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Did you hear about HIV self-testing? HIV self-testing awareness after community-based HIVST distribution in rural Zimbabwe

Did you hear about HIV self-testing? HIV self-testing awareness after community-based HIVST... Background: Several trials of community-based HIV self-testing (HIVST ) provide evidence on the acceptability and feasibility of campaign-style distribution to reach first-time testers, men and adolescents. However, we do not know how many remain unaware of HIVST after distribution campaigns, and who these individuals are. Here we look at factors associated with never having heard of HIVST after community-based campaign-style HIVST distribution in rural Zimbabwe between September 2016 and July 2017. Methods: Analysis of representative population-based trial survey data collected from 7146 individuals following community-based HIVST distribution to households was conducted. Factors associated with having never heard of HIVST were determined using multivariable mixed-effects logistic regression adjusted for clustered design. Results: Among survey participants, 1308 (18.3%) self-reported having never heard of HIVST. Individuals who were between 20 and 60 years old {20–29 years: [aOR = 0.74, 95% CI (0.58–0.95)], 30–39 years: [aOR = 0.56, 95% CI (0.42– 0.74)], 40–49 years: [aOR = 0.50, 95% CI (0.36–0.68)], 50–59 years [aOR = 0.58, 95% CI (0.42–0.82)]}, who had attained at least ordinary level education [aOR = 0.51, 95% CI (0.34–0.76)], and who had an HIV test before [aOR = 0.30, 95% CI (0.25–0.37)] were less likely to have never heard of HIVST compared with individuals who were between 16 and 19 years old, who had a lower educational level and who had never tested for HIV before, respectively. In addition, non-household heads or household head representatives [aOR = 1.21, 95% CI (1.01–1.45)] were more likely to report never having heard of HIVST compared to household head and representatives. Conclusions: Around one fifth of survey participants remain unaware of HIVST even after an intensive community- based door-to-door HIVST distribution. Of note, those least likely to have heard of self-testing were younger, less educated and less likely to have tested previously. Household heads appear to play an important role in granting or denying access to self-testing to other household members during door-to-door distribution. Differentiated distribu- tion models are needed to ensure access to all. Trial registration PACTR, PACTR201607001701788. Registered 29 June 2016, https:// pactr. samrc. ac. za/ PACTR201607001701788 Keywords: HIV self-testing, Community-based distribution Background *Correspondence: arotsaert@itg.be Globally, 19% of people living with human immunodefi - Department of Public Health, Institute of Tropical Medicine, ciency virus (HIV) are undiagnosed [1], with men, young Nationalestraat 155, 2000 Antwerp, Belgium people (i.e., 15–24  years old), rural and key populations Full list of author information is available at the end of the article © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Rotsaert et al. BMC Infectious Diseases (2022) 22:51 Page 2 of 7 least likely being aware of their status [2]. Innovations Enumeration Areas (EA) per community. Within each to close the gaps in testing coverage and reach under- EA, Open Data kit was used to randomly select 50% of served are urgently required [3]. Investing in additional, the households for survey participation, with the aim of innovative HIV testing strategies such as HIV self-testing recruiting 200 adults per community. Only household (HIVST), where individuals take their own test and inter- members older than or equal to 16 years old were eligible pret the result, may both increase testing coverage and for survey completion, after written informed consent. decrease inequities in access. The survey questionnaire was self-administered on elec - In 2015, Unitaid invested in a large-scale implementa- tronic tablets, using Audio Computer Assisted Self Inter- tion project, called the Self-Testing AfRica (STAR) ini- view (ACASI) and included socio-demographic details, tiative. The focus was on generating extensive experience history of HIV testing and ART uptake; access to, use and and evidence to scale up access to HIVST across Sub- results of self-testing; and uptake of any health services Saharan Africa. Since then, HIVST acceptability, feasi- including confirmatory testing and ART following kit bility and scalability has been demonstrated across many distribution (Additional file 1). delivery models in different Eastern and Southern Afri - The outcome of interest for this analysis was “ever hav - can countries [4–9] allowing policy makers to select the ing heard of HIVST”. The variable was defined from the most appropriate HIVST delivery models for their con- question “Have you heard about HIV self-testing as a text to complement their existing national HIV testing method for testing for HIV?”. Guided by the definition for strategies [10]. Community-based distribution can occur HIV self-testing: “HIV self-testing is a process whereby a during campaigns, at events, through mobile outreach or person who wants to know his or her HIV status collects door-to-door [11]. Previous studies have demonstrated a specimen, performs a test, and interprets the test result the effectiveness of community-led HIVST campaigns, in private”. A binary yes or no response was captured. As community-based secondary or peer-led distribution the research objective of the analysis is focussing on the in increasing HIV testing in underserved subgroups study population who never heard of HIVST, the refer- [12–14]. Community-based door-to-door distribution ence category for analysis is those who have ever heard has been shown to both increase testing coverage among of HIVST. first-time testers, men and adolescents as well as linkage Based on the questions asked in the population-based to antiretroviral therapy (ART) [15]. We do not clearly survey, the following socio-demographic and socio-eco- understand who is left out by door-to-door distribution, nomic characteristics were considered for the analysis: including what proportion remain unaware of HIVST age, sex, marital status, highest level of education, able to after distribution campaigns, and who these individuals read newspaper or letter, religion, tribe, occupation, regu- are. The aim here is to describe those who self-reported lar salary, perception of general