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International audience; IntroductionHIV epidemics in Western and Central Africa (WCA) remain concentrated among key populations, who are often unaware of their status. HIV self-testing (HIVST) and its secondary distribution among key populations, and their partners and relatives, could reduce gaps in diagnosis coverage.We aimed to document and understand secondary HIVST distribution practices by men who have sex with men (MSM), female sex workers (FSW), people who use drugs (PWUD); and the use of HIVST by their networks in Côte d’Ivoire, Mali, and Senegal.MethodsA qualitative study was conducted in 2021 involving (a) face-to-face interviews with MSM, FSW, and PWUD who received HIVST kits from peer educators (primary users) and (b) telephone interviews with people who received kits from primary contacts (secondary users). These individual interviews were audio-recorded, transcribed, and coded using Dedoose software. Thematic analysis was performed.ResultsA total of 89 participants, including 65 primary users and 24 secondary users were interviewed. Results showed that HIVST were effectively redistributed through peers and key populations networks. The main reported motivations for HIVST distribution included allowing others to access testing and protecting oneself by verifying the status of partners/clients. The main barrier to distribution was the fear of sexual partners’ reactions. Findings suggest that members of key populations raised awareness of HIVST and referred those in need of HIVST to peer educators. One FSW reported physical abuse.Secondary users generally completed HIVST within two days of receiving the kit. The test was used half the times in the physical presence of another person, partly for psychological support need. Users who reported a reactive test sought confirmatory testing and were linked to care. Some participants mentioned difficulties in collecting the biological sample (2 participants) and interpreting the result (4 participants).ConclusionThe redistribution of HIVST was common among key populations, with minor negative attitudes. Users encountered few difficulties using the kits. Reactive test cases were generally confirmed. These secondary distribution practices support the deployment of HIVST to key populations, their partners, and other relatives. In similar WCA countries, members of key populations can assist in the distribution of HIVST, contributing to closing HIV diagnosis gaps.

Ce working paper est une traduction en français de l’article suivant: Rouveau N, Ky-Zerbo O, Boye S, Simo Fotso A, d’Elbée M, Maheu-Giroux M, Silhol R, Kouassi AK, Vautier A, Doumenc-Aïdara C, Breton G, Keita A, Ehui E, Ndour CT, Boilly MC, Terris-Prestholt F, Pourette D, Desclaux A, Larmarange J for the ATLAS Team. Describing, analysing and understanding the effects of the introduction of HIV self-testing in West Africa through the ATLAS programme in Côte d’Ivoire, Mali and Senegal. BMC Public Health. 2021, 21, 181.doi.org/10.1186/s12889-021-10212-1 Contexte:Le programme ATLAS vise à promouvoir et à déployer l’autodépistage du VIH (ADVIH) dans trois pays d’Afrique de l’Ouest: Côte d’Ivoire, Mali et Sénégal. Sur la période 2019-2021, en étroite collaboration avec les parte-naires nationaux de mise en œuvre de la lutte contre le sida et les communautés, ATLAS prévoit de distribuer 500 000 kits VIHST à travers huit canaux de distribution, combinant des stratégies fixes et des stratégies avancées, une distribution primaire et une distribution secondaire d’ADVIH. Tenant compte de l’épidémiologie ouest-africaine, les cibles du programme ATLAS sont les populations difficiles à atteindre: les populations clés (travailleuses de sexe, hommes ayant des rapports sexuels avec des hommes et usager·e·s de drogues), leurs clients ou partenaires sexuels, les partenaires des personnes vivant avec le VIH et les patients diagnostiqués avec des infections sexuellement transmissibles et leurs partenaires. Le programme ATLAS intégrer ainsi un volet recherche ayant pour objectif d’accompagner cette mise en œuvre et de générer des connaissances sur le passage à l’échelle de l’ADVIH en Afrique de l’Ouest. L’objectif principal est de décrire, d’analyser et de comprendre les effets sociaux, sanitaires, épidémiologiques et économiques de l’introduction de l’autodépistage du VIH en Côte d’Ivoire, au Mali et au Sénégal pour améliorer l’offre de dépistage (accessibilité, efficacité, éthique). Méthodes:La recherche ATLAS est organisée en cinq work packages (WP) multidisciplinaires: WP Populations clés: enquêtes qualitatives (entretiens individuels approfondis, discussions de groupe) menées auprès des acteurs clés, des populations clés et des utilisateurs des services de dépistage du VIH. WP Dépistage des cas index: observation ethnographique de trois services de soins VIH introduisant l’ADVIH pour le dépistage du partenaire. WP Enquête coupons: une enquête téléphonique anonyme auprès des utilisateurs de l’ADVIH. WP Volet économique: analyse des coûts économiques différentiels de chaque modèle de dispensation à l’aide d’une approche descendante avec collecte des coûts programmatiques, complété par une approche ascen-dante auprès d’un échantillon de sites de dispensations de l’ADVIH, et une étude temps-mouvement auprès d’un échantillon d’agent·e·s dispensateurs. WP Modélisation: adaptation, paramétrisation et calibration d’un modèle compartimental dynamique qui prend en compte les diverses populations ciblées par le programme ATLAS et les différentes modalités et stra-tégies de dépistage. Discussion:Le programme ATLAS est la première étude complète sur l’autodépistage du VIH en Afrique de l’Ouest. Le programme ATLAS se concentre particulièrement sur la distribution secondaire de l’ADVIH. Ce protocole a été ap-prouvé par trois comités d’éthique nationaux et par le comité d’éthique de la recherche de l’OMS. Mots-clés:VIH/SIDA, autodépistage du VIH, Afrique de l’Ouest, Sénégal, Côte d’Ivoire, Mali.

