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Background: This study evaluates the implementation and running costs of an HIV self-testing (HIVST) distribution program in Eswatini. HIVST kits were delivered through community-based and workplace models using primary and secondary distribution. Primary clients could self-test onsite or offsite. This study presents total running economic costs of kit distribution per model between April 2019 and March 2020, and estimates average cost per HIVST kit distributed, per client self-tested, per client self-tested reactive, per client confirmed positive, and per client initiating antiretroviral therapy (ART). Methods: Distribution data and follow-up phone interviews were analysed to estimate implementation outcomes. Results were presented for each step of the care cascade using best-case and worst-case scenarios. A top-down incremental cost-analysis was conducted from the provider perspective using project expenditures. Sensitivity and scenario analyses explored effects of economic and epidemiological parameters on average costs. Results: Nineteen thousand one hundred fifty-five HIVST kits were distributed to 13,031 individuals over a 12-month period, averaging 1.5 kits per recipient. 83% and 17% of kits were distributed via the community and workplace models, respectively. Clients reached via the workplace model were less likely to opt for onsite testing than clients in the community model (8% vs 29%). 6% of onsite workplace testers tested reactive compared to 2% of onsite community testers. Best-case scenario estimated 17,458 (91%) clients self-tested, 633 (4%) received reactive-test results, 606 (96%) linked to confirmatory testing, and 505 (83%) initiated ART. Personnel and HIVST kits represented 60% and 32% of total costs, respectively. Average costs were: per kit distributed US$17.23, per client tested US$18.91, per client with a reactive test US$521.54, per client confirmed positive US$550.83, and per client initiating ART US$708.60. Lower rates for testing, reactivity, and linkage to care in the worst-case scenario resulted in higher average costs along the treatment cascade. Conclusion: This study fills a significant evidence gap regarding costs of HIVST provision along the client care cascade in Eswatini. Workplace and community-based distribution of HIVST accompanied with effective linkage to care strategies can support countries to reach cascade objectives. [ABSTRACT FROM AUTHOR]

Background Measuring homophobia at country level is important to guide public health policy as reductions in stigma are associated with improved health outcomes among gay men and other men who have sex with men. Methods: We developed a Homophobic Climate Index incorporating institutional and social components of homophobia. Institutional homophobia was based on the level of enforcement of laws that criminalise, protect or recognise same-sex relations. Social homophobia was based on the level of acceptance and justifiability of homosexuality. We estimated the Index for 158 countries and assessed its robustness and validity. Results Western Europe is the most inclusive region, followed by Latin America. Africa and the Middle East are home to the most homophobic countries with two exceptions: South Africa and Cabo Verde. We found that a 1% decrease in the level of homophobia is associated with a 10% increase in the gross domestic product per capita. Countries whose citizens face gender inequality, human rights abuses, low health expenditures and low life satisfaction are the ones with a higher homophobic climate. Moreover, a 10% increase in the level of homophobia at country level is associated with a 1.7-year loss in life expectancy for males. A higher level of homophobia is associated with increased AIDS-related death among HIV-positive men. Conclusion The socioecological approach of this index demonstrates the negative social, economic and health consequences of homophobia in low- and middle-income countries. It provides sound evidence for public health policy in favour of the inclusion of sexual minorities. [ABSTRACT FROM AUTHOR]

