HIV self-testing among female sex workers in Zambia: A cluster randomized controlled trial

Michael M Chanda, Katrina F Ortblad, Magdalene Mwale, Steven Chongo, Catherine Kanchele, Nyambe Kamungoma, Andrew Fullem, Caitlin Dunn, Leah G Barresi, Guy Harling, Till Bärnighausen, Catherine E Oldenburg, Michael M Chanda, Katrina F Ortblad, Magdalene Mwale, Steven Chongo, Catherine Kanchele, Nyambe Kamungoma, Andrew Fullem, Caitlin Dunn, Leah G Barresi, Guy Harling, Till Bärnighausen, Catherine E Oldenburg

Abstract

Background: HIV self-testing (HIVST) may play a role in addressing gaps in HIV testing coverage and as an entry point for HIV prevention services. We conducted a cluster randomized trial of 2 HIVST distribution mechanisms compared to the standard of care among female sex workers (FSWs) in Zambia.

Methods and findings: Trained peer educators in Kapiri Mposhi, Chirundu, and Livingstone, Zambia, each recruited 6 FSW participants. Peer educator-FSW groups were randomized to 1 of 3 arms: (1) delivery (direct distribution of an oral HIVST from the peer educator), (2) coupon (a coupon for collection of an oral HIVST from a health clinic/pharmacy), or (3) standard-of-care HIV testing. Participants in the 2 HIVST arms received 2 kits: 1 at baseline and 1 at 10 weeks. The primary outcome was any self-reported HIV testing in the past month at the 1- and 4-month visits, as HIVST can replace other types of HIV testing. Secondary outcomes included linkage to care, HIVST use in the HIVST arms, and adverse events. Participants completed questionnaires at 1 and 4 months following peer educator interventions. In all, 965 participants were enrolled between September 16 and October 12, 2016 (delivery, N = 316; coupon, N = 329; standard of care, N = 320); 20% had never tested for HIV. Overall HIV testing at 1 month was 94.9% in the delivery arm, 84.4% in the coupon arm, and 88.5% in the standard-of-care arm (delivery versus standard of care risk ratio [RR] = 1.07, 95% CI 0.99-1.15, P = 0.10; coupon versus standard of care RR = 0.95, 95% CI 0.86-1.05, P = 0.29; delivery versus coupon RR = 1.13, 95% CI 1.04-1.22, P = 0.005). Four-month rates were 84.1% for the delivery arm, 79.8% for the coupon arm, and 75.1% for the standard-of-care arm (delivery versus standard of care RR = 1.11, 95% CI 0.98-1.27, P = 0.11; coupon versus standard of care RR = 1.06, 95% CI 0.92-1.22, P = 0.42; delivery versus coupon RR = 1.05, 95% CI 0.94-1.18, P = 0.40). At 1 month, the majority of HIV tests were self-tests (88.4%). HIV self-test use was higher in the delivery arm compared to the coupon arm (RR = 1.14, 95% CI 1.05-1.23, P = 0.001) at 1 month, but there was no difference at 4 months. Among participants reporting a positive HIV test at 1 (N = 144) and 4 months (N = 235), linkage to care was non-significantly lower in the 2 HIVST arms compared to the standard-of-care arm. There were 4 instances of intimate partner violence related to study participation, 3 of which were related to HIV self-test use. Limitations include the self-reported nature of study outcomes and overall high uptake of HIV testing.

Conclusions: In this study among FSWs in Zambia, we found that HIVST was acceptable and accessible. However, HIVST may not substantially increase HIV cascade progression in contexts where overall testing and linkage are already high.

Trial registration: ClinicalTrials.gov NCT02827240.

Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1. CONSORT flow diagram of screened,…
Fig 1. CONSORT flow diagram of screened, randomized, and analyzed participants.
Fig 2. HIV care cascade among women…
Fig 2. HIV care cascade among women who self-reported a positive HIV status at 1 and 4 months after randomization.
Note that by definition all women are aware of their status, as this figure is restricted to women who self-reported having tested positive for HIV.