Ce working paper est une traduction en français de l’article suivant: Boye S, Bouaré S, Ky-Zerbo O, Rouveau N, Simo Fotso A, d’Elbée M, Silhol R, Maheu-Giroux M, Vautier A, Breton G, Keita A, Beke-lynck A, Desclaux A, Larmarange J and Pourette D (2021) Challenges of HIV Self-Test Distribution for Index Testing When HIV Status Disclosure Is Low: Preliminary Results of a Qualitative Study in Bamako (Mali) as Part of the ATLAS Project. Front. Public Health 9:653543.https://doi.org/10.3389/fpubh.2021.653543 Contexte: Le taux de partage du statut VIH aux partenaires est faible au Mali, un pays d'Afrique de l'Ouest avec une prévalence nationale du VIH de 1,2%. L'autodépistage du VIH (ADVIH) pourrait augmenter la couverture du dépistage chez les partenaires des personnes vivant avec le VIH (PVVIH). Le programme AutoTest-VIH, Libre d'accéder à la connaissance de son Statut (ATLAS) a été lancé en Afrique de l'Ouest avec l'objectif de distribuer près d'un demi-million d'autotests VIH de 2019 à 2021 en Côte d'Ivoire, au Mali et au Sénégal. Le programme ATLAS intègre plusieurs activités de recherche. Cet article présente les résultats préliminaires de l’étude qualitative du programme ATLAS au Mali. Cette étude vise à améliorer notre compréhension des pratiques, des limites et des enjeux liés à la distribution des autotests VIH aux PVVIH afin qu'elles puissent proposer ces tests à leurs partenaires sexuels. Méthodes: Cette étude qualitative a été menée en 2019 dans une clinique de prise en charge du VIH à Bamako. Elle a consisté en (i) des entretiens individuels avec 8 professionnels de santé impliqués dans la distribution des autotests VIH; (ii) 591 observations de consultations médicales, y compris de consultations de services sociaux, avec des PVVIH; (iii) 7 observations de discussions de groupe de PVVIH animées par des pairs éducateurs, entretiens avec les professionnels de santé et les notes d'observation ont fait l’objet d'une analyse de contenu. Résultats: L’ADVIH a été abordé dans seulement 9% des consultations observées (51/591). Lorsque l’ADVIH était abordée, la discussion était presque toujours initiée par le professionnel de santé plutôt que par la PVVIH. La discussion sur l’ADVIH était peu fréquente car, dans la plupart des consultations, il n'était pas approprié de proposer l’ADVIH au partenaire (par exemple, lorsque les PVVIH étaient veuves, n'avaient pas de partenaire ou avaient délégué quelqu'un pour renouveler leurs ordonnances). Certaines PVVIH n'avaient pas révélé leur statut VIH à leur partenaire. La distribution de l’ADVIH prenait beaucoup de temps, et les consultations médicales étaient très courtes. Trois principaux obstacles à la distribution d’ADVIH lorsque le statut VIH n'avait pas été divulgué aux partenaires ont été identifiés: (1) la quasi-totalité des professionnels de santé évitaient de proposer l’ADVIH aux PVVIH lorsqu'ils pensaient ou savaient que les PVVIH n'avaient pas révélé leur statut VIH à leurs partenaires; (2) les PVVIH étaient réticentes à proposer l’ADVIH à leurs partenaires s'ils ne leur avaient pas révélé leur séropositivité; (3) l'utilisation des stratégies de soutien à la divulgation du statut VIH était limitée. Conclusion: Il est essentiel de renforcer les stratégies de soutien à la révélation du statut VIH+. Il est nécessaire de développer une approche spécifique pour la mise à disposition des autotests VIH pour les partenaires des PVVIH en repensant l'implication des acteurs. Cette approche doit leur permettre de bénéficier d'une formation adaptée aux problématiques liées à la (non)divulgation du statut VIH et aux inégalités de genre, et d'améliorer le conseil aux PVVIH. Mots-clés :Autodépistage du VIH, Dépistage cas index, Connaissance du statut VIH, Divulgation du statut VIH, Mali, Personnes vivant avec le VIH, Partenaires de PVVIH, Dépistage.