health, having lived in the having never heard of HIVST despite living in a commu- community for the last 12  months, ever tested for HIV nity receiving intensive door-to-door community-based and whether one was a head of the household. A house- HIVST distribution to inform future HIVST delivery hold head was defined as the person who is regarded strategies. This information is essential to optimize cov - as the custodian of the family and is deferred to for the erage of HIVST and to close the gaps in HIV testing. important decisions of the household. A household rep- resentative is the person in charge of the household when Methods the household head is absent. Common mental disorders Secondary analysis was undertaken on a subset of the were measured using the Shona Symptom Questionnaire population-based survey data collected as part of a (SSQ), an indigenous 14-item measure in the Shona lan- cluster-randomized trial of supply-side financial incen - guage, developed in Zimbabwe, with a cut-off point of tives to increase uptake of HIVST and linkage to post- 9/14 [17]. All continuous variables were changed into test services nested within a time-trend analysis of categorical variables to understand how the outcome was linkage to care. The study has been published elsewhere distributed among sub-populations. Categorical variables (PACTR201607001701788) [16]. were constructed based on the answer options provided In brief, trained community-based distributors deliv- in the population-based survey. ered HIVST kits through door-to-door distribution to The analysis was conducted in STATA 15.1 (Stata Cor - all households in 38 rural Zimbabwean communities poration, College Station, TX, USA). Descriptive analyses between September 2016 and July 2017. Distribution describe the characteristics of the survey participants. was carried out over 19  days (range 19–25  days) per Factors associated with never having heard of HIVST community. Six to eight weeks later, after completion of were determined using multivariable mixed-effects logis - HIVST distribution, a population-based survey was con- tic regression of individual-level data with adjustment ducted in four randomly selected National Census Office for random effects to account for the clustered unit of R otsaert et al. BMC Infectious Diseases (2022) 22:51 Page 3 of 7 randomisation, i.e., household and community level. To Non-Shona people, except for the Tonga people, had select the final minimum adequate model, a backward a statistically significant increased odds of not having stepwise selection reduction was applied using the like- heard about HIVST compared to Shona people Ndebele: lihood-ratio test to assess the goodness of fit of two com - [aOR = 1.28, 95% CI (1.02–1.61)], Kalanga: [aOR = 1.58, peting statistical models. All independent variables were 95% CI (1.21–2.07)], Other: [aOR = 1.47, 95% CI (1.04– included in the model except for ‘regular salary’ and ‘able 2.07)]. Individuals who perceive their health to be poor to read a newspaper or letter’. These latter variables were [aOR = 1.30, 95% CI (1.01–1.67)], or who did not answer excluded as they are interrelated with the variables ‘occu- the general health perception question [aOR = 2.15, pation’ and ‘highest level of education’. 95% CI (1.27–3.65)] have increased odds of never hav- ing heard of HIVST compared with those who perceive Results their general health to be good. Individuals who are not Characteristics of survey participants household heads or household head representatives have The population-based survey included 7146 people from increased odds of never having heard of HIVST com- 3813 households, with a response rate of 83.4%. Not pared to household heads or household head representa- being at home (n = 1091, 12.7%) was main reason for tives [aOR = 1.21, 95% CI (1.01–1.45)]. non-response. Almost three quarters of the households No significant association was found between having (n = 2769, 72.6%) received an HIVST kit during the distri- never heard of HIVST among individuals with a formal bution campaign. The sample included 2767 men (38.7%) employment compared to those in other employment and 4379 women (61.3%). About 42% (n = 3001) of the categories [aOR = 1.17 95% CI (0.81–1.70)]. participants were between 20 and 39  years old. Almost 60% (n = 4240) were married. The predominant religion Discussion was Apostolic (34.3%, n = 2450). Most participants were This study provides insight into factors associated with Shona (69.3%, n = 4949). About 46% of the participants never having heard of HIVST after intensive commu- (n = 3333) were not a household head or a household nity-based campaign-style HIVST distribution in rural head representative. Almost half of the survey population Zimbabwe. Among survey participants, nearly one fifth (43.3%, n = 3092) had no education or only primary edu- self-reported having never heard of HIVST. Individuals cation. Being a subsistence farmer (64.7%, n = 4620) was who were between 16 and 19 years old, who had no for- the main occupation with 16.1% (n = 1153) earning a reg- mal education or had only attended primary school and ular salary. More than half of the participants perceived who had never tested before for HIV were more likely to their general health to be very good (25.9%, n = 1852) or have never heard of HIVST. In addition, those who were good (37.9%, n = 2713) and 45.1% (n = 3221) of the par- not household heads or household head representatives ticipants had a SSQ score above 9 points suggesting they were more likely to have never heard of HIVST. were at risk of common mental disorders. Although 6335 Understanding who is missed by door-to-door com- participants (88.7%) reported ever having tested for HIV munity-based test distribution will be helpful for design- in the past, 18.3% (n = 1308) self-reported that they had ing future HIVST distribution models [18]. Zimbabwe never having heard of HIVST. was an early adopter of HIVST. At a time when small HIVST pilot studies were being implemented [19], the Factors associated with never having heard of HIVST Zimbabwean 2015–2016 Demographic and Health Sur- The multivariable mixed-effects analysis shows that par - vey (DHS) data showed a population-level awareness for ticipants between 20 and 60  years old are less likely to HIVST of only 14.5% [20]. Comparing this low percent- have never heard of HIVST {20–29  years: [aOR = 0.74, age with the 81.7% found in this study, shows the positive 95% CI (0.58–0.95)], 30–39  