Findings from the Tushirikiane mobile health (mHealth) HIV self-testing pragmatic trial with refugee adolescents and youth living in informal settlements in Kampala, Uganda

Carmen H Logie, Moses Okumu, Isha Berry, Robert Hakiza, Stefan D Baral, Daniel Kibuuka Musoke, Aidah Nakitende, Simon Mwima, Peter Kyambadde, Miranda Loutet, Shamilah Batte, Richard Lester, Stella Neema, Katie Newby, Lawrence Mbuagbaw, Carmen H Logie, Moses Okumu, Isha Berry, Robert Hakiza, Stefan D Baral, Daniel Kibuuka Musoke, Aidah Nakitende, Simon Mwima, Peter Kyambadde, Miranda Loutet, Shamilah Batte, Richard Lester, Stella Neema, Katie Newby, Lawrence Mbuagbaw

Abstract

Introduction: Urban refugee youth remain underserved by current HIV prevention strategies, including HIV self-testing (HIVST). Examining HIVST feasibility with refugees can inform tailored HIV testing strategies. We examined if HIVST and mobile health (mHealth) delivery approaches could increase HIV testing uptake and HIV status knowledge among refugee youth in Kampala, Uganda.

Methods: We conducted a three-arm pragmatic controlled trial across five informal settlements grouped into three sites in Kampala from 2020 to 2021 with peer-recruited refugee youth aged 16-24 years. The intervention was HIVST and HIVST + mHealth (HIVST with bidirectional SMS), compared with standard of care (SOC). Primary outcomes were self-reported HIV testing uptake and correct status knowledge verified by point-of-care testing. Some secondary outcomes included: depression, HIV-related stigma, and adolescent sexual and reproductive health (SRH) stigma at three time points (baseline [T0], 8 months [T1] and 12 months [T2]). We used generalized estimating equation regression models to estimate crude and adjusted odds ratios comparing arms over time, adjusting for age, gender and baseline imbalances. We assessed study pragmatism across PRECIS-2 dimensions.

Results: We enrolled 450 participants (50.7% cisgender men, 48.7% cisgender women, 0.7% transgender women; mean age: 20.0, standard deviation: 2.4) across three sites. Self-reported HIV testing uptake increased significantly from T0 to T1 in intervention arms: HIVST arm: (27.6% [n = 43] at T0 vs. 91.2% [n = 135] at T1; HIVST + mHealth: 30.9% [n = 47] at T0 vs. 94.2% [n = 113] at T1]) compared with SOC (35.5% [n = 50] at T0 vs. 24.8% [ = 27] at T1) and remained significantly higher than SOC at T2 (p<0.001). HIV status knowledge in intervention arms (HIVST arm: 100% [n = 121], HIVST + mHealth arm: 97.9% [n = 95]) was significantly higher than SOC (61.5% [n = 59]) at T2. There were modest changes in secondary outcomes in intervention arms, including decreased depression alongside increased HIV-related stigma and adolescent SRH stigma. The trial employed both pragmatic (eligibility criteria, setting, organization, outcome, analysis) and explanatory approaches (recruitment path, flexibility of delivery flexibility, adherence flexibility, follow-up).

Conclusions: Offering HIVST is a promising approach to increase HIV testing uptake among urban refugee youth in Kampala. We share lessons learned to inform future youth-focused HIVST trials in urban humanitarian settings.

Trial registration: ClinicalTrials.gov NCT04504097.

Keywords: HIV self-testing; Uganda; humanitarian health; mHealth; refugees; youth.

Conflict of interest statement

RL is an academic physician‐researcher and also has interests in a non‐profit and private company social enterprise, WelTel Inc., that develops and provides digital health software. He is not being paid or otherwise compensated by WelTel for this project. No other authors declare a conflict of interest.

© 2023 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of International AIDS Society.

Figures

Figure 1
Figure 1
Overview of primary and secondary outcome variables collected across time points in the Tushirikiane Trial, Kampala, Uganda.
Figure 2
Figure 2
Flow chart of participation of refugee youth enrolled in the Tushirikiane Trial, Kampala, Uganda.
Figure 3
Figure 3
Estimated predicted probabilities and confidence intervals (CI) for time by treatment group interaction effects for primary HIV testing outcome among Tushirikiane Trial participants, Kampala, Uganda, 2020–2021. The blue line is standard of care, the green line is HIV self‐test and the red line is HIV self‐test + mHealth arm.