International audience; ObjectifsDans le cadre de son projet d’introduction de l’auto dépistage du VIH (ADVIH), le programme ATLAS a initié une étude pour documenter les modalités de dispensation des kits d’ADVIH aux patient.e.s présentant une Infection Sexuellement Transmissible (IST) et leurs partenaires à Abidjan/Côte d’Ivoire.Matériels et MéthodesUne enquête qualitative a été réalisée entre mars et août 2021 dans trois services dispensant des ADVIH auprès des patient.e.s IST: (1) consultation prénatale (CPN) ; (2) consultation générale incluant IST et (3) dispensaire IST dédié. Les données ont été collectées par (i) des observations de consultations médicales de patient·e·s IST (N=98) et (ii) des entretiens auprès de soignants impliqués dans la dispensation des kits d’ADVIH (N=18), de patient.e.s ayant reçu des kits ADVIH à proposer à leurs partenaires (N=21) et de partenaires de patientes IST ayant réalisé l’ADVIH (N=2).RésultatsLes trois services présentent des différences d’organisation du circuit du patient et des modalités de dispensation des kits d’ADVIH. En CPN, le dépistage du VIH est proposé systématiquement à toute femme enceinte lors de la première consultation. Lorsqu’une IST est diagnostiquée, un ADVIH est proposé presque systématiquement pour le partenaire (N=27/29). En consultation générale, il y a eu peu de propositions de dépistage et d’ADVIH aux patient.e.s IST et pour leurs partenaires (N=3/16). Malgré l’existence d’une délégation des tâches du dépistage et l’offre d’ADVIH, il n’y a pas de routinisation du dépistage dans ce service. Au dispensaire IST, le circuit du patient est mieux défini : diffusion de la vidéo ADVIH en salle d’attente, consultation des patient.e.s et référencement aux infirmières pour le dépistage avec proposition fréquente de kits d’ADVIH aux patient.e.s IST pour leurs partenaires (N=28/53).De manière générale, l’ADVIH est accepté lorsqu’il est proposé. Mais, la proposition de l’ADVIH aux partenaires n’est pas toujours facile, surtout pour les femmes : difficultés à aborder la question du VIH avec le conjoint, relation de couple « fragile ».Les soignants en général ont une perception positive des ADVIH, mais, ils soulignent le caractère chronophage de la dispensation des ADVIH et souhaitent une meilleure organisation : délégation des tâches (CPN).ConclusionL’organisation des consultations est déterminante : les contraintes structurelles (organisation du service, délégation des tâches) influent sur la proposition d’un dépistage VIH et l’ADVIH ne suffit pas à les lever. La proposition par les soignants d’un ADVIH pour les partenaires nécessite du temps et un accompagnement des patients.e.s. La proposition est plus systématique quand le dépistage est « routinisé » et concerne tous les patient.e.s. Quand l’ADVIH est proposé, il est en général accepté. Si l’ADVIH constitue une opportunité d’améliorer l’accès au dépistage des patient.e.s et de leurs partenaires, une intégration réussie implique d’améliorer l’organisation des services et de promouvoir la délégation des tâches.

International audience; ObjectifsL’autodépistage du VIH (ADVIH), notamment la distribution dans les réseaux des personnes en contact avec des programmes de prévention (distribution secondaire), permet de rejoindre des personnes ayant faiblement accès au dépistage. Dans le cadre du projet ATLAS, une analyse des pratiques d’utilisation et de redistribution de l’ADVIH parmi les hommes qui ont des rapports sexuels avec des hommes (HSH), les travailleuses du sexe (TS), les usagers de drogues (UD) et leurs partenaires a été réalisée en Côte d’Ivoire, au Mali et au Sénégal.Matériels et MéthodesUne enquête qualitative a été conduite de janvier à juillet 2021. Des entretiens face-à-face et par téléphone ont été réalisés avec des utilisateurꞏtrices de l’ADVIH identifiéꞏes par (i) des pairsꞏes éducateurꞏtrices HSH, TS et UD ou (ii) via une enquête téléphonique anonyme.RésultatsAu total 80 personnes ont été interviewées (65 en face-à-face, 15 par téléphone). À la première utilisation, la majorité a réalisé l’ADVIH sans la présence d’unꞏe professionnelꞏle (2/3). Ils l’ont justifié par la facilité de réalisation de l’ADVIH et l’existence d’outils de supports. La majorité a redistribué des kits d’ADVIH à des partenaires sexuelsꞏles, pairꞏes/amiꞏes, clients pour les TS et d’autres types derelations sans difficulté majeure. Leur motivation commune était l’intérêt de la connaissance du statut VIH pour l’utilisateurꞏtrice finalꞏe. Cependant vis-à-vis des partenaires sexuelsꞏles et des clients des TS, il s’agissait surtout de s’informer du statut de ce/cette dernier-ère pour décider des mesures préventives à adopter. Les réactions des utilisateurꞏtrices secondaires étaient majoritairement positives parce que ce nouvel outil répondait à une attente liée au besoin de connaître leur statut VIH, certainꞏes n’ayant par ailleurs jamais fait de dépistage VIH. Quelques cas de refus ont été rencontrés, surtout de la part des clients occasionnels pour les TS. Un cas de violence physique de la part d’un client a été rapporté.Les raisons de non-proposition de l’ADVIH à son réseau variaient suivant les catégories de populations clés et les utilisateurꞏtrices secondaires. Les trois populations clés, surtout les UD, ont rapporté des craintes de réactions négatives de certainꞏes partenaires sexuelsꞏles. Les HSH et les UD en ont moins distribué à leurs pairꞏes/amiꞏes par rapport aux partenaires sexuelꞏles parce qu’ils/elles estimaient que ceux/celles-ci étaient dans les mêmes réseaux de distribution des kits d’ADVIH et en avaient donc déjà reçus. Chez les TS, l’ADVIH était moins souvent proposé aux clients et aux partenaires qui acceptaient l’utilisation du préservatif.ConclusionLes résultats montrent une bonne acceptation de l’ADVIH tant en distribution primaire que secondaire. La redistribution de l’ADVIH dans les réseaux des populations clés peut permettre d’accroitre l’accès au dépistage parmi les populations peu dépistées, sans répercussion négative pour les personnes qui le proposent.

Background: In West Africa, female sex workers are at increased risk of HIV acquisition and transmission. HIV self-testing could be an effective tool to improve access to and frequency of HIV testing to female sex workers, their clients and partners. This article explores their perceptions regarding HIV self-testing use and the redistribution of HIV self-testing kits to their partners and clients. Methods: Embedded within ATLAS, a qualitative study was conducted in Côte-d’Ivoire, Mali, and Senegal in 2020. Nine focus group discussions were conducted. A thematic analysis was performed. Results: A total of 87 participants expressed both positive attitudes toward HIV self-testing and their willingness to use or reuse HIV self-testing. HIV self-testing was perceived to be discreet, confidential, and convenient. HIV self-testing provides autonomy from testing by providers and reduces stigma. Some perceived HIV self-testing as a valuable tool for testing their clients who are willing to offer a premium for condomless sex. While highlighting some potential issues, overall, female sex workers were optimistic about linkage to confirmatory testing following a reactive HIV self-testing. Female sex workers expressed positive attitudes toward secondary distribution to their partners and clients, although it depended on relationship types. They seemed more enthusiastic about secondary distribution to their regular/emotional partners and regular clients with whom they had difficulty using condoms, and whom they knew enough to discuss HIV self-testing. However, they expressed that it could be more difficult with casual clients; the duration of the interaction being too short to discuss HIV self-testing, and they fear violence and/or losing them. Conclusion: Overall, female sex workers have positive attitudes toward HIV self-testing use and are willing to redistribute to their regular partners and clients. However, they are reluctant to promote such use with their casual clients. HIV self-testing can improve access to HIV testing for female sex workers and the members of their sexual and social network.