References

    1. Joint United Nations Programme on HIV/AIDS. 90-90-90: an ambitious treatment target to help end the AIDS epidemic. Geneva: Joint United Nations Programme on HIV/AIDS; 2014 Oct [cited 2017 Oct 17]. Available from: .
    1. World Health Organization. Guidelines on HIV self-testing and partner notification: supplement to consolidated guidelines on HIV testing services. Geneva: World Health Organization; 2016. December [cited 2017 Oct 17]. Available from: .
    1. World Health Organization; Consolidated guidelines on HIV testing. Geneva: World Health Organization; 2015. July [cited 2017 Oct 17]. Available from: .
    1. Bodkin K, Delahunty-Pike A, O’Shea T. Reducing stigma in healthcare and law enforcement: a novel approach to service provision for street level sex workers. Int J Equity Health. 2015;14:322–7. doi:
    1. King EJ, Maman S, Bowling JM, Moracco KE, Dudina V. The influence of stigma and discrimination on female sex workers’ access to HIV services in St. Petersburg, Russia . AIDS Behav. 2013;17:2597–603. doi:
    1. Oldenburg CE, Reisner SL, Mayer KH, Mimiaga MJ, Barnighausen T, Perez-Brumer AG, et al. Human rights protections and HIV prevalence among MSM who sell sex: cross-country comparisons from a systematic review and meta- analysis. Glob Public Health. 2016. March 15 doi:
    1. Stevens DR, Vrana CJ, Dlin RE, Korte JE. A global review of HIV self-testing: themes and implications. AIDS Behav. 2017. February 2 doi:
    1. Jamil MS, Prestage G, Fairley CK, Grulich AE, Smith KS, Chen M, et al. Effect of availability of HIV self-testing on HIV testing frequency in gay and bisexual men at high risk of infection (FORTH): a waiting-list randomised controlled trial. Lancet HIV. 2017;4:e241–50. doi:
    1. Masters SH, Agot K, Obonyo B, Napierala-Mavedzenge S, Maman S, Thirumurthy H. Promoting Partner testing and couples testing through secondary distribution of HIV self-tests: a randomized clinical trial. PLoS Med. 2016;13:e1002166 doi:
    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 doi:
    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. In press. doi:
    1. Thirumurthy H, Masters SH, Mavedzenge SN, Maman S, Omanga E, Agot K. Promoting male partner HIV testing and safer sexual decision making through secondary distribution of self-tests by HIV-negative female sex workers and women receiving antenatal and post-partum care in Kenya: a cohort study. Lancet HIV. 2016;3:e266–74. doi:
    1. Gupta S, Granich R. National HIV care continua for key populations. J Int Assoc Provid AIDS Care. 2017;16:125–32. doi:
    1. Cowan FM, Davey C, Fearon E, Mushati P, Mushati, Dirawo J, et al. The HIV care cascade among female sex workers in Zimbabwe: results of a population-based survey from the Sisters Antiretroviral Therapy Programme for Prevention of HIV, an Integrated Response (SAPPH-IRe) Trial. J Acquir Immune Defic Syndr. 2017;74:375–82. doi:
    1. Schwartz S, Lambert A, Phaswana-Mafuya N, Kose Z, Mcingana M, Holland C, et al. Engagement in the HIV care cascade and barriers to antiretroviral therapy uptake among female sex workers in Port Elizabeth, South Africa: findings from a respondent-driven sampling study. Sex Transm Infect. 2017;93:290–6. doi:
    1. Oldenburg CE, Ortblad KF, Chanda M, Mwanda K, Nicodemus W, Sikaundi R, et al. Zambian Peer Educators for HIV Self-Testing (ZEST) study: rationale and design of a cluster randomized trial of HIV self-testing among female sex workers in Zambia. BMJ Open. 2017;20:e014780.
    1. Chanda MM, Perez-Brumer AG, Ortblad KF, Mwale M, Chongo S, Kamungoma N, et al. Barriers and facilitators to HIV testing among Zambian female sex workers in three transit hubs. AIDS Patient Care STDs. 2017;31:290–6. doi:
    1. Family Health International. Round 3: behavioural surveillance survey—Zambia, 2006. Female sex workers in border and transportation routes: with trend analysis 2000–2006. Durham (North Carolina): Family Health International; 2006Jun [cited 2017 Oct 17]. Available from: .
    1. Wilson D. Corridors of hope southern Africa: HIV prevention needs and opportunities in four border towns. Durham (North Carolina): Family Health International; 2005.
    1. Zou G. A modified poisson regression approach to prospective studies with binary data. Am J Epidemiol. 2004;159:702–6. doi:
    1. Krishnamurthy P, Hui SK, Shivkumar N, Gowda C, Pushpalatha R. Assessing the impact of peer educator outreach on the likelihood and acceleration of clinic utilization among sex workers. PLoS ONE. 2016;11:e0159656 doi:
    1. Oldenburg CE, Biello KB, Colby D, Closson EF, Nguyen T, Trang NNN, et al. Engagement with peer health educators is associated with willingness to use pre-exposure prophylaxis among male sex workers in Ho Chi Minh City, Vietnam. AIDS Patient Care STDs. 2014;28:109–12. doi:
    1. Sarafian I. Process assessment of a peer education programme for HIV prevention among sex workers in Dhaka, Bangladesh: a social support framework. Soc Sci Med. 2012;75:668–75. doi:
    1. Onyango MA, Adu-Sarkodie Y, Agyarko-Poku T, Asafo MK, Sylvester J, Wondergem P, et al. “It’s all about making a life”: poverty, HIV, violence, and other vulnerabilities faced by young female sex workers in Kumasi, Ghana. J Acquir Immune Defic Syndr. 2016;68:S131–7.
    1. Hoffman IF, Latkin CA, Kukhareva PV, Malov SV, Batluk JV, Shaboltas AV, et al. A peer-educator network HIV prevention intervention among injection drug users: results of a randomized controlled trial in St. Petersburg, Russia. AIDS Behav. 2013;17:2510–20. doi:
    1. Geibel S, King’ola N, Temmerman M, Luchters S. The impact of peer outreach on HIV knowledge and prevention behaviours of male sex workers in Mombasa, Kenya. Sex Transm Infect. 2012;88:357–62. doi:
    1. Morisky DE, Malow RM, Tiglao TV, Lyu S- Y, Vissman AT, Rhodes SD. Reducing sexual risk among Filipina female bar workers: effects of a CBPR-developed structural and network intervention. AIDS Educ Prev. 2010;22:371–85. doi:
    1. Medley A, Kennedy C, O’Reilly K, Sweat M. Effectiveness of peer education interventions for HIV prevention in developing countries: a systematic review and meta-analysis. AIDS Educ Prev. 2009;21:181–206. doi:
    1. Shahmanesh M, Patel V, Mabey D, Cowan F. Effectiveness of interventions for the prevention of HIV and other sexually transmitted infections in female sex workers in resource poor setting: a systematic review. Trop Med Int Health. 2008;13:659–79. doi:
    1. Bain LE, Ditah CM, Awah PK, Ekukwe NC. Ethical implications of HIV self-testing: the game is far from being over. Pan Afr Med J. 2016;