years: [aOR = 0.56, 95% CI impact of large-scale implementation studies, such as the (0.42–0.74)], 40–49  years: [aOR = 0.50, 95% CI (0.36– STAR Initiative on awareness. As there is a constant evo- 0.68)], 50–59  years [aOR = 0.58, 95% CI (0.42–0.82)]} lution in exposure and presence of HIVST overtime, it compared to participants between 16 and 19  years old remains important to examine awareness trends in future (Table 1). Individuals who have been living in the area for national surveys such as DHS. the last 12 months [aOR = 0.48, 95% CI (0.36–0.63)], who Similar conclusions in terms of those aware of HIVST had an HIV test before [aOR = 0.30, 95% CI (0.25–0.37)] were found in the 2015–2016 DHS. Awareness was and who have attained at least ordinary level education lower among respondents who were younger (below [aOR = 0.51, 95% CI (0.34–0.76)] are less likely to have 20  years) and with lower levels of education (primary never heard of HIVST than individuals who had not lived education or less) [20]. This is in line with other stud - in the area over the last 12 months, who had never tested ies which found that HIV testing and knowledge of HIV for HIV before and who have a lower educational level. status increases with age and educational level [21–23]. Rotsaert et al. BMC Infectious Diseases (2022) 22:51 Page 4 of 7 Table 1 Results multivariable mixed effect logistic regression adjusted for clustering on household and community level Individual characteristics Ever heard of HIVST Never heard of OR* 95% CI P-value aOR 95% CI P-value N = 5838 (Row %) HIVST N = 1308 (Row %) Age in groups 16–19 years 820 (74.3%) 284 (25.7%) – – < 0.001 – – < 0.001 20–29 years 1300 (82.4%) 277 (17.6%) 0.57 0.46–0.71 0.74 0.58–0.95 30–39 years 1239 (87.0%) 185 (13.0%) 0.38 0.30–0.49 0.56 0.42–0.74 40–49 years 929 (87.6%) 131 (12.4%) 0.35 0.27–0.45 0.50 0.36–0.68 50–59 years 662 (84.0%) 126 (16.0%) 0.49 0.37–0.64 0.58 0.42–0.82 60 years and older 867 (75.1%) 288 (24.9%) 0.94 0.75–1.17 0.99 0.72–1.36 Constant – – 0.27 0.21–0.34 < 0.001 – – – Sex Male 2213 (79.9%) 554 (20.1%) – – < 0.001 – – – Female 3625 (82.8%) 754 (17.2%) 0.80 0.70–0.92 – – – Constant – – 0.18 0.15–0.22 < 0.001 – – – Marital status Married 3585 (84.6%) 655 (15.4%) – – < 0.001 – – – Never married 1227 (75.9%) 390 (24.1%) 1.92 1.63–2.27 – – – Widowed/separated/divorced 1026 (79.6%) 263 (20.4%) 1.50 1.24–1.82 – – – Constant – – 0.12 0.10–0.15 < 0.001 – – – Highest level of education None/primary 2412 (78.1%) 680 (21.9%) – – < 0.001 – – < 0.001 Some secondary 1556 (81.4%) 355 (18.6%) 0.82 0.69–0.96 0.84 0.70–1.02 O levels complete 1571 (87.4%) 227 (12.6%) 0.50 0.42–0.61 0.58 0.46–0.72 A levels and above 299 (86.7%) 46 (13.3%) 0.54 0.37–0.78 0.51 0.34–0.76 Constant – – 0.21 0.17–0.25 < 0.001 – – – Able to read newspaper or letter No 866 (72.8%) 323 (27.2%) – – < 0.001 – – – Yes 4972 (83.5%) 985 (16.5%) 0.50 0.42–0.59 – – – Constant – – 0.28 0.23–0.35 < 0.001 – – – Religion Apostolic 2005 (81.8%) 445 (18.2%) – – 0.245 – – – Other Christian denomination 1863 (83.1%) 380 (16.9%) 0.99 0.83–1.19 – – – Other, including no religion 1970 (80.3%) 483 (19.7%) 1.14 0.95–1.35 – – – Constant – – 0.15 0.12–0.19 < 0.001 – – – Tribe Shona 4142 (83.7%) 807 (16.3%) – – < 0.001 – – 0.0060 Ndebele 925 (78.5%) 254 (21.5%) 1.43 1.14–1.79 1.28 1.02–1.61 Kalanga 489 (75.2%) 161 (24.8%) 1.76 1.36–2.29 1.58 1.21–2.07 Tonga 23 (82.1%) 5 (17.9%) 1.21 0.39–3.70 0.93 0.29–3.03 Other 250 (76.5%) 77 (23.5%) 1.66 1.20–2.31 1.47 1.04–2.07 I don’t wish to answer 9 (69.2%) 4 (30.8%) 2.70 0.67–10.94 2.56 0.61–10.73 Constant – – 0.14 0.12–0.17 < 0.001 – – – Occupation Student 531 (75.9%) 168 (24.1%) – – < 0.001 – – Subsistence farmer 3836 (83.1%) 784 (16.9%) 0.57 0.46–0.72 0.83 0.62–1.10 Self-employed 1045 (80.2%) 258 (19.8%) 0.70 0.54–0.92 1.08 0.79–1.46 0.0131 Formal employment 426 (81.3%) 98 (18.7%) 0.68 0.49–0.95 1.17 0.81–1.70 Constant – – 0.25 0.19–0.32 < 0.001 – – – R otsaert et al. BMC Infectious Diseases (2022) 22:51 Page 5 of 7 Table 1 (continued) Individual characteristics Ever heard of HIVST Never heard of OR* 95% CI P-value aOR 95% CI P-value N = 5838 (Row %) HIVST N = 1308 (Row %) Regular salary No 4909 (81.9%) 1084 (18.1%) - - 0.327 – – – Yes 929 (80.6%) 224 (19.4%) 1.10 0.91–1.33 – – – Constant – – 0.16 0.13–0.19 < 0.001 – – – Perception general health Very good 1534 (82.8%) 318 (17.2%) – – 0.027 – – 0.0165 Good 2247 (82.8%) 466 (17.2%) 0.96 0.80–1.15 1.04 0.85–1.25 Fair 1184 (80.9%) 278 (19.1%) 1.02 0.83–1.26 1.10 0.88–1.38 Poor 797 (78.8%) 214 (21.2%) 1.20 0.96–1.51 1.30 1.01–1.67 Don’t want to answer 76 (70.4%) 32 (29.6%) 1.93 1.16–3.22 2.15 1.27–3.65 Constant – – 0.16 0.13–0.19 < 0.001 – – – Living here last 12 months No 292 (70.7%) 121 (29.3%) – – < 0.001 – – < 0.001 Yes 5546 (82.4%) 1187 (17.6%) 0.44 0.33–0.57 0.48 0.36–0.63 Constant – – 0.34 0.25–0.46 < 0.001 – – – SSQ ≥ 9 No 490 (60.4%) 732 (39.6%) – – 0.262 – – – Yes 5348 (84.4%) 576 (15.6%) 0.92 0.80–1.06 – – – Constant – – 0.16 0.14–0.20 < 0.001 – – – Ever tested for HIV No 3193 (81.3%) 321 (18.7%) – – < 0.001 – – < 0.001 Yes 2645 (82.1%) 987 (17.9%) 0.24 0.20–0.30 0.30 0.25–0.37 Constant – – 0.55 0.44–0.69 < 0.001 – – – Household head Household head 2398 (83.2%) 485 (16.8%) – – 0.0008 – – 0.1002 Household head representative 777 (83.6%) 153 (16.4%) 0.93 0.74–1.17 1.07 0.83–1.37 Not head/represent 2663 (79.9%) 670 (20.1%) 1.27 1.10–1.47 1.21 1.01–1.45 Constant – – 0.14 0.12–0.18 < 0.001 – – – Constant multivariable model – – – – – 1.30 0.84–2.03 0.245 *OR: odds ratio, bivariable analysis, adjusted for clustering on community and household level, people having heard of HIVST as reference group; $ = aOR: adjusted odds ratio, multivariable mixed-effect logistic regression, adjusted for clustering on community and household level after backward reduction, people having heard of HIVST as reference group; µ = Ordinary (O) Level—basic level of the General Certificate of Education completed in the third/fourth years secondary school, a subject-based qualification; £ = Advanced (A) Level—advanced level of the General Certificate of Education completed in the fifth/sixth years of secondary school, a subject-based qualification Possible explanations may be linked to general trends in programmes will be needed to reach those remaining HIV testing. Younger people and those less educated are unaware [30–36]. less knowledgeable about HIV, and thus may know less Non-household heads were more likely to not have about different HIV testing options, including