Background The ATLAS programme aims to promote and implement HIV self-testing (HIVST) in three West African countries: Côte d’Ivoire, Mali, and Senegal. During 2019–2021, in close collaboration with the national AIDS implementing partners and communities, ATLAS plans to distribute 500,000 HIVST kits through eight delivery channels, combining facility-based, community-based strategies, primary and secondary distribution of HIVST. Considering the characteristics of West African HIV epidemics, the targets of the ATLAS programme are hard-to-reach populations: key populations (female sex workers, men who have sex with men, and drug users), their clients or sexual partners, partners of people living with HIV and patients diagnosed with sexually transmitted infections and their partners. The ATLAS programme includes research support implementation to generate evidence for HIVST scale-up in West Africa. The main objective is to describe, analyse and understand the social, health, epidemiological effects and cost-effectiveness of HIVST introduction in Côte d’Ivoire, Mali and Senegal to improve the overall HIV testing strategy (accessibility, efficacy, ethics). Methods ATLAS research is organised into five multidisciplinary workpackages (WPs): Key Populations WP: qualitative surveys (individual in-depth interviews, focus group discussions) conducted with key actors, key populations, and HIVST users.Index testing WP: ethnographic observation of three HIV care services introducing HIVST for partner testing.Coupons survey WP: an anonymous telephone survey of HIVST users.Cost study WP: incremental economic cost analysis of each delivery model using a top-down costing with programmatic data, complemented by a bottom-up costing of a representative sample of HIVST distribution sites, and a time-motion study for health professionals providing HIVST.Modelling WP: Adaptation, parameterisation and calibration of a dynamic compartmental model that considers the varied populations targeted by the ATLAS programme and the different testing modalities and strategies. Discussion ATLAS is the first comprehensive study on HIV self-testing in West Africa. The ATLAS programme focuses particularly on the secondary distribution of HIVST. This protocol was approved by three national ethic committees and the WHO’s Ethical Research Committee. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-10212-1.

International audience; Since 2019, the ATLAS project, coordinated by Solthis in collaboration with national AIDS programs, has introduced, promoted and delivered HIV self-testing (HIVST) in Côte d'Ivoire, Mali and Senegal. Several delivery channels have been defined, including key populations: men who have sex with men, female sex workers and people who use injectable drugs. At project initiation, a qualitative study analyzing the perceptions and attitudes of key stakeholders regarding the introduction of HIVST in their countries and its integration with other testing strategies for key populations was conducted. The study was conducted from September to November 2019 within 3 months of the initiation of HIVST distribution. Individual interviews were conducted with 60 key informants involved in the project or in providing support and care to key populations: members of health ministries, national AIDS councils, international organizations, national and international non-governmental organizations, and peer educators. Semi structured interviews were recorded, translated when necessary, and transcribed. Data were coded using Dedoose© software for thematic analyses. We found that stakeholders' perceptions and attitudes are favorable to the introduction and integration of HIVST for several reasons. Some of these reasons are held in common, and some are specific to each key population and country. Overall, HIVST is considered able to reduce stigma; preserve anonymity and confidentiality; reach key populations that do not access testing via the usual strategies; remove spatial barriers; save time for users and providers; and empower users with autonomy and responsibility. It is non-invasive and easy to use. However, participants also fear, question and doubt users' autonomy regarding their ability to use HIVST kits correctly; to ensure quality secondary distribution; to accept a reactive test result; and to use confirmation testing and care services. For stakeholders, HIVST is considered an attractive strategy to improve access to HIV testing for key populations. Their doubts about users' capacities could be a matter for reflective communication with stakeholders and local adaptation before the implementation of HIVST in new countries. Those perceptions may reflect the West African HIV situation through the emphasis they place on the roles of HIV stigma and disclosure in HIVST efficiency.

International audience; Abstract Background Due to the discreet and private nature of HIV self-testing (HIVST), it is particularly challenging to monitor and assess the impacts of this testing strategy. To overcome this challenge, we conducted a study in Côte d’Ivoire to characterize the profile of end users of HIVST kits distributed through the ATLAS project ( AutoTest VIH, Libre d’Accéder à la connaissance de son Statut ). Feasibility was assessed using a pilot phone-based survey. Methods The ATLAS project aims to distribute 221300 HIVST kits in Côte d’Ivoire from 2019 to 2021 through both primary (e.g., direct distribution to primary users) and secondary distribution (e.g., for partner testing). The pilot survey used a passive recruitment strategy—whereby participants voluntarily called a toll-free survey phone number—to enrol participants. The survey was promoted through a sticker on the HIVST instruction leaflet and hotline invitations and informal promotion by HIVST kit-dispensing agents. Importantly, participation was not financially incentivized, even though surveys focussed on key populations usually use incentives in this context. Results After a 7-month period in which 25,000 HIVST kits were distributed, only 42 questionnaires were completed. Nevertheless, the survey collected data from users receiving HIVST kits via both primary and secondary distribution (69% and 31%, respectively). Conclusion This paper provides guidance on how to improve the design of future surveys of this type. It discusses the need to financial incentivize participation, to reorganize the questionnaire, the importance of better informing and training stakeholders involved in the distribution of HIVST, and the use of flyers to increase the enrolment of users reached through secondary distribution.

