Cargando…
Effect of community-led delivery of HIV self-testing on HIV testing and antiretroviral therapy initiation in Malawi: A cluster-randomised trial
BACKGROUND: Undiagnosed HIV infection remains substantial in key population subgroups including adolescents, older adults, and men, driving ongoing transmission in sub-Saharan Africa. We evaluated the impact, safety, and costs of community-led delivery of HIV self-testing (HIVST), aiming to increase...
Autores principales: | , , , , , , , , , , , , |
---|---|
Formato: | Online Artículo Texto |
Lenguaje: | English |
Publicado: |
Public Library of Science
2021
|
Materias: | |
Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8112698/ https://www.ncbi.nlm.nih.gov/pubmed/33974621 http://dx.doi.org/10.1371/journal.pmed.1003608 |
_version_ | 1783690722509062144 |
---|---|
author | Indravudh, Pitchaya P. Fielding, Katherine Kumwenda, Moses K. Nzawa, Rebecca Chilongosi, Richard Desmond, Nicola Nyirenda, Rose Neuman, Melissa Johnson, Cheryl C. Baggaley, Rachel Hatzold, Karin Terris-Prestholt, Fern Corbett, Elizabeth L. |
author_facet | Indravudh, Pitchaya P. Fielding, Katherine Kumwenda, Moses K. Nzawa, Rebecca Chilongosi, Richard Desmond, Nicola Nyirenda, Rose Neuman, Melissa Johnson, Cheryl C. Baggaley, Rachel Hatzold, Karin Terris-Prestholt, Fern Corbett, Elizabeth L. |
author_sort | Indravudh, Pitchaya P. |
collection | PubMed |
description | BACKGROUND: Undiagnosed HIV infection remains substantial in key population subgroups including adolescents, older adults, and men, driving ongoing transmission in sub-Saharan Africa. We evaluated the impact, safety, and costs of community-led delivery of HIV self-testing (HIVST), aiming to increase HIV testing in underserved subgroups and stimulate demand for antiretroviral therapy (ART). METHODS AND FINDINGS: This cluster-randomised trial, conducted between October 2018 and July 2019, used restricted randomisation (1:1) to allocate 30 group village head clusters in Mangochi district, Malawi to the community-led HIVST intervention in addition to the standard of care (SOC) or the SOC alone. The intervention involved mobilising community health groups to lead the design and implementation of 7-day HIVST campaigns, with cluster residents (≥15 years) eligible for HIVST. The primary outcome compared lifetime HIV testing among adolescents (15 to 19 years) between arms. Secondary outcomes compared: recent HIV testing (in the last 3 months) among older adults (≥40 years) and men; cumulative 6-month incidence of ART initiation per 100,000 population; knowledge of the preventive benefits of HIV treatment; and HIV testing stigma. Outcomes were measured through a post-intervention survey and at neighboring health facilities. Analysis used intention-to-treat for cluster-level outcomes. Community health groups delivered 24,316 oral fluid-based HIVST kits. The survey included 90.2% (3,960/4,388) of listed participants in the 15 community-led HIVST clusters and 89.2% (3,920/4,394) of listed participants in the 15 SOC clusters. Overall, the proportion of men was 39.0% (3,072/7,880). Most participants obtained primary-level education or below, were married, and reported a sexual partner. Lifetime HIV testing among adolescents was higher in the community-led HIVST arm (84.6%, 770/910) than the SOC arm (67.1%, 582/867; adjusted risk difference [RD] 15.2%, 95% CI 7.5% to 22.9%; p < 0.001), especially among 15 to 17 year olds and boys. Recent testing among older adults was also higher in the community-led HIVST arm (74.5%, 869/1,166) than the SOC arm (31.5%, 350/1,111; adjusted RD 42.1%, 95% CI 34.9% to 49.4%; p < 0.001). Similarly, the proportions of recently tested men were 74.6% (1,177/1,577) and 33.9% (507/1,495) in the community-led HIVST and SOC arms, respectively (adjusted RD 40.2%, 95% CI 32.9% to 47.4%; p < 0.001). Knowledge of HIV treatment benefits and HIV testing stigma showed no differences between arms. Cumulative incidence of ART initiation was respectively 305.3 and 226.1 per 100,000 population in the community-led HIVST and SOC arms (RD 72.3, 95% CI −36.2 to 180.8; p = 0.18). In post hoc analysis, ART initiations in the 3-month post-intervention period were higher in the community-led HIVST arm than the SOC arm (RD 