self-testing heard of HIVST. As was reported in qualitative studies [24, 25]. Despite the high HIVST awareness achieved that were done alongside this research (data not reported by our community-based distribution model, culminat- here), this may be because when distributors approach ing in high testing rates among individuals who might households, they are culturally expected to first approach not otherwise test (i.e., men, young people, those testing the head of household, who may not invite the rest of the for the first time), some still remained unaware of their household to the discussion [37]. Future efforts should HIV status [26–29]. Complementing community-based ensure that everyone in a household is invited to discus- distribution with other HIVST distribution models such sions, with platforms created for separate discussions as as those through health facilities and youth clinics, by appropriate (e.g., young people would like HIVST discus- sexual partners or secondary distribution and workplace sions to be held separately from their parents/guardians) Rotsaert et al. BMC Infectious Diseases (2022) 22:51 Page 6 of 7 University College London, the Liverpool School of Tropical Medicine, the [37]. A community-based program on HIVST in rural World Health Organization, CeSHHAR, Zambart and the Malawi‐Liverpool‐ Malawi found that HIVST was more prevalent among Wellcome Trust Clinical Research Unit. individuals who shared a household with someone who About this supplement reported HIVST [29]. Understanding the role of house- This article has been published as part of BMC Infectious Diseases Volume 22 hold dynamics on facilitating community-based distri- Supplement 1 2021: Innovating with HIV self-testing for impact in southern bution activities within the household should be further Africa: Lessons learned from the STAR (Self-Testing AfRica) Initiative. The full contents of the supplement are available at https:// bmcin fectd is. biome dcent investigated. Alongside, alternative distribution methods ral. com/ artic les/ suppl ements/ volume- 22- suppl ement-1. should be implemented for those who are uncomfortable accepting and performing an HIV self-test in the pres- Authors’ contributions AR, ES, FC conceptualized the paper. AR conducted the analysis and wrote the ence of other household members, for example, through first draft. KH, CJ, EC, MN, FC and ES contributed to revisions of the manuscript, youth centres or peer to peer distribution for young peo- and all authors have reviewed the final manuscript. All authors read and ple [37–41] Furthermore, appropriate promotion tools approved the final manuscript. such as mobile platforms and social media technology Funding should be used to increase HIVST awareness among The STAR Initiative is funded by UNITAID (PO# 10140‐0‐600 and PO# young people [39]. 8477‐0‐600). The population-based survey outcomes were based on Availability of data and materials self-reporting, which may have been subject to social The datasets used and/or analysed during the current study are available from desirability bias. To minimize this bias, ACASI was the corresponding author on reasonable request. used [42]. Despite this, this study provides new insights into characteristics of individuals who remain unaware Declarations of HIVST following community-based HIVST kit dis- Ethics approval and consent to participate tribution and confirms the presence of ongoing bar - Ethical approval was obtained from Medical Research Council of Zimbabwe riers to HIV testing. Lastly, our results are specific for (MRCZ/A/2038), University College London Ethics Committee (6084/004) and London School of Hygiene and Tropical. Medicine Ethics Committee (11738). community-based door-to-door distribution of HIVST Before filling in the questionnaire, participants were informed about the study, kits. Other distribution models or a different interven - the procedures and the voluntary nature of study participation. Participants tion design might have affected awareness of HIVST provided written consent to participate. differently. Consent for publication Not applicable. Conclusions Competing interests Around one fifth of survey participants remain unaware The authors have no competing interests. of HIVST even after an intensive community-based door- Author details to-door HIVST distribution. Of note, those least likely to Department of Public Health, Institute of Tropical Medicine, Nationalestraat have heard of self-testing were younger, less educated 2 155, 2000 Antwerp, Belgium. Centre for Sexual Health and HIV AIDS Research and less likely to have tested previously. Household heads (CeSHHAR), Harare, Zimbabwe. Liverpool School of Tropical Medicine, Liver- 4 5 pool, UK. Population Services International, Cape Town, South Africa. Global appear to play an important role in granting or denying HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, access to self-testing to other household members dur- 6 Switzerland. Department of Clinical Research and Infection Disease, London ing door-to-door distribution. 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Mavengere Y, Sibanda EL, Hatzold K, Cowan F, Mugurungi O, Mavedzenge Springer Nature remains neutral with regard to jurisdictional claims in pub- S. Can ‘late-read’ of self-test devices be used as a quality assurance meas- lished maps and institutional affiliations. ure? Results of a pilot HIV self-test project in Zimbabwe. 2016;541. 20. Johnson C, et al. Use and awareness of and willingness to self-test for HIV: an analysis of cross-sectional population-based surveys in Malawi and Zimbabwe. BMC Public Health. 2020;20(1):1–13. 21. Takarinda KC, et al. Factors associated with ever being HIV-tested in Zim- babwe: an extended analysis of the Zimbabwe Demographic and Health Survey (2010–2011). PLoS ONE. 2016;11(1):1–18. 22. Peltzer K, Matseke G, Mzolo T, Majaja M. Determinants of knowledge of HIV status in South Africa: results from a population-based HIV survey. BMC Public Health. 2009; 9(174). 23. Giguère K et al. 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Available: https:// www. unaids. org/ en/ resou rces/ press centre/ • gold Open Access which fosters wider collaboration and increased citations featu resto ries/ 2019/ decem ber/ young- people- and- men- less- likely- to- know- their- hiv- status. [Accessed: 16-Apr-2020]. maximum visibility for your research: over 100M website views per year 28. Sibanda E, Neuman M, Tumushime M, Hatzold K. Linkage to care after HIV self-testing in Zimbabwe: a cluster-randomised trial. in CROI 2018, 2018. At BMC, research is always in progress. 29. Indravudh PP, et al. Who is reached by HIV self-testing? Individual factors Learn more biomedcentral.com/submissions associated with self-testing within a community-based program in Rural Malawi. JAIDS J Acquir Immune Defic Syndr. 2020;85(2):165–73. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Infectious Diseases Springer Journals