BACKGROUND: HIV self-testing (HIVST) is a way to improve HIV status knowledge and access to HIV testing. Since 2019, the ATLAS project has introduced, promoted, and delivered HIVST in Côte d'Ivoire, Mali, and Senegal, in particular among female sex workers (FSW), men who have sex with men (MSM), people who use drugs (PWUD), these key populations being particularly vulnerable to HIV and stigmatized in West Africa. Stakeholders involved in HIV testing activities targeting key populations are essential for the deployment of HIVST. Here, we analyze their perceptions of the introduction of HIVST in their countries.METHODS: A qualitative survey was conducted from September to November 2019 within three months of HIVST distribution initiation. Individual interviews were conducted with 60 stakeholders (Côte d'Ivoire, 19; Mali, 20; Senegal, 21). Semi-structured interviews were recorded, translated when necessary, and transcribed. Data were coded using Dedoose"© software for thematic analyses.RESULTS: In the three countries, stakeholders express enthusiasm and willingness to introduce HIVST for several reasons. HIVST is considered able to reduce stigma, preserve anonymity and confidentiality, especially for MSM and PWUD; reach key populations that do not access testing via usual strategies and HIV+ key populations; remove spatial barriers; save time for providers and users, notably for FSW; and empower users with autonomy and responsibility. HIVST is noninvasive and easy to use. Secondary distribution of HIVST seems appropriate for reaching partners of MSM, with confidentiality. However, stakeholders expressed doubts about key populations' ability, particularly PWUD, to correctly use HIVST kits, ensure quality secondary distribution, accept a reactive test result, and use confirmation testing and care services. They also mentioned that FSW might have difficulties redistributing HIVST to their clients and partners.CONCLUSIONS: HIVST is considered an attractive strategy to improve access to HIV testing for key populations. The doubts about users' capacities could be a matter of reflective communication with stakeholders before HIVST implementation in other western African countries.

Context: The rate of HIV status disclosure to partners is low in Mali, a West African country with a national HIV prevalence of 1.2%. HIV self-testing (HIVST) could increase testing coverage among partners of people living with HIV (PLHIV). The AutoTest-VIH, Libre d'accéder à la connaissance de son Statut (ATLAS) program was launched in West Africa with the objective of distributing nearly half a million HIV self-tests from 2019 to 2021 in Côte d'Ivoire, Mali, and Senegal. The ATLAS program integrates several research activities. This article presents the preliminary results of the qualitative study of the ATLAS program in Mali. This study aims to improve our understanding of the practices, limitations and issues related to the distribution of HIV self-tests to PLHIV so that they can offer the tests to their sexual partners. Methods: This qualitative study was conducted in 2019 in an HIV care clinic in Bamako. It consisted of (i) individual interviews with eight health professionals involved in the distribution of HIV self-tests; (ii) 591 observations of medical consultations, including social service consultations, with PLHIV; (iii) seven observations of peer educator-led PLHIV group discussions. The interviews with health professionals and the observations notes have been subject to content analysis. Results: HIVST was discussed in only 9% of the observed consultations (51/591). When HIVST was discussed, the discussion was almost always initiated by the health professional rather than PLHIV. HIVST was discussed infrequently because, in most of the consultations, it was not appropriate to propose partner HIVST (e.g., when PLHIV were widowed, did not have partners, or had delegated someone to renew their prescriptions). Some PLHIV had not disclosed their HIV status to their partners. Dispensing HIV self-tests was time-consuming, and medical consultations were very short. Three main barriers to HIVST distribution when HIV status had not been disclosed to partners were identified: (1) almost all health professionals avoided offering HIVST to PLHIV when they thought or knew that the PLHIV had not disclosed their HIV status to partners; (2) PLHIV were reluctant to offer HIVST to their partners if they had not disclosed their HIV-positive status to them; (3) there was limited use of strategies to support the disclosure of HIV status. Conclusion: It is essential to strengthen strategies to support the disclosure of HIV+ status. It is necessary to develop a specific approach for the provision of HIV self-tests for the partners of PLHIV by rethinking the involvement of stakeholders. This approach should provide them with training tailored to the issues related to the (non)disclosure of HIV status and gender inequalities, and improving counseling for PLHIV.

Additional file 1.

International audience; Background: The ATLAS project introduced HIV self-testing (HIVST) in consultations of people living with HIV (PLHIV) at public health facilities in Côte d'Ivoire, Mali and Senegal for secondary distribution to their partners. Preliminary data from a qualitative study (observations of consultations, interviews with distributing agents) carried out in two clinics in Mali highlight implementation challenges associated with the counselling on self-testing and kit distribution currently done by the medical staff (doctor/nurse) and reported time-consuming. While implementation teams are considering the possibility of delegating certain tasks, it is important to consider the cost of alternative delivery models.Materials & Methods: We analysed preliminary economic costs data for the provision of rapid HIV testing services (HTS) (analysis period: October 2018 – September 2019) and HIVST services (August 2019 – October 2019) in these same two Malian clinics. Above service level costs are excluded. We then modelled the costs of provision using alternative cadres of medical and non-medical staff (psychosocial counsellors/peer educators) and the consumables used to simulate task shifting scenarios for the provision of HTS and HIVST services. The three scenarios correspond to 1. partial delegation: individual counselling done by non-medical staff and HIVST distribution by the medical staff ; 2. total delegation: individual counselling and distribution done by non-medical staff only; and 3. total delegation with group counselling: where group counselling and distribution are done by non-medical staff only.Results: Findings show that the unit costs per HIVST provided for the observed model are 58% higher than those of a conventional rapid test: $7,50 and $4.75, respectively. The costs are less high in scenarios of partial ($5.45, +15%) or total ($5.29, +11%) delegation but always higher than those of a rapid test due to the greater costs of consumables (HIVST kit). Finally, in the case where counselling on self-testing were carried out in a group, the costs per kit provided ($4.44, -6%) would become slightly lower than those of a rapid test, where counselling is always done individually.Conclusion: Task delegation from medical to non-medical staff can generate substantial cost savings. These preliminary results can guide the implementation strategy of HIVST in care consultations, to ensure sustainability from early introduction through scale-up.