Background: Consultations for sexually transmitted infection (STI) provide an opportunity to offer HIV testing to both patients and their partners. This study describes the organisation of HIV self-testing (HIVST) distribution during STI consultations in Abidjan (Côte d'Ivoire) and analyse the perceived barriers and facilitators associated with the use and redistribution of HIVST kits by STI patients. Materials and methods: A qualitative study was conducted between March and August 2021 to investigate three services providing HIVST: an antenatal care clinic (ANC), a general health centre that also provided STI consultations, and a dedicated STI clinic. Data were collected through observations of medical consultations with STI patients (N = 98) and interviews with both health professionals involved in HIVST distribution (N = 18) and STI patients who received HIVST kits for their partners (N = 20). Results: In the ANC clinic, HIV testing was routinely offered during the first prenatal visit. HIVST was commonly offered to women who had been diagnosed with an STI for their partner's use (27/29 observations). In the general health centre, two parallel pathways coexisted: before the consultation, a risk assessment tool was used to offer HIV testing to eligible patients and, after the consultation, patients who had been diagnosed with an STI were referred to a care assistant for HIVST. Due to this HIV testing patient flow, few offers of HIV testing and HIVST were made in this setting (3/16). At the dedicated STI clinic, an HIVST video was played in the waiting room. According to the health professionals interviewed, this video helped reduce the time required to offer HIVST after the consultation. Task-shifting was implemented there: patients were referred to a nurse for HIV testing, and HIVST was commonly offered to STI patients for their partners' use (28/53). When an HIVST was offered, it was generally accepted (54/58). Both health professionals and patients perceived HIVST positively despite experiencing a few difficulties with respect to offering HIVST to partners and structural barriers associated with the organisation of services. Conclusion: The organisation of patient flow and task-shifting influenced HIV testing and offers of HIVST kits. Proposing HIVST is more systematic when HIV testing is routinely offered to all patients. Successful integration requires improving the organisation of services, including task-shifting. [ABSTRACT FROM AUTHOR]

Introduction: New HIV testing strategies are needed to reach the United Nations' 90‐90‐90 target. HIV self‐testing (HIVST) can increase uptake, but users' perspectives on optimal models of distribution and post‐test services are uncertain. We used discrete choice experiments (DCEs) to explore the impact of service characteristics on uptake along the testing cascade. Methods: DCEs are a quantitative survey method that present respondents with repeated choices between packages of service characteristics, and estimate relative strengths of preferences for service characteristics. From June to October 2016, we embedded DCEs within a population‐based survey following door‐to‐door HIVST distribution by community volunteers in two rural Zimbabwean districts: one DCE addressed HIVST distribution preferences; and the other preferences for linkage to confirmatory testing (LCT) following self‐testing. Using preference coefficients/utilities, we identified key drivers of uptake for each service and simulated the effect of changes of outreach and static/public clinics' characteristics on LCT. Results: Distribution and LCT DCEs surveyed 296/329 (90.0%) and 496/594 (83.5%) participants; 81.8% and 84.9% had ever‐tested, respectively. The strongest distribution preferences were for: (1) free kits – a $1 increase in the kit price was associated with a disutility (U) of −2.017; (2) door‐to‐door kit delivery (U = +1.029) relative to collection from public/outreach clinic; (3) telephone helpline for pretest support relative to in‐person or no support (U = +0.415); (4) distributors from own/local village (U = +0.145) versus those from external communities. Participants who had never HIV tested valued phone helplines more than those previously tested. The strongest LCT preferences were: (1) immediate antiretroviral therapy (ART) availability: U = +0.614 and U = +1.052 for public and outreach clinics, respectively; (2) free services: a $1 user fee increase decreased utility at public (U = −0.381) and outreach clinics (U = −0.761); (3) proximity of clinic (U = −0.38 per hour walking). Participants reported willingness to link to either location; but never‐testers were more averse to LCT. Simulations showed the importance of availability of ART: ART unavailability at public clinics would reduce LCT by 24%. Conclusions: Free HIVST distribution by local volunteers and immediately available ART were the strongest relative preferences identified. Accommodating LCT preferences, notably ensuring efficient provision of ART, could facilitate "resistant testers" to test while maximizing uptake of post‐test services. [ABSTRACT FROM AUTHOR]