References

    1. Vasylyeva TI, Horyniak D, Bojorquez I, Pham MD. Left behind on the path to 90‐90‐90: understanding and responding to HIV among displaced people. J Int AIDS Soc. 2022;25:e26031.
    1. Singh NS, Smith J, Aryasinghe S, Khosla R, Say L, Blanchet K. Evaluating the effectiveness of sexual and reproductive health services during humanitarian crises: a systematic review. PLoS One. 2018;. 13:e0199300.
    1. Singh NS, Aryasinghe S, Smith J, Khosla R, Say L, Blanchet K. A long way to go: a systematic review to assess the utilisation of sexual and reproductive health services during humanitarian crises. BMJ Glob Health. 2018;. 3:e000682.
    1. Warren E, Post N, Hossain M, Blanchet K, Roberts B. Systematic review of the evidence on the effectiveness of sexual and reproductive health interventions in humanitarian crises. BMJ Open. 2015;. 5:e008226.
    1. Witzel TC, Eshun‐Wilson I, Jamil MS, Tilouche N, Figueroa C, Johnson CC, et al. Comparing the effects of HIV self‐testing to standard HIV testing for key populations: a systematic review and meta‐analysis. BMC Med. 2020;18:381.
    1. Qin Y, Han L, Babbitt A, Walker JS, Liu F, Thirumurthy H, et al. Experiences using and organizing HIV self‐testing. AIDS. 2018;32:371–381.
    1. Johnson CC, Kennedy C, Fonner V, Siegfried N, Figueroa C, Dalal S, et al. Examining the effects of HIV self‐testing compared to standard HIV testing services: a systematic review and meta‐analysis. J Int AIDS Soc. 2017;20:21594.
    1. Logie CH, Okumu M, Musoke DK, Hakiza R, Mwima S, Kyambadde P, et al. Intersecting stigma and HIV testing practices among urban refugee adolescents and youth in Kampala, Uganda : qualitative findings. J Int AIDS Soc. 2021;24(3):e25674.
    1. Logie CH, Okumu M, Mwima SP, Kyambadde P, Hakiza R, Kibathi IP, et al. Exploring associations between adolescent sexual and reproductive health stigma and HIV testing awareness and uptake among urban refugee and displaced youth in Kampala, Uganda. Sex Reprod Health Matters. 2019;27:86–106.
    1. O'Laughlin KN, Rouhani SA, Faustin ZM, Ware NC. Testing experiences of HIV positive refugees in Nakivale refugee settlement in Uganda: informing interventions to encourage priority shifting. Confl Health. 2013;7:2.
    1. Logie CH, Okumu M, Kibuuka Musoke D, Hakiza R, Mwima S, Kacholia V, et al. The role of context in shaping HIV testing and prevention engagement among urban refugee and displaced adolescents and youth in Kampala, Uganda: findings from a qualitative study. Trop Med Int Health. 2021;26(5):572–581.
    1. O'Laughlin KN, Kasozi J, Walensky RP, Parker RA, Faustin ZM, Doraiswamy S, et al. Clinic‐based routine voluntary HIV testing in a refugee settlement in Uganda. J Acquir Immune Defic Syndr. 2014;67:409–413.
    1. O'Laughlin KN, He W, Greenwald KE, Kasozi J, Chang Y, Mulogo E, et al. Feasibility and acceptability of home‐based HIV testing among refugees: a pilot study in Nakivale refugee settlement in southwestern Uganda. BMC Infect Dis. 2018;18:332.
    1. Logie CH, Khoshnood K, Okumu M, Rashid SF, Senova F, Meghari H, et al. Self care interventions could advance sexual and reproductive health in humanitarian settings. BMJ. 2019;365:l1083.
    1. Choko AT, MacPherson P, Webb EL, Willey BA, Feasy H, Sambakunsi R, et al. Uptake, accuracy, safety, and linkage into care over two years of promoting annual self‐testing for HIV in Blantyre, Malawi: a community‐based prospective study. PLoS Med. 2015;12:e1001873.
    1. Smith P, Wallace M, Bekker L. Adolescents ’ experience of a rapid HIV self‐testing device in youth‐friendly clinic settings in Cape Town South Africa : a cross‐sectional community based usability study. J Int AIDS Soc. 2016;19:21111.
    1. Hatzold K, Gudukeya S, Mutseta MN, Chilongosi R, Nalubamba M, Nkhoma C, et al. HIV self‐testing: breaking the barriers to uptake of testing among men and adolescents in sub‐Saharan Africa, experiences from STAR demonstration projects in Malawi, Zambia and Zimbabwe. J Int AIDS Soc. 2019;22:43–52.