Research component of the ATLAS programmeThe ATLAS programme (2019-2021) aims to promote and deploy HIV self-testing (HIVST) in Côte d'Ivoire, Mali and Senegal and to distribute half a million HIVST through various delivery channels, targeting in particular key populations (sex workers, men who have sex with men, drug users), partners of people living with HIV (PLHIV) and patients with sexually transmitted infections. The dispensation of HIVST will be carried out in routine care, through the three countries' national AIDS strategies and in an integrated manner with existing screening policies, through eight delivery channels combining fixed and advanced strategies, primary distribution and secondary distribution. The research component presented here includes a set of observational surveys to describe, analyze and understand the social, health, epidemiological and economic effects of the introduction of HIVST in Côte d'Ivoire, Mali and Senegal to improve testing offer (accessibility, effectiveness and ethics). It is organized into 5 work packages: (i) a qualitative survey on HIVST targeted key populations, based on qualitative individual and group interviews with key implementers, members of key population communities and HIVST users; (ii) an ethnography on the integration of HIVST for screening of PLHIV’s partners in three HIV care clinics and an exploratory sub-survey on HIVST distribution in STI consultations; (iii) an anonymous telephone survey of HIVST users recruited through an invitation on HIVST kits to call a toll-free number; (iv) an economic survey of HIVST incremental costs with cost collections from a sample of HIVST dispensing sites and a time and motion study; (v) an epidemiological modelling (dynamic compartmental model) of the three countries and of the health and economic impacts of different scaling scenarios.; Volet recherche du programme ATLASLe programme ATLAS (2019-2021) vise à promouvoir et à déployer l’autodépistage du VIH (ADVIH) en Côte d’Ivoire, au Mali et au Sénégal et prévoit la distribution d’un demi millions d’autotests à travers différents canaux de dispensation, visant en particulier les populations clés (travailleuses du sexe, hommes ayant des rapports sexuels avec des hommes, usager·e·s de drogues), les partenaires des personnes vivant avec le VIH (PvVIH) et les patient·e·s atteint·e·s d’une infection sexuellement transmissible. La dispensation des kits d’ADVIH sera réalisée en soins courants, dans le cadre des stratégies nationales de lutte contre le sida des trois pays et de manière intégrée aux politiques de dépistage déjà en place, à travers huit canaux de dispensation combinant des stratégies fixes et des stratégies avancées, une distribution primaire et une distribution secondaire. Le volet recherche présenté ici comporte un ensemble d’enquêtes observationnelles visant à décrire, analyser et comprendre les effets sociaux, sanitaires, épidémiologiques et économiques de l’introduction de l’autodépistage du VIH en Côte d’Ivoire, au Mali et au Sénégal pour améliorer l’offre de dépistage (accessibilité, efficacité et éthique). Il est organisé en 5 paquets d’activités : (i) une enquête qualitative sur l’ADVIH auprès des populations clés reposant sur des entretiens qualitatifs individuels et de groupes auprès d’acteurs clés de la mise en œuvre, de membres des communautés de populations clés et d’utilisatrices et utilisateurs de l’ADVIH ; (ii) une ethnographie portant sur l’intégration de l’ADVIH pour le dépistage des partenaires de PvVIH dans trois sites de prise en charge du VIH et une sous enquête exploratoire portant sur la diffusion de l’ADVIH à travers les consultations IST ; (iii) une enquête téléphonique anonyme auprès des utilisatrices et utilisateurs de l’ADVIH recruté·e·s via une invitation à appeler un numéro vert apposée sur les kits d’ADVIH distribués ; (iv) une enquête économique des coûts incrémentiels de l’ADVIH avec une collecte des coûts auprès d’un échantillon de sites de dispensation de l’ADVIH et une étude des temps et mouvements ; (v) une modélisation épidémiologique (modèle compartimental dynamique) des trois pays et des impacts sanitaires et économiques de différents scénarios de passage à l’échelle.

Context and Objective: In Côte d'Ivoire, Mali and Senegal, ATLAS project has introduced HIV self-testing (HIVST) as an index testing strategy, distributing HIVST kits to people living with HIV (PLHIV) during consultations for secondary distribution to their partners. Here, we present preliminary results of an ethnographic survey conducted in one HIV clinic in Bamako, Mali, where most HIV patients have not disclosed their HIV status to their partner(s), notably for women for fear of jeopardizing their relationships. In such a context, how non-disclosure affect the distribution of HIVST kits?Method: The study was conducted from September 25 to November 27, 2019, and included individual interviews with 8 health workers; 591 observations of medical consultations; and 7 observations of patient groups discussions led by peer educators.Results: Three principal barriers to HIVST distribution for index testing were identified. (1) Reluctance of PLHIV to offer HIVST to partners to whom they have not (yet) disclosed their status and desire to learn tactics for offering testing without disclosing their HIV status. (2) Near-universal hesitancy among health workers to offer HIVST to persons who, they believe, have not disclosed their HIV status to their partner(s). (3) Absence of strategies, among health workers, to support discussion of status disclosure with PLHIV. In the rare cases where HIVST was offered to a PLHIV whose partner did not know their status, either the PLHIV declined the offer or the provider left it to the patient to find a way to deliver the HIVST without disclosing his/her status.Conclusion: HIV self-testing distribution could serve as an opportunity for PLHIV to disclose their HIV status to partners. The continuing reluctance of PLHIV to heed advice to share their status and promote secondary HIV self-testing distribution highlights the structural factors (social inequalities and stigma) that limit awareness of HIV status and that favour the persistence of the epidemic.