Background: Coverage of HIV testing remains sub-optimal in West Africa. Between 2019 and 2022, the ATLAS program distributed ~400 000 oral HIV self-tests (HIVST) in Côte d'Ivoire, Mali, and Senegal, prioritising female sex workers (FSW) and men having sex with men (MSM), and relying on secondary redistribution of HIVST to partners, peers and clients to reach individuals not tested through conventional testing. This study assesses the proportion of first-time testers among HIVST users and the associated factors. Methods: A phone-based survey was implemented among HIVST users recruited using dedicated leaflets inviting them to anonymously call a free phone number. We collected socio-demographics, sexual behaviours, HIV testing history, HIVST use, and satisfaction with HIVST. We reported the proportion of first-time testers and computed associated factors using logistic regression. Results: Between March and June 2021, 2 615 participants were recruited for 50 940 distributed HIVST (participation rate: 5.1%). Among participants, 30% received their HIVST kit through secondary distribution (from a friend, sexual partner, family member, or colleague). The proportion who had never tested for HIV before HIVST (first-time testers) was 41%. The main factors associated with being a first-time tester were sex, age group, education level, condom use, and secondary distribution. A higher proportion was observed among those aged 24 years or less (55% vs 32% for 25–34, aOR: 0.37 [95%CI: 0.30–0.44], and 26% for 35 years or more, aOR: 0.28 [0.21–0.37]); those less educated (48% for none/primary education vs 45% for secondary education, aOR: 0.60 [0.47–0.77], and 29% for higher education, aOR: 0.33 [0.25–0.44]). A lower proportion was observed among women (37% vs 43%, aOR: 0.49 [0.40–0.60]); those reporting always using a condom over the last year (36% vs 51% for those reporting never using them, aOR: 2.02 [1.59–2.56]); and those who received their HISVST kit through primary distribution (39% vs 46% for secondary distribution, aOR: 1.32 [1.08–1.60]). Conclusion: ATLAS HIVST strategy, including secondary distribution, successfully reached a significant proportion of first-time testers. HIVST has the potential to reach underserved populations and contribute to the expansion of HIV testing services in West Africa. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

A telephone survey among self-test end users in Côte d'Ivoire, Mali, and Senegal Correction: Can HIV self-testing reach first-time testers? B BMC Infectious Diseases (2023) 22:972 b https://doi.org/10.1186/s12879-023-08626-w The original publication of this article contained an incorrect author name. [Extracted from the article]

Background: Providing HIV testing at health facilities remains the most common approach to ensuring access to HIV treatment and prevention services for the millions of undiagnosed HIV-infected individuals in sub-Saharan Africa. We sought to explore the costs of providing these services across three southern African countries with high HIV burden. Methods: Primary costing studies were undertaken in 54 health facilities providing HIV testing services (HTS) in Malawi, Zambia and Zimbabwe. Routinely collected monitoring and evaluation data for the health facilities were extracted to estimate the costs per individual tested and costs per HIV-positive individual identified. Costs are presented in 2016 US dollars. Sensitivity analysis explored key drivers of costs. Results: Health facilities were testing on average 2290 individuals annually, albeit with wide variations. The mean cost per individual tested was US$5.03.9 in Malawi, US$4.24 in Zambia and US$8.79 in Zimbabwe. The mean cost per HIV-positive individual identified was US$79.58, US$73.63 and US$178.92 in Malawi, Zambia and Zimbabwe respectively. Both cost estimates were sensitive to scale of testing, facility staffing levels and the costs of HIV test kits. Conclusions: Health facility based HIV testing remains an essential service to meet HIV universal access goals. The low costs and potential for economies of scale suggests an opportunity for further scale-up. However low uptake in many settings suggests that demand creation or alternative testing models may be needed to achieve economies of scale and reach populations less willing to attend facility based services. [ABSTRACT FROM AUTHOR]