97.7, 95% CI 33.4 to 162.1; p = 0.004). HIVST uptake was 74.7% (2,956/3,960), with few adverse events (0.6%, 18/2,955) and at US$5.70 per HIVST kit distributed. The main limitations include the use of self-reported HIV testing outcomes and lack of baseline measurement for the primary outcome. CONCLUSIONS: In this study, we found that community-led HIVST was effective, safe, and affordable, with population impact and coverage rapidly realised at low cost. This approach could enable community HIV testing in high HIV prevalence settings and demonstrates potential for economies of scale and scope. TRIAL REGISTRATION: Clinicaltrials.gov NCT03541382. |
format | Online Article Text |
id | pubmed-8112698 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2021 |
publisher | Public Library of Science |
record_format | MEDLINE/PubMed |
spelling | pubmed-81126982021-05-24 Effect of community-led delivery of HIV self-testing on HIV testing and antiretroviral therapy initiation in Malawi: A cluster-randomised trial Indravudh, Pitchaya P. Fielding, Katherine Kumwenda, Moses K. Nzawa, Rebecca Chilongosi, Richard Desmond, Nicola Nyirenda, Rose Neuman, Melissa Johnson, Cheryl C. Baggaley, Rachel Hatzold, Karin Terris-Prestholt, Fern Corbett, Elizabeth L. PLoS Med Research Article BACKGROUND: Undiagnosed HIV infection remains substantial in key population subgroups including adolescents, older adults, and men, driving ongoing transmission in sub-Saharan Africa. We evaluated the impact, safety, and costs of community-led delivery of HIV self-testing (HIVST), aiming to increase HIV testing in underserved subgroups and stimulate demand for antiretroviral therapy (ART). METHODS AND FINDINGS: This cluster-randomised trial, conducted between October 2018 and July 2019, used restricted randomisation (1:1) to allocate 30 group village head clusters in Mangochi district, Malawi to the community-led HIVST intervention in addition to the standard of care (SOC) or the SOC alone. The intervention involved mobilising community health groups to lead the design and implementation of 7-day HIVST campaigns, with cluster residents (≥15 years) eligible for HIVST. The primary outcome compared lifetime HIV testing among adolescents (15 to 19 years) between arms. Secondary outcomes compared: recent HIV testing (in the last 3 months) among older adults (≥40 years) and men; cumulative 6-month incidence of ART initiation per 100,000 population; knowledge of the preventive benefits of HIV treatment; and HIV testing stigma. Outcomes were measured through a post-intervention survey and at neighboring health facilities. Analysis used intention-to-treat for cluster-level outcomes. Community health groups delivered 24,316 oral fluid-based HIVST kits. The survey included 90.2% (3,960/4,388) of listed participants in the 15 community-led HIVST clusters and 89.2% (3,920/4,394) of listed participants in the 15 SOC clusters. Overall, the proportion of men was 39.0% (3,072/7,880). Most participants obtained primary-level education or below, were married, and reported a sexual partner. Lifetime HIV testing among adolescents was higher in the community-led HIVST arm (84.6%, 770/910) than the SOC arm (67.1%, 582/867; adjusted risk difference [RD] 15.2%, 95% CI 7.5% to 22.9%; p < 0.001), especially among 15 to 17 year olds and boys. Recent testing among older adults was also higher in the community-led HIVST arm (74.5%, 869/1,166) than the SOC arm (31.5%, 350/1,111; adjusted RD 42.1%, 95% CI 34.9% to 49.4%; p < 0.001). Similarly, the proportions of recently tested men were 74.6% (1,177/1,577) and 33.9% (507/1,495) in the community-led HIVST and SOC arms, respectively (adjusted RD 40.2%, 95% CI 32.9% to 47.4%; p < 0.001). Knowledge of HIV treatment benefits and HIV testing stigma showed no differences between arms. Cumulative incidence of ART initiation was respectively 305.3 and 226.1 per 100,000 population in the community-led HIVST and SOC arms (RD 72.3, 95% CI −36.2 to 180.8; p = 0.18). In post hoc analysis, ART initiations in the 3-month post-intervention period were higher in the community-led HIVST arm than the SOC arm (RD 97.7, 95% CI 33.4 to 162.1; p = 0.004). HIVST uptake was 74.7% (2,956/3,960), with few adverse events (0.6%, 18/2,955) and at