Introduction Sub-Saharan Africa bears more than two-thirds of the worldwide burden of HIV; however, data among transgender women from the region are sparse. Transgender women across the world face significant vulnerability to HIV. This analysis aimed to assess HIV prevalence as well as psychosocial and behavioral drivers of HIV infection among transgender women compared with cisgender (non-transgender) men who have sex with men (cis-MSM) in 8 sub-Saharan African countries. Methods and findings Respondent-driven sampling targeted cis-MSM for enrollment. Data collection took place at 14 sites across 8 countries: Burkina Faso (January–August 2013), Côte d’Ivoire (March 2015–February 2016), The Gambia (July–December 2011), Lesotho (February–September 2014), Malawi (July 2011–March 2012), Senegal (February–November 2015), Swaziland (August–December 2011), and Togo (January–June 2013). Surveys gathered information on sexual orientation, gender identity, stigma, mental health, sexual behavior, and HIV testing. Rapid tests for HIV were conducted. Data were merged, and mixed effects logistic regression models were used to estimate relationships between gender identity and HIV infection. Among 4,586 participants assigned male sex at birth, 937 (20%) identified as transgender or female, and 3,649 were cis-MSM. The mean age of study participants was approximately 24 years, with no difference between transgender participants and cis-MSM. Compared to cis-MSM participants, transgender women were more likely to experience family exclusion (odds ratio [OR] 1.75, 95% CI 1.42–2.16, p < 0.001), rape (OR 1.95, 95% CI 1.63–2.36, p < 0.001), and depressive symptoms (OR 1.30, 95% CI 1.12–1.52, p < 0.001). Transgender women were more likely to report condomless receptive anal sex in the prior 12 months (OR 2.44, 95% CI 2.05–2.90, p < 0.001) and to be currently living with HIV (OR 1.81, 95% CI 1.49–2.19, p < 0.001). Overall HIV prevalence was 25% (235/926) in transgender women and 14% (505/3,594) in cis-MSM. When adjusted for age, condomless receptive anal sex, depression, interpersonal stigma, law enforcement stigma, and violence, and the interaction of gender with condomless receptive anal sex, the odds of HIV infection for transgender women were 2.2 times greater than the odds for cis-MSM (95% CI 1.65–2.87, p < 0.001). Limitations of the study included sampling strategies tailored for cis-MSM and merging of datasets with non-identical survey instruments. Conclusions In this study in sub-Saharan Africa, we found that HIV burden and stigma differed between transgender women and cis-MSM, indicating a need to address gender diversity within HIV research and programs., In a cross-sectional analysis of data from African countries, Tonia Poteat and colleagues report on risk factors for infection and HIV prevalence in transgender women and men who have sex with men., Author summary Why was this study done? Sub-Saharan Africa includes countries with the most broadly generalized HIV epidemics. Transgender women have unmet HIV prevention and treatment needs around the world; however, study of their specific needs across sub-Saharan Africa has been limited. What did the researchers do and find? We merged HIV test results and survey data from studies initially focused on gay men and other men who have sex with men (MSM) in 8 countries in sub-Saharan Africa, then specifically assessed transgender women separately from cisgender MSM. We identified 937 transgender women among the total sample of 4,586 individuals. We found that transgender women were more likely than cisgender MSM to test positive for HIV as well as report experiences of stigma, depressive symptoms, and condomless sex. What do these findings mean? Gender identities are as complex across sub-Saharan Africa as they are in other regions. These data highlight the limitations of an essentialist gender binary framework for HIV prevention and treatment programs in sub-Saharan Africa. Advancing HIV prevention and treatment in sub-Saharan Africa necessitates specifically studying the appropriate content and implementation of programs that reach transgender women.

Background. Treatments are effective for people living with HIVAIDS (PLWHA) care and prevention. However, only 55% of PLWHA are aware of their status. This rate is lower in Central and West Africa (35%). In July 2015, WHO published new guidelines on HIV testing. In Sub-Saharan Africa, there are many studies which results are used to define policies and guidelines on HIV testing at the international level. Few of them are implemented in low HIV prevalence countries, notably French-Speaking West Africa. The overall objective of this thesis is to analyze the challenges and limitations of HIV testing and counselling (HTC) policies and programs in low prevalence countries, over the situation in Burkina Faso and propose new measures to increase the access to HTC services.Methods. Two studies have been conducted. The first one was carried out in the « Multi-country African Testing and Counselling for HIV » (MATCH) project which was implemented in four countries (Burkina Faso, Kenya, Malawi, Uganda). It aimed to analyze the motivations and barriers to HTC services practices by users, non-users and providers. In Burkina Faso, the study was carried out in Urban (Ouagadougou) and rural (Dédougou) areas in 2008-2009. In each locality, study sites (client initiated testing and provider initiated testing sites) were chosen, given the level of utilization. Quantitative and qualitative methods were used. The second study was conducted in 2015, with HTC providers and decision makers at national level. The objective was to analyze their perceptions on WHO 2015 guidelines. A data collection tool explaining the changes introduced in the guidelines has been designed and transmitted via electronic means. Their opinions were analyzed.Results. Guidelines for HTC in Burkina Faso were from 2008. In client initiated testing sites, there were more women (58.5%). However, men (p=0.02), 18-34 years old (p=0.01), and the more educated ones (p=0.001) appeared to have used early services. In multivariate analysis, those categories used often campaigns. Women (p=0.008), 35 years of age and over (p