Did you hear about HIV self-testing? HIV self-testing awareness after community-based HIVST distribution in rural Zimbabwe

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Abstract

Background: Several trials of community-based HIV self-testing (HIVST ) provide evidence on the acceptability and feasibility of campaign-style distribution to reach first-time testers, men and adolescents. However, we do not know how many remain unaware of HIVST after distribution campaigns, and who these individuals are. Here we look at factors associated with never having heard of HIVST after community-based campaign-style HIVST distribution in rural Zimbabwe between September 2016 and July 2017. Methods: Analysis of representative population-based trial survey data collected from 7146 individuals following community-based HIVST distribution to households was conducted. Factors associated with having never heard of HIVST were determined using multivariable mixed-effects logistic regression adjusted for clustered design. Results: Among survey participants, 1308 (18.3%) self-reported having never heard of HIVST. Individuals who were between 20 and 60 years old {20–29 years: [aOR = 0.74, 95% CI (0.58–0.95)], 30–39 years: [aOR = 0.56, 95% CI (0.42– 0.74)], 40–49 years: [aOR = 0.50, 95% CI (0.36–0.68)], 50–59 years [aOR = 0.58, 95% CI (0.42–0.82)]}, who had attained at least ordinary level education [aOR = 0.51, 95% CI (0.34–0.76)], and who had an HIV test before [aOR = 0.30, 95% CI (0.25–0.37)] were less likely to have never heard of HIVST compared with individuals who were between 16 and 19 years old, who had a lower educational level and who had never tested for HIV before, respectively. In addition, non-household heads or household head representatives [aOR = 1.21, 95% CI (1.01–1.45)] were more likely to report never having heard of HIVST compared to household head and representatives. Conclusions: Around one fifth of survey participants remain unaware of HIVST even after an intensive community- based door-to-door HIVST distribution. Of note, those least likely to have heard of self-testing were younger, less educated and less likely to have tested previously. Household heads appear to play an important role in granting or denying access to self-testing to other household members during door-to-door distribution. Differentiated distribu- tion models are needed to ensure access to all. Trial registration PACTR, PACTR201607001701788. Registered 29 June 2016, https:// pactr. samrc. ac. za/ PACTR201607001701788 Keywords: HIV self-testing, Community-based distribution Background *Correspondence: arotsaert@itg.be Globally, 19% of people living with human immunodefi - Department of Public Health, Institute of Tropical Medicine, ciency virus (HIV) are undiagnosed [1], with men, young Nationalestraat 155, 2000 Antwerp, Belgium people (i.e., 15–24  years old), rural and key populations Full list of author information is available at the end of the article © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Rotsaert et al. BMC Infectious Diseases (2022) 22:51 Page 2 of 7 least likely being aware of their status [2]. Innovations Enumeration Areas (EA) per community. Within each to close the gaps in testing coverage and reach under- EA, Open Data kit was used to randomly select 50% of served are urgently required [3]. Investing in additional, the households for survey participation, with the aim of innovative HIV testing strategies such as HIV self-testing recruiting 200 adults per community. Only household (HIVST), where individuals take their own test and inter- members older than or equal to 16 years old were eligible pret the result, may both increase testing coverage and for survey completion, after written informed consent. decrease inequities in access. The survey questionnaire was self-administered on elec - In 2015, Unitaid invested in a large-scale implementa- tronic tablets, using Audio Computer Assisted Self Inter- tion project, called the Self-Testing AfRica (STAR) ini- view (ACASI) and included socio-demographic details, tiative. The focus was on generating extensive experience history of HIV testing and ART uptake; access to, use and and evidence to scale up access to HIVST across Sub- results of self-testing; and uptake of any health services Saharan Africa. Since then, HIVST acceptability, feasi- including confirmatory testing and ART following kit bility and scalability has been demonstrated across many distribution (Additional file 1). delivery models in different Eastern and Southern Afri - The outcome of interest for this analysis was “ever hav - can countries [4–9] allowing policy makers to select the ing heard of HIVST”. The variable was defined from the most appropriate HIVST delivery models for their con- question “Have you heard about HIV self-testing as a text to complement their existing national HIV testing method for testing for HIV?”. Guided by the definition for strategies [10]. Community-based distribution can occur HIV self-testing: “HIV self-testing is a process whereby a during campaigns, at events, through mobile outreach or person who wants to know his or her HIV status collects door-to-door [11]. Previous studies have demonstrated a specimen, performs a test, and interprets the test result the effectiveness of community-led HIVST campaigns, in private”. A binary yes or no response was captured. As community-based secondary or peer-led distribution the research objective of the analysis is focussing on the in increasing HIV testing in underserved subgroups study population who never heard of HIVST, the refer- [12–14]. Community-based door-to-door distribution ence category for analysis is those who have ever heard has been shown to both increase testing coverage among of HIVST. first-time testers, men and adolescents as well as linkage Based on the questions asked in the population-based to antiretroviral therapy (ART) [15]. We do not clearly survey, the following socio-demographic and socio-eco- understand who is left out by