US$5.70 per HIVST kit distributed. The main limitations include the use of self-reported HIV testing outcomes and lack of baseline measurement for the primary outcome. CONCLUSIONS: In this study, we found that community-led HIVST was effective, safe, and affordable, with population impact and coverage rapidly realised at low cost. This approach could enable community HIV testing in high HIV prevalence settings and demonstrates potential for economies of scale and scope. TRIAL REGISTRATION: Clinicaltrials.gov NCT03541382. Public Library of Science 2021-05-11 /pmc/articles/PMC8112698/ /pubmed/33974621 http://dx.doi.org/10.1371/journal.pmed.1003608 Text en © 2021 Indravudh et al https://creativecommons.org/licenses/by/4.0/This is an open access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/) , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. |
spellingShingle | Research Article Indravudh, Pitchaya P. Fielding, Katherine Kumwenda, Moses K. Nzawa, Rebecca Chilongosi, Richard Desmond, Nicola Nyirenda, Rose Neuman, Melissa Johnson, Cheryl C. Baggaley, Rachel Hatzold, Karin Terris-Prestholt, Fern Corbett, Elizabeth L. Effect of community-led delivery of HIV self-testing on HIV testing and antiretroviral therapy initiation in Malawi: A cluster-randomised trial |
title | Effect of community-led delivery of HIV self-testing on HIV testing and antiretroviral therapy initiation in Malawi: A cluster-randomised trial |
title_full | Effect of community-led delivery of HIV self-testing on HIV testing and antiretroviral therapy initiation in Malawi: A cluster-randomised trial |
title_fullStr | Effect of community-led delivery of HIV self-testing on HIV testing and antiretroviral therapy initiation in Malawi: A cluster-randomised trial |
title_full_unstemmed | Effect of community-led delivery of HIV self-testing on HIV testing and antiretroviral therapy initiation in Malawi: A cluster-randomised trial |
title_short | Effect of community-led delivery of HIV self-testing on HIV testing and antiretroviral therapy initiation in Malawi: A cluster-randomised trial |
title_sort | effect of community-led delivery of hiv self-testing on hiv testing and antiretroviral therapy initiation in malawi: a cluster-randomised trial |
topic | Research Article |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8112698/ https://www.ncbi.nlm.nih.gov/pubmed/33974621 http://dx.doi.org/10.1371/journal.pmed.1003608 |
work_keys_str_mv | AT indravudhpitchayap effectofcommunityleddeliveryofhivselftestingonhivtestingandantiretroviraltherapyinitiationinmalawiaclusterrandomisedtrial AT fieldingkatherine effectofcommunityleddeliveryofhivselftestingonhivtestingandantiretroviraltherapyinitiationinmalawiaclusterrandomisedtrial AT kumwendamosesk effectofcommunityleddeliveryofhivselftestingonhivtestingandantiretroviraltherapyinitiationinmalawiaclusterrandomisedtrial AT nzawarebecca effectofcommunityleddeliveryofhivselftestingonhivtestingandantiretroviraltherapyinitiationinmalawiaclusterrandomisedtrial AT chilongosirichard effectofcommunityleddeliveryofhivselftestingonhivtestingandantiretroviraltherapyinitiationinmalawiaclusterrandomisedtrial AT desmondnicola effectofcommunityleddeliveryofhivselftestingonhivtestingandantiretroviraltherapyinitiationinmalawiaclusterrandomisedtrial AT nyirendarose effectofcommunityleddeliveryofhivselftestingonhivtestingandantiretroviraltherapyinitiationinmalawiaclusterrandomisedtrial AT neumanmelissa effectofcommunityleddeliveryofhivselftestingonhivtestingandantiretroviraltherapyinitiationinmalawiaclusterrandomisedtrial AT johnsoncherylc effectofcommunityleddeliveryofhivselftestingonhivtestingandantiretroviraltherapyinitiationinmalawiaclusterrandomisedtrial AT baggaleyrachel effectofcommunityleddeliveryofhivselftestingonhivtestingandantiretroviraltherapyinitiationinmalawiaclusterrandomisedtrial AT hatzoldkarin effectofcommunityleddeliveryofhivselftestingonhivtestingandantiretroviraltherapyinitiationinmalawiaclusterrandomisedtrial AT terrisprestholtfern effectofcommunityleddeliveryofhivselftestingonhivtestingandantiretroviraltherapyinitiationinmalawiaclusterrandomisedtrial AT corbettelizabethl effectofcommunityleddeliveryofhivselftestingonhivtestingandantiretroviraltherapyinitiationinmalawiaclusterrandomisedtrial |