BACKGROUND: Breastfeeding is essential for child health and development in low-resource settings but carries a significant risk of transmission of HIV-1 especially in late stages of maternal disease. We aimed to assess the efficacy and safety of triple antiretroviral compared with zidovudine and single-dose nevirapine prophylaxis in pregnant women infected with HIV. METHODS: Pregnant women with WHO stage 1 2 or 3 HIV-1 infection who had CD4 cell counts of 200-500 cells per muL were enrolled at five study sites in Burkina Faso Kenya and South Africa to start study treatment at 28-36 weeks gestation. Women were randomly assigned (1:1) by a computer generated random sequence to either triple antiretroviral prophylaxis (a combination of 300 mg zidovudine 150 mg lamivudine and 400 mg lopinavir plus 100 mg ritonavir twice daily until cessation of breastfeeding to a maximum of 6.5 months post partum) or zidovudine and single-dose nevirapine (300 mg zidovudine twice daily until delivery and a dose of 600 mg zidovudine plus 200 mg nevirapine at the onset of labour and after a protocol amendment in December 2006 1 week post-partum zidovudine 300 mg twice daily and lamivudine 150 mg twice daily). All infants received a 0.6 mL dose of nevirapine at birth and from December 2006 4 mg/kg twice daily of zidovudine for 1 week after birth. Patients and investigators were not masked to treatment. The primary endpoints were HIV-free infant survival at 6 weeks and 12 months; HIV-free survival at 12 months in infants who were ever breastfed; AIDS-free survival in mothers at 18 months; and serious adverse events in mothers and babies. Analysis was by intention to treat. This trial is registered with Current Controlled Trials ISRCTN71468401. FINDINGS: From June 2005 to August 2008 882 women were enrolled 824 of whom were randomised and gave birth to 805 singleton or first liveborn infants. The cumulative rate of HIV transmission at 6 weeks was 3.3% (95% CI 1.9-5.6%) in the triple antiretroviral group compared with 5.0% (3.3-7.7%) in the zidovudine and single-dose nevirapine group and at 12 months was 5.4% (3.6-8.1%) in the triple antiretroviral group compared with 9.5% (7.0-12.9%) in the zidovudine and single-dose nevirapine group (p=0.029). The cumulative rate of HIV transmission or death at 12 months was 10.2% (95% CI 7.6-13.6%) in the triple antiretroviral group compared with 16.0% (12.7-20.0%) in the zidovudine and single-dose nevirapine group (p=0.017). In infants whose mothers declared they intended to breastfeed the cumulative rate of HIV transmission at 12 months was 5.6% (95% CI 3.4-8.9%) in the triple antiretroviral group compared with 10.7% (7.6-14.8%) in the zidovudine and single-dose nevirapine group (p=0.02). AIDS-free survival in mothers at 18 months will be reported in a different publication. The incidence of laboratory and clinical serious adverse events in both mothers and their babies was similar between groups. INTERPRETATION: Triple antiretroviral prophylaxis during pregnancy and breastfeeding is safe and reduces the risk of HIV transmission to infants. Revised WHO guidelines now recommend antiretroviral prophylaxis (either to the mother or to the baby) during breastfeeding if the mother is not already receiving antiretroviral treatment for her own health. FUNDING: Agence nationale de recherches sur le sida et les hepatites virales Department for International Development European and Developing Countries Clinical Trials Partnership Thrasher Research Fund Belgian Directorate General for International Cooperation Centers for Disease Control and Prevention Eunice Kennedy Shriver National Institute of Child Health and Human Development and UNDP/UNFPA/World Bank/WHO Special Programme of Research Development and Research Training in Human Reproduction. Copyright (c) 2011 Elsevier Ltd. All rights reserved.

To evaluate strategies to reduce HIV-1 transmission through breastfeeding, a multicentre study including a nested randomized controlled trial was implemented in five research sites in West, East and South Africa (The Kesho Bora Study). The aim was to optimize the use of antiretroviral (ARV) drugs during pregnancy, delivery and breastfeeding to prevent mother-to-child transmission of HIV-1 (PMTCT) and to preserve the health of the HIV-1-infected mother. The study included long-term ARV treatment for women with advanced disease, and short-course ARV prophylaxis stopped at delivery for women with early disease. Women with intermediate disease participated in a randomized controlled trial to compare safety and efficacy of triple-ARV prophylaxis prolonged during breastfeeding with short-course ARV prophylaxis stopped at delivery. Between January 2005 and August 2008 a total of 1140 women were enrolled. This paper describes the study design, interventions and protocol amendments introduced to adapt to evolving scientific knowledge, international guidelines and availability of ARV treatment. The paper highlights the successes and challenges during the conduct of the trial. The Kesho Bora Study included one of the few randomized controlled trials to assess safety and efficacy of ARV prophylaxis continued during breastfeeding and the only randomized trial to assess maternal prophylaxis started during pregnancy. The findings have been important for informing international and national guidelines on MTCT prevention in developing countries where, due to poverty, lack of reliable and affordable supply of replacement feed and stigma associated with HIV/AIDS, HIV-infected women have little or no option other than to breastfeed their infants. (ISRCTN71468401).