door-to-door distribution, nomic characteristics were considered for the analysis: including what proportion remain unaware of HIVST age, sex, marital status, highest level of education, able to after distribution campaigns, and who these individuals read newspaper or letter, religion, tribe, occupation, regu- are. The aim here is to describe those who self-reported lar salary, perception of general health, having lived in the having never heard of HIVST despite living in a commu- community for the last 12  months, ever tested for HIV nity receiving intensive door-to-door community-based and whether one was a head of the household. A house- HIVST distribution to inform future HIVST delivery hold head was defined as the person who is regarded strategies. This information is essential to optimize cov - as the custodian of the family and is deferred to for the erage of HIVST and to close the gaps in HIV testing. important decisions of the household. A household rep- resentative is the person in charge of the household when Methods the household head is absent. Common mental disorders Secondary analysis was undertaken on a subset of the were measured using the Shona Symptom Questionnaire population-based survey data collected as part of a (SSQ), an indigenous 14-item measure in the Shona lan- cluster-randomized trial of supply-side financial incen - guage, developed in Zimbabwe, with a cut-off point of tives to increase uptake of HIVST and linkage to post- 9/14 [17]. All continuous variables were changed into test services nested within a time-trend analysis of categorical variables to understand how the outcome was linkage to care. The study has been published elsewhere distributed among sub-populations. Categorical variables (PACTR201607001701788) [16]. were constructed based on the answer options provided In brief, trained community-based distributors deliv- in the population-based survey. ered HIVST kits through door-to-door distribution to The analysis was conducted in STATA 15.1 (Stata Cor - all households in 38 rural Zimbabwean communities poration, College Station, TX, USA). Descriptive analyses between September 2016 and July 2017. Distribution describe the characteristics of the survey participants. was carried out over 19  days (range 19–25  days) per Factors associated with never having heard of HIVST community. Six to eight weeks later, after completion of were determined using multivariable mixed-effects logis - HIVST distribution, a population-based survey was con- tic regression of individual-level data with adjustment ducted in four randomly selected National Census Office for random effects to account for the clustered unit of R otsaert et al. BMC Infectious Diseases (2022) 22:51 Page 3 of 7 randomisation, i.e., household and community level. To Non-Shona people, except for the Tonga people, had select the final minimum adequate model, a backward a statistically significant increased odds of not having stepwise selection reduction was applied using the like- heard about HIVST compared to Shona people Ndebele: lihood-ratio test to assess the goodness of fit of two com - [aOR = 1.28, 95% CI (1.02–1.61)], Kalanga: [aOR = 1.58, peting statistical models. All independent variables were 95% CI (1.21–2.07)], Other: [aOR = 1.47, 95% CI (1.04– included in the model except for ‘regular salary’ and ‘able 2.07)]. Individuals who perceive their health to be poor to read a newspaper or letter’. These latter variables were [aOR = 1.30, 95% CI (1.01–1.67)], or who did not answer excluded as they are interrelated with the variables ‘occu- the general health perception question [aOR = 2.15, pation’ and ‘highest level of education’. 95% CI (1.27–3.65)] have increased odds of never hav- ing heard of HIVST compared with those who perceive Results their general health to be good. Individuals who are not Characteristics of survey participants household heads or household head representatives have The population-based survey included 7146 people from increased odds of never having heard of HIVST com- 3813 households, with a response rate of 83.4%. Not pared to household heads or household head representa- being at home (n = 1091, 12.7%) was main reason for tives [aOR = 1.21, 95% CI (1.01–1.45)]. non-response. Almost three quarters of the households No significant association was found between having (n = 2769, 72.6%) received an HIVST kit during the distri- never heard of HIVST among individuals with a formal bution campaign. The sample included 2767 men (38.7%) employment compared to those in other employment and 4379 women (61.3%). About 42% (n = 3001) of the categories [aOR = 1.17 95% CI (0.81–1.70)]. participants were between 20 and 39  years old. Almost 60% (n = 4240) were married. The predominant religion Discussion was Apostolic (34.3%, n = 2450). Most participants were This study provides insight into factors associated with Shona (69.3%, n = 4949). About 46% of the participants never having heard of HIVST after intensive commu- (n = 3333) were not a household head or a household nity-based campaign-style HIVST distribution in rural head representative. Almost half of the survey population Zimbabwe. Among survey participants, nearly one fifth (43.3%, n = 3092) had no education or only primary edu- self-reported having never heard of HIVST. Individuals cation. Being a subsistence farmer (64.7%, n = 4620) was who were between 16 and 19 years old, who had no for- the main occupation with 16.1% (n = 1153) earning a reg- mal education or had only attended primary school and ular salary. More than half of the participants perceived who had never tested before for HIV were more likely to their general health to be very good (25.9%, n = 1852) or have never heard of HIVST. In addition, those who were good (37.9%, n = 2713) and 45.1% (n = 3221) of the par- not household heads or household head representatives ticipants had a SSQ score above 9 points suggesting they were more likely to have never heard of HIVST. were at risk of common mental disorders. Although 6335 Understanding who is missed by door-to-door com- participants (88.7%) reported ever having tested for HIV munity-based test distribution will be helpful for design- in the past, 18.3% (n = 1308) self-reported that they had ing future HIVST distribution models [18]. Zimbabwe never having heard of HIVST. was an early adopter of HIVST. At a time when small HIVST pilot studies were being implemented [19], the Factors associated with never having heard of HIVST Zimbabwean 