population increased in the three months after the intervention, with 186 residents treated in the community-led self-testing arm, compared with 93 residents in the standard of care arm.
- Self-reported uptake of self-testing reached 74.7%, ranging from 68.5% in men over the age of 40 to 84.7% in women aged 20-24 years. Self-test uptake was only 3.7% in the standard of care arm.
- The investigators also report an average cost of $5.70 US dollars per self-testing kit distributed, which was lower than the cost of door-to-door self-testing in other programmes in rural areas ($8.15, 2017) and in the city of Blantyre ($8.78, 2014).
This study is probably the first to assess, in a randomised way, the impact of community-led delivery of HIV self-testing services. By reporting a substantially higher self-testing uptake coverage and more effective targeting than past studies, it demonstrates how significant the engagement of community in the design and implementation of a self-testing campaign can be.
Indravudh and colleagues suggest that this community-led self-testing model could be used in other diseases such as malaria and tuberculosis. Further, they highlight that “the impact attained within a short period of time makes community-led self-testing a promising candidate for national HIV programmes to consider for periodic implementation to reach underserved subgroups.”
Indravudh PP et al. Effect of community-led delivery of HIV self-testing on HIV testing and antiretroviral therapy initiation in Malawi: A cluster-randomised trial. PLOS Medicine 18(5): e1003608, 2021 (open access).
Full image credit: "Oral HIV self-testing" by Alain Amstutz, University of Basel. SNSF Scientific Image Competition. Available at www.flickr.com/photos/snsf_image_competition/49725500877/ under a Creative Commons licence CC BY-NC-ND 2.0.