    1. UNHCR . Performance snapshot: Kampala Uganda refugee response plan. 2021.
    1. UNHCR . Global trends: forced displacement in 2020. Geneva, Switzerland: UNHCR; 2020.
    1. Park BH. The power of cities. 2019.
    1. Murillo F. Migrants and rapid urbanization: a new agenda for humanitarian and development urban planning? Population Division, Department of Economic and Social Affairs United Nations; 2017.
    1. UNHCR . Uganda—refugee statistics. Kampala; 2022.
    1. Sabila S, Silver I. Cities as partners: the case of Kampala. Forced Migr Rev. 2020;63:41–43.
    1. Omata N, Kaplan J. Refugee livelihoods in Kampala, Nakivale and Kyangwali refugee settlements. Patterns of engagement with the private sector. 2013.
    1. Lyytinen E. Informal places of protection: Congolese refugees’ ‘communities of trust’ in Kampala, Uganda. J Ethn Migr Stud. 2017;43:991–1008.
    1. Dahab M, Spiegel PB, Njogu PM, Schilperoord M. Changes in HIV‐related behaviours, knowledge and testing among refugees and surrounding national populations: a multicountry study. AIDS Care. 2013;25:998–1009.
    1. Logie C, Okumu M, Mwima S, Hakiza R, Irungi KP, Kyambadde P, et al. Social ecological factors associated with experiencing violence among urban refugee and displaced adolescent girls and young women in informal settlements in Kampala, Uganda: a cross‐sectional study. Confl Health. 2019;13:60.
    1. J. Madise N, Ziraba AK, Inungu J, Khamadi SA, Ezeh A, Zulu EM, et al. Are slum dwellers at heightened risk of HIV infection than other urban residents? Evidence from population‐based HIV prevalence surveys in Kenya. Health Place. 2012;18:1144–1152.
    1. Baluku JB, Anguzu G, Nassozi S, Babirye F, Namiiro S, Buyungo R, et al. Prevalence of HIV infection and bacteriologically confirmed tuberculosis among individuals found at bars in Kampala slums, Uganda. Sci Rep. 2020;10:13438.
    1. Ssensamba JT, Nakafeero M, Ssemakula DM, Ssenyonga R, Nnakate JB. The burden of HIV/AIDS among slum‐dwelling school‐age children in Kampala, Uganda. HIV AIDS Rev. 2019;18(4):267–272.
    1. Swahn MH, Culbreth R, Salazar LF, Kasirye R, Seeley J. Prevalence of HIV and associated risks of sex work among youth in the slums of Kampala. AIDS Res Treat. 2016;2016:5360180.
    1. Swahn MH, Culbreth R, Salazar LF, Tumwesigye NM, Kasirye R. Psychosocial correlates of self‐reported HIV among youth in the slums of Kampala. BMC Public Health. 2019;19:1176.
    1. Culbreth R, Swahn MH, Salazar LF, Ametewee LA, Kasirye R. Risk factors associated with HIV, sexually transmitted infections (STI), and HIV/STI co‐infection among youth living in the slums of Kampala, Uganda. AIDS Behav. 2020;24:1023–1031.
    1. Swahn MH, Culbreth R, Masyn KE, Salazar LF, Wagman J, Kasirye R. The intersection of alcohol use, gender based violence and HIV: empirical findings among disadvantaged service‐seeking youth in Kampala, Uganda. AIDS Behav. 2021;25:3106–3114.
    1. Secondary CA, Author C, Logie C, Okumu M, Latif M, Parker S, et al. AIDS and behavior relational factors and HIV testing practices: qualitative insights from urban refugee youth in Kampala, Uganda.
    1. McGuire M, de Waal A, Karellis A, Janssen R, Engel N, Sampath R, et al. HIV self‐testing with digital supports as the new paradigm: a systematic review of global evidence (2010–2021). EClinicalMedicine. 2021;39:101059.
    1. Ko JS, Stafylis C, Klausner JD. Mobile health promotion of human immunodeficiency virus self‐testing in the United States. mHealth. 2020;6:10.
    1. Gillespie M, Ampofo L, Cheesman M, Faith B, Iliadou E, Issa A, et al. Mapping refugee media journeys smartphones and social media networks research report. 2016.
    1. Kelvin EA, George G, Kinyanjui S, Mwai E, Romo ML, Oruko F, et al. Announcing the availability of oral HIV self‐test kits via text message to increase HIV testing among hard‐to‐reach truckers in Kenya: a randomized controlled trial. BMC Public Health. 2019;19:7.