2015–2016 Demographic and Health Sur- The multivariable mixed-effects analysis shows that par - vey (DHS) data showed a population-level awareness for ticipants between 20 and 60  years old are less likely to HIVST of only 14.5% [20]. Comparing this low percent- have never heard of HIVST {20–29  years: [aOR = 0.74, age with the 81.7% found in this study, shows the positive 95% CI (0.58–0.95)], 30–39  years: [aOR = 0.56, 95% CI impact of large-scale implementation studies, such as the (0.42–0.74)], 40–49  years: [aOR = 0.50, 95% CI (0.36– STAR Initiative on awareness. As there is a constant evo- 0.68)], 50–59  years [aOR = 0.58, 95% CI (0.42–0.82)]} lution in exposure and presence of HIVST overtime, it compared to participants between 16 and 19  years old remains important to examine awareness trends in future (Table 1). Individuals who have been living in the area for national surveys such as DHS. the last 12 months [aOR = 0.48, 95% CI (0.36–0.63)], who Similar conclusions in terms of those aware of HIVST had an HIV test before [aOR = 0.30, 95% CI (0.25–0.37)] were found in the 2015–2016 DHS. Awareness was and who have attained at least ordinary level education lower among respondents who were younger (below [aOR = 0.51, 95% CI (0.34–0.76)] are less likely to have 20  years) and with lower levels of education (primary never heard of HIVST than individuals who had not lived education or less) [20]. This is in line with other stud - in the area over the last 12 months, who had never tested ies which found that HIV testing and knowledge of HIV for HIV before and who have a lower educational level. status increases with age and educational level [21–23]. Rotsaert et al. BMC Infectious Diseases (2022) 22:51 Page 4 of 7 Table 1 Results multivariable mixed effect logistic regression adjusted for clustering on household and community level Individual characteristics Ever heard of HIVST Never heard of OR* 95% CI P-value aOR 95% CI P-value N = 5838 (Row %) HIVST N = 1308 (Row %) Age in groups 16–19 years 820 (74.3%) 284 (25.7%) – – < 0.001 – – < 0.001 20–29 years 1300 (82.4%) 277 (17.6%) 0.57 0.46–0.71 0.74 0.58–0.95 30–39 years 1239 (87.0%) 185 (13.0%) 0.38 0.30–0.49 0.56 0.42–0.74 40–49 years 929 (87.6%) 131 (12.4%) 0.35 0.27–0.45 0.50 0.36–0.68 50–59 years 662 (84.0%) 126 (16.0%) 0.49 0.37–0.64 0.58 0.42–0.82 60 years and older 867 (75.1%) 288 (24.9%) 0.94 0.75–1.17 0.99 0.72–1.36 Constant – – 0.27 0.21–0.34 < 0.001 – – – Sex Male 2213 (79.9%) 554 (20.1%) – – < 0.001 – – – Female 3625 (82.8%) 754 (17.2%) 0.80 0.70–0.92 – – – Constant – – 0.18 0.15–0.22 < 0.001 – – – Marital status Married 3585 (84.6%) 655 (15.4%) – – < 0.001 – – – Never married 1227 (75.9%) 390 (24.1%) 1.92 1.63–2.27 – – – Widowed/separated/divorced 1026 (79.6%) 263 (20.4%) 1.50 1.24–1.82 – – – Constant – – 0.12 0.10–0.15 < 0.001 – – – Highest level of education None/primary 2412 (78.1%) 680 (21.9%) – – < 0.001 – – < 0.001 Some secondary 1556 (81.4%) 355 (18.6%) 0.82 0.69–0.96 0.84 0.70–1.02 O levels complete 1571 (87.4%) 227 (12.6%) 0.50 0.42–0.61 0.58 0.46–0.72 A levels and above 299 (86.7%) 46 (13.3%) 0.54 0.37–0.78 0.51 0.34–0.76 Constant – – 0.21 0.17–0.25 < 0.001 – – – Able to read newspaper or letter No 866 (72.8%) 323 (27.2%) – – < 0.001 – – – Yes 4972 (83.5%) 985 (16.5%) 0.50 0.42–0.59 – – – Constant – – 0.28 0.23–0.35 < 0.001 – – – Religion Apostolic 2005 (81.8%) 445 (18.2%) – – 0.245 – – – Other Christian denomination 1863 (83.1%) 380 (16.9%) 0.99 0.83–1.19 – – – Other, including no religion 1970 (80.3%) 483 (19.7%) 1.14 0.95–1.35 – – – Constant – – 0.15 0.12–0.19 < 0.001 – – – Tribe Shona 4142 (83.7%) 807 (16.3%) – – < 0.001 – – 0.0060 Ndebele 925 (78.5%) 254 (21.5%) 1.43 1.14–1.79 1.28 1.02–1.61 Kalanga 489 (75.2%) 161 (24.8%) 1.76 1.36–2.29 1.58 1.21–2.07 Tonga 23 (82.1%) 5 (17.9%) 1.21 0.39–3.70 0.93 0.29–3.03 Other 250 (76.5%) 77 (23.5%) 1.66 1.20–2.31 1.47 1.04–2.07 I don’t wish to answer 9 (69.2%) 4 (30.8%) 2.70 0.67–10.94 2.56 0.61–10.73 Constant – – 0.14 0.12–0.17 < 0.001 – – – Occupation Student 531 (75.9%) 168 (24.1%) – – < 0.001 – – Subsistence farmer 3836 (83.1%) 784 (16.9%) 0.57 0.46–0.72 0.83 0.62–1.10 Self-employed 1045 (80.2%) 258 (19.8%) 0.70 0.54–0.92 1.08 0.79–1.46 0.0131 Formal employment 426 (81.3%) 98 (18.7%) 0.68 0.49–0.95 1.17 0.81–1.70 Constant – – 0.25 0.19–0.32 < 0.001 – – – R otsaert et al. BMC Infectious Diseases (2022) 22:51 Page 5 of 7 Table 1 (continued) Individual characteristics Ever heard of HIVST Never heard of OR* 95% CI P-value aOR 95% CI P-value N = 5838 (Row %) HIVST N = 1308 (Row %) Regular salary No 4909 (81.9%) 1084 (18.1%) - - 0.327 – – – Yes 929 (80.6%) 224 (19.4%) 1.10 0.91–1.33 – – – Constant – – 0.16 0.13–0.19 < 0.001 – – – Perception general health Very good 1534 (82.8%) 318 (17.2%) – – 0.027 – – 0.0165 Good 2247 (82.8%) 466 (17.2%) 0.96 0.80–1.15 1.04 0.85–1.25 Fair 1184 (80.9%) 278 (19.1%) 1.02 0.83–1.26 1.10 0.88–1.38 Poor 797 (78.8%) 214 (21.2%) 1.20 0.96–1.51 1.30 1.01–1.67 Don’t want to answer 76 (70.4%) 32 (29.6%) 1.93 1.16–3.22 2.15 1.27–3.65 Constant – – 0.16 0.13–0.19 < 0.001 – – – Living here last 12 months No 292 (70.7%) 121 (29.3%) – – < 0.001 – – < 0.001 Yes 5546 (82.4%) 1187 (17.6%) 0.44 0.33–0.57 0.48 0.36–0.63 Constant – – 0.34 0.25–0.46 < 0.001 – – – SSQ ≥ 9 No 490 (60.4%) 732 (39.6%) – – 0.262 – – – Yes 5348 (84.4%) 576 (15.6%) 0.92 0.80–1.06 – – – Constant – – 0.16 0.14–0.20 < 0.001 – – – Ever tested for HIV No 3193 (81.3%) 321 (18.7%) – – < 0.001 – – < 0.001 Yes 2645 (82.1%) 987 (17.9%) 0.24 0.20–0.30 0.30 0.25–0.37 Constant – – 0.55 0.44–0.69 < 0.001 – – – Household head Household head 2398 (83.2%) 485 (16.8%) – – 0.0008 – – 0.1002 Household head representative 777 (83.6%) 153 (16.4%) 0.93 0.74–1.17 1.07 0.83–1.37 Not head/represent 2663 (79.9%) 670 (20.1%) 1.27 1.10–1.47 1.21 1.01–1.45 Constant – – 0.14 0.12–0.18 < 0.001 – – – Constant multivariable model – – – – – 1.30 0.84–2.03 0.245 *OR: odds ratio, bivariable analysis, adjusted for clustering on community and household level, people having heard of HIVST as reference group; $ = aOR: adjusted odds ratio, multivariable mixed-effect logistic regression, adjusted for clustering on community and household level after backward reduction, people having heard of HIVST as reference group; µ = Ordinary (O) Level—basic level of the General Certificate of Education completed in the third/fourth years secondary school, a subject-based qualification; £ = Advanced (A) Level—advanced level of the General Certificate of Education completed