Introduction: HIV self‐testing (HIVST) is recommended by the World Health Organization in addition to other testing modalities to increase uptake of HIV testing, particularly among harder‐to‐reach populations. This study provides the first empirical evidence of the costs of door‐to‐door community‐based HIVST distribution in Malawi, Zambia and Zimbabwe. Methods: HIVST kits were distributed door‐to‐door in 71 sites across Malawi, Zambia and Zimbabwe from June 2016 to May 2017. Programme expenditures, supplemented by on‐site observation and monitoring and evaluation data were used to estimate total economic and unit costs of HIVST distribution, by input and site. Inputs were categorized into start‐up, capital and recurrent costs. Sensitivity and scenario analyses were performed to assess the impact of key parameters on unit costs. Results: In total, 152,671, 103,589 and 93,459 HIVST kits were distributed in Malawi, Zambia and Zimbabwe over 12, 11 and 10 months respectively. Across these countries, 43% to 51% of HIVST kits were distributed to men. The average cost per HIVST kit distributed was US$8.15, US$16.42 and US$13.84 in Malawi, Zambia and Zimbabwe, respectively, with pronounced intersite variation within countries driven largely by site‐level fixed costs. Site‐level recurrent costs were 70% to 92% of full costs and 20% to 62% higher than routine HIV testing services (HTS) costs. Personnel costs contributed from 26% to 52% of total costs across countries reflecting differences in remuneration approaches and country GDP. Conclusions: These early door‐to‐door community HIVST distribution programmes show large potential, both for reaching untested populations and for substantial economies of scale as HIVST programmes scale‐up and mature. From a societal perspective, the costs of HIVST appear similar to conventional HTS, with the higher providers' costs substantially offsetting user costs. Future approaches to minimizing cost and/or maximize testing coverage could include unpaid door‐to‐door community‐led distribution to reach end‐users and integrating HIVST into routine clinical services via direct or secondary distribution strategies with lower fixed costs. [ABSTRACT FROM AUTHOR]

Background: Knowledge of HIV status remains below target in sub-Saharan Africa, especially among men and adolescents. HIV self-testing (HIVST) is a novel approach that enables unique distribution strategies, with potential to be highly decentralised and to provide complementary coverage to facility-based testing approaches. However, substantial gaps in evidence remain on the effectiveness and cost-effectiveness of HIVST, particularly in rural settings, and on approaches to facilitate linkage to confirmatory HIV testing, prevention, and treatment services. This protocol describes two cluster-randomized trials (CRT) included within the UNITAID/PSI HIV Self-Testing Africa (STAR) project.Methods: Two independent CRTs were designed around existing reproductive health programmes in rural Malawi and rural/peri-urban Zambia. Common features include use of constrained randomisation to allocate health clinic catchment areas to either standard HIV testing (SOC) or SOC plus community-based distribution of OraQuick HIV Self Tests (Bethlehem, PA USA, assembled in Thailand) by trained lay distributors selected by the community. Community-based distribution agents will be trained (3-day curriculum) to provide brief demonstration of kit use and interpretation, information and encouragement to access follow up services, and management of social harm. The primary outcome of both CRTs is the proportion of the population aged 16 years and older who tested for HIV within the 12-month intervention period. Secondary outcomes in both trials include lifetime HIV testing, antiretroviral therapy (ART) initiation and ART use. Circumcision status among males will be a secondary outcome in Zambia and clinic-level demand for ART will be a secondary outcome in Malawi. Outcomes will be measured using cross-sectional household surveys, and routine data extraction from participating clinics. Costing studies will be used to evaluate the cost-effectiveness of the intervention arm. Qualitative research will be used to guide distribution and explore reasons for testing and linkage to onward care.Discussion: The STAR-Malawi and STAR-Zambia trials will provide rigorous evidence of whether community-based lay HIVST distribution is an effective and cost-effective approach to increasing coverage of HIV testing and demand for follow-on HIV services in rural and peri-urban communities in sub-Saharan Africa.Trial Registration: Clinicaltrials.gov, Malawi: NCT02718274 , 18 March 2016; Zambia: NCT02793804 , 3 June 2016. Protocol date: 21 February 2018. [ABSTRACT FROM AUTHOR]