Effect of peer-distributed HIV self-test kits on demand for biomedical HIV prevention in rural KwaZulu-Natal, South Africa: a three-armed cluster-randomised trial comparing social networks versus direct delivery

Maryam Shahmanesh, T Nondumiso Mthiyane, Carina Herbsst, Melissa Neuman, Oluwafemi Adeagbo, Paul Mee, Natsayi Chimbindi, Theresa Smit, Nonhlanhla Okesola, Guy Harling, Nuala McGrath, Lorraine Sherr, Janet Seeley, Hasina Subedar, Cheryl Johnson, Karin Hatzold, Fern Terris-Prestholt, Frances M Cowan, Elizabeth Lucy Corbett, Maryam Shahmanesh, T Nondumiso Mthiyane, Carina Herbsst, Melissa Neuman, Oluwafemi Adeagbo, Paul Mee, Natsayi Chimbindi, Theresa Smit, Nonhlanhla Okesola, Guy Harling, Nuala McGrath, Lorraine Sherr, Janet Seeley, Hasina Subedar, Cheryl Johnson, Karin Hatzold, Fern Terris-Prestholt, Frances M Cowan, Elizabeth Lucy Corbett

Abstract

Study objective: We investigated two peer distribution models of HIV self-testing (HIVST) in HIV prevention demand creation compared with trained young community members (peer navigators).

Methods: We used restricted randomisation to allocate 24 peer navigator pairs (clusters) in KwaZulu-Natal 1:1:1: (1) standard of care (SOC): peer navigators distributed clinic referrals, pre-exposure prophylaxis (PrEP) and antiretroviral therapy (ART) information to 18-30 year olds. (2) peer navigator direct distribution (PND): Peer navigators distributed HIVST packs (SOC plus two OraQuick HIVST kits) (3) incentivised peer networks (IPN): peer navigators recruited young community members (seeds) to distribute up to five HIVST packs to 18-30 year olds within their social networks. Seeds received 20 Rand (US$1.5) for each recipient who distributed further packs. The primary outcome was PrEP/ART linkage, defined as screening for PrEP/ART eligibility within 90 days of pack distribution per peer navigator month (pnm) of outreach, in women aged 18-24 (a priority for HIV prevention). Investigators and statisticians were blinded to allocation. Analysis was intention to treat. Total and unit costs were collected prospectively.

Results: Between March and December 2019, 4163 packs (1098 SOC, 1480 PND, 1585 IPN) were distributed across 24 clusters. During 144 pnm, 272 18-30 year olds linked to PrEP/ART (1.9/pnm). Linkage rates for 18-24-year-old women were lower for IPN (n=26, 0.54/pnm) than PND (n=45, 0.80/pnm; SOC n=49, 0.85/pnm). Rate ratios were 0.68 (95% CI 0.28 to 1.66) for IPN versus PND, 0.64 (95% CI 0.26 to 1.62) for IPN versus SOC and 0.95 (95% CI 0.38 to 2.36) for PND versus SOC. In 18-30 year olds, PND had significantly more linkages than IPN (2.11 vs 0.88/pnm, RR 0.42, 95% CI 0.18 to 0.98). Cost per pack distributed was cheapest for IPN (US$36) c.f. SOC (US$64). Cost per person linked to PrEP/ART was cheaper in both peer navigator arms compared with IPN.

Discussion: HIVST did not increase demand for PrEP/ART. Incentivised social network distribution reached large numbers with HIVST but resulted in fewer linkages compared with PrEP/ART promotion by peer navigators.

Trial registration number: NCT03751826.

Keywords: HIV; cluster randomized trial; other diagnostic or tool; prevention strategies; public health.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.

Figures

Figure 1
Figure 1
Consort diagram for cluster RCT of different models of peer-led HIVST distribution on uptake of biomedical HIV prevention and care. ART, antiretroviral therapy; HIVST, HIV self-testing; PrEP, pre-exposure prophylaxis; RCT, randomised controlled trial.
Figure 2
Figure 2
Incentivised peer navigator distribution chains (n=1585). Arm 1: incentivised peer (social) network packs. n = 55 female seeds aged 18–24 approached across 8 clusters. n=216 incentivised recruitments distributed n=1585 packages.

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