in the fifth/sixth years of secondary school, a subject-based qualification Possible explanations may be linked to general trends in programmes will be needed to reach those remaining HIV testing. Younger people and those less educated are unaware [30–36]. less knowledgeable about HIV, and thus may know less Non-household heads were more likely to not have about different HIV testing options, including self-testing heard of HIVST. As was reported in qualitative studies [24, 25]. Despite the high HIVST awareness achieved that were done alongside this research (data not reported by our community-based distribution model, culminat- here), this may be because when distributors approach ing in high testing rates among individuals who might households, they are culturally expected to first approach not otherwise test (i.e., men, young people, those testing the head of household, who may not invite the rest of the for the first time), some still remained unaware of their household to the discussion [37]. Future efforts should HIV status [26–29]. Complementing community-based ensure that everyone in a household is invited to discus- distribution with other HIVST distribution models such sions, with platforms created for separate discussions as as those through health facilities and youth clinics, by appropriate (e.g., young people would like HIVST discus- sexual partners or secondary distribution and workplace sions to be held separately from their parents/guardians) Rotsaert et al. BMC Infectious Diseases (2022) 22:51 Page 6 of 7 University College London, the Liverpool School of Tropical Medicine, the [37]. A community-based program on HIVST in rural World Health Organization, CeSHHAR, Zambart and the Malawi‐Liverpool‐ Malawi found that HIVST was more prevalent among Wellcome Trust Clinical Research Unit. individuals who shared a household with someone who About this supplement reported HIVST [29]. Understanding the role of house- This article has been published as part of BMC Infectious Diseases Volume 22 hold dynamics on facilitating community-based distri- Supplement 1 2021: Innovating with HIV self-testing for impact in southern bution activities within the household should be further Africa: Lessons learned from the STAR (Self-Testing AfRica) Initiative. The full contents of the supplement are available at https:// bmcin fectd is. biome dcent investigated. Alongside, alternative distribution methods ral. com/ artic les/ suppl ements/ volume- 22- suppl ement-1. should be implemented for those who are uncomfortable accepting and performing an HIV self-test in the pres- Authors’ contributions AR, ES, FC conceptualized the paper. AR conducted the analysis and wrote the ence of other household members, for example, through first draft. KH, CJ, EC, MN, FC and ES contributed to revisions of the manuscript, youth centres or peer to peer distribution for young peo- and all authors have reviewed the final manuscript. All authors read and ple [37–41] Furthermore, appropriate promotion tools approved the final manuscript. such as mobile platforms and social media technology Funding should be used to increase HIVST awareness among The STAR Initiative is funded by UNITAID (PO# 10140‐0‐600 and PO# young people [39]. 8477‐0‐600). The population-based survey outcomes were based on Availability of data and materials self-reporting, which may have been subject to social The datasets used and/or analysed during the current study are available from desirability bias. To minimize this bias, ACASI was the corresponding author on reasonable request. used [42]. Despite this, this study provides new insights into characteristics of individuals who remain unaware Declarations of HIVST following community-based HIVST kit dis- Ethics approval and consent to participate tribution and confirms the presence of ongoing bar - Ethical approval was obtained from Medical Research Council of Zimbabwe riers to HIV testing. Lastly, our results are specific for (MRCZ/A/2038), University College London Ethics Committee (6084/004) and London School of Hygiene and Tropical. Medicine Ethics Committee (11738). community-based door-to-door distribution of HIVST Before filling in the questionnaire, participants were informed about the study, kits. Other distribution models or a different interven - the procedures and the voluntary nature of study participation. Participants tion design might have affected awareness of HIVST provided written consent to participate. differently. Consent for publication Not applicable. Conclusions Competing interests Around one fifth of survey participants remain unaware The authors have no competing interests. of HIVST even after an intensive community-based door- Author details to-door HIVST distribution. Of note, those least likely to Department of Public Health, Institute of Tropical Medicine, Nationalestraat have heard of self-testing were younger, less educated 2 155, 2000 Antwerp, Belgium. Centre for Sexual Health and HIV AIDS Research and less likely to have tested previously. Household heads (CeSHHAR), Harare, Zimbabwe. Liverpool School of Tropical Medicine, Liver- 4 5 pool, UK. Population Services International, Cape Town, South Africa. Global appear to play an important role in granting or denying HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, access to self-testing to other household members dur- 6 Switzerland. Department of Clinical Research and Infection Disease, London ing door-to-door distribution. 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Available: https:// www. unaids. org/ en/ resou rces/ press centre/ • gold Open Access which fosters wider collaboration and increased citations featu resto ries/ 2019/ decem ber/ young- people- and- men- less- likely- to- know- their- hiv- status. [Accessed: 16-Apr-2020]. maximum visibility for your research: over 100M website views per year 28. Sibanda E, Neuman M, Tumushime M, Hatzold K. Linkage to care after HIV self-testing in Zimbabwe: a cluster-randomised trial. in CROI 2018, 2018. At BMC, research is always in progress. 29. Indravudh PP, et al. Who is reached by HIV self-testing? Individual factors Learn more biomedcentral.com/submissions associated with self-testing within a community-based program in Rural Malawi. JAIDS J Acquir Immune Defic Syndr. 2020;85(2):165–73.

Journal

BMC Infectious Diseases – Springer Journals

Published: Jan 13, 2022

Keywords: HIV self-testing; Community-based distribution

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