    1. Kelvin EA, George G, Mwai E, Kinyanjui S, Romo ML, Odhiambo JO, et al. A randomized controlled trial to increase HIV testing demand among female sex workers in Kenya through announcing the availability of HIV self‐testing via text message. AIDS Behav. 2019;23:116–125.
    1. Brown W, Lopez Rios J, Sheinfil A, Frasca T, Cruz Torres C, Crespo R, et al. Text messaging and disaster preparedness aids engagement, re‐engagement, retention, and communication among Puerto Rican participants in a human immunodeficiency virus (HIV) self‐testing study after hurricanes Irma and Maria. Disaster Med Public Health Prep. 2020;17:e2.
    1. Sibanda EL, d'Elbée M, Maringwa G, Ruhode N, Tumushime M, Madanhire C, et al. Applying user preferences to optimize the contribution of HIV self‐testing to reaching the “first 90” target of UNAIDS Fast‐track strategy: results from discrete choice experiments in Zimbabwe. J Int AIDS Soc. 2019;22:e25245.
    1. Loudon K, Treweek S, Sullivan F, Donnan P, Thorpe KE, Zwarenstein M. The PRECIS‐2 tool: designing trials that are fit for purpose. BMJ. 2015;350:h2147.
    1. Horn R, Bizimana D, Nasinyama S, Aporo L, Kironde E, Canavera M, et al. Community based child protection mechanisms amongst urban refugees in Kampala, Uganda: an ethnographic study. 2013.
    1. Women's Refugee Commission . The living ain’ t easy urban refugees in Kampala. 2011.
    1. Logie CH. Mobile health‐supported HIV self‐testing strategy among urban refugee and displaced youth in Kampala, Uganda: protocol for a cluster randomized trial (Tushirikiane, supporting each other). JMIR Res Protoc. 2021;10(2):e26192.
    1. Okumu M, Logie CH, Ansong D, Mwima S, Hakiza R, Newman PA. Support for texting‐based condom negotiation among forcibly displaced adolescents in the slums of Kampala, Uganda: cross‐sectional validation of the condom use negotiated experiences through technology scale. JMIR Public Health Surveill. 2022;8:e27792.
    1. About. WelTel. 2020.
    1. Kroenke K, Spitzer RL, Williams JBW. The PHQ‐9. J Gen Intern Med. 2001;16:606–613.
    1. Shaweno D, Tekletsadik E. Validation of the condom use self‐efficacy scale in Ethiopia. BMC Int Health Hum Rights. 2013;13:22.
    1. Brafford LJ, Beck KH. Development and validation of a condom self‐efficacy scale for college students. J Am Coll Health. 1991;39:219–225.
    1. Pulerwitz J, Gortmaker SL, DeJong W. Measuring sexual relationship power in HIV/STD research. Sex Roles. 2000;42:637–660.
    1. Steward WT, Herek GM, Ramakrishna J, Bharat S, Chandy S, Wrubel J, et al. HIV‐related stigma: adapting a theoretical framework for use in India. Soc Sci Med. 2008;67:1225–1235.
    1. Hall KS, Manu A, Morhe E, Harris LH, Loll D, Ela E, et al. Development and validation of a scale to measure adolescent sexual and reproductive health stigma: results from young women in Ghana. J Sex Res. 2018;55:60–72.
    1. Logie CH, Okumu M, Berry I, Loutet M, Hakiza R, Kibuuka Musoke D, et al. Social contextual factors associated with lifetime HIV testing among the Tushirikiane urban refugee youth cohort in Kampala, Uganda: cross‐sectional findings. Int J STD AIDS. 2022;33:374–384.
    1. Zhang J, Pals SL, Medley A, Nichols C, Bachanas P, van Zyl D, et al. Parameters for sample size estimation from a group‐randomized HIV prevention trial in HIV clinics in sub‐Saharan Africa. AIDS Behav. 2014;18:2359–2365.
    1. Chow SC, Shao J, Wang H, Lokhnygina Y. Sample size calculations in clinical research, third edition. 2017.
    1. Dimick JB, Ryan AM. Methods for evaluating changes in health care policy: the difference‐in‐differences approach. JAMA. 2014;312:2401.
    1. Ford ND, Behrman JR, Hoddinott JF, Maluccio JA, Martorell R, Ramirez‐Zea M, et al. Exposure to improved nutrition from conception to age 2 years and adult cardiometabolic disease risk: a modelling study. Lancet Glob Health. 2018;6:e875–e884.
    1. Wu S, Crespi CM, Wong WK. Comparison of methods for estimating the intraclass correlation coefficient for binary responses in cancer prevention cluster randomized trials. Contemp Clin Trials. 2012;33:869–880.
    1. Logie C. The prevalence and correlates of depression before and after the COVID‐19 pandemic declaration among urban refugee adolescents and youth in informal settlements in Kampala, Uganda: a longitudinal cohort study. Ann Epidemiol. 2022;66:37–43.
    1. Shrive FM, Stuart H, Quan H, Ghali WA. Dealing with missing data in a multi‐question depression scale: a comparison of imputation methods. BMC Med Res Method. 2006;6.
    1. Dal‐Ré R, Janiaud P, Ioannidis JPA. Real‐world evidence: how pragmatic are randomized controlled trials labeled as pragmatic? BMC Med. 2018;16:49.
    1. Ortblad K, Kibuuka Musoke D, Ngabirano T, Nakitende A, Magoola J, Kayiira P, et al. Direct provision versus facility collection of HIV self‐tests among female sex workers in Uganda: a cluster‐randomized controlled health systems trial. PLoS Med. 2017;14(11):e1002458.
    1. Asiimwe S, Oloya J, Song X, Whalen CC. Accuracy of un‐supervised versus provider‐supervised self‐administered HIV testing in Uganda: a randomized implementation trial. AIDS Behav. 2014;18:2477–2484.
    1. Okoboi S, Castelnuovo B, Geertruyden J Van KR, Mujugira A. Cost‐effectiveness of peer‐delivered HIV self‐tests for MSM in Uganda. Front Public Health. 2021;9:651325.
    1. Logie CH, Okumu M, Latif M, Parker S, Hakiza R, Kibuuka Musoke D, et al. Relational factors and HIV testing practices: qualitative insights from urban refugee youth in Kampala, Uganda. AIDS Behav. 2022;26(7):2191–2202.
    1. Okoboi S, Lazarus O, Castelnuovo B, Nanfuka M, Kambugu A, Mujugira A, et al. Peer distribution of HIV self‐test kits to men who have sex with men to identify undiagnosed HIV infection in Uganda: a pilot study. PLoS One. 2020;15:e0227741.
    1. Okoboi S, Twimukye A, Lazarus O, Castelnuovo B, Agaba C, Immaculate M, et al. Acceptability, perceived reliability and challenges associated with distributing HIV self‐test kits to young MSM in Uganda: a qualitative study. J Int AIDS Soc. 2019;22:e25269.
    1. McGowan M, Roche SD, Nakitende A, Wachinger J, Nanyiri E, Amongin J, et al. Understanding how social support influences peer‐delivered HIV prevention interventions among Ugandan female sex workers: a case study from HIV self‐testing. BMC Public Health. 2022;22:427.
    1. Wirtz AAL, Logie CH, Mbuagbaw L. Addressing health inequities in digital clinical trials: a review of challenges and solutions from the field of HIV research. Epidemiol Rev. 2022;44(1):87–109.
    1. Wray TB, Chan PA, Simpanen EM. Longitudinal effects of home‐based HIV self‐testing on well‐being and health empowerment among men who have sex with men (MSM) in the United States. AIDS Care. 2020;32:148–154.
    1. Kiene SM, Dove M, Wanyenze RK. Depressive symptoms, disclosure, HIV‐related stigma, and coping following HIV testing among outpatients in Uganda: a daily process analysis. AIDS Behav. 2018;22:1639–1651.
    1. Ortblad KF, Kibuuka Musoke D, Ngabirano T, Nakitende A, Harling G, Haberer JE, et al. The effect of HIV self‐testing delivery models on female sex workers’ sexual behaviors: a randomized controlled trial in urban Uganda. AIDS Behav. 2019;23:1225–1239.
    1. Singh NS, Abrahim O, Altare C, Blanchet K, Favas C, Odlum A, et al. COVID‐19 in humanitarian settings: documenting and sharing context‐specific programmatic experiences. Confl Health. 2020;14:79.
    1. Kluge HHP, Jakab Z, Bartovic J, D'Anna V, Severoni S. Refugee and migrant health in the COVID‐19 response. Lancet. 2020;395:1237–1239.
    1. Ezeh A, Oyebode O, Satterthwaite D, Chen Y‐F, Ndugwa R, Sartori J, et al. The history, geography, and sociology of slums and the health problems of people who live in slums. Lancet. 2017;389:547–558.

Source: PubMed

Patrocinadores y Colaboradores

Condiciones médicas

Intervenciones de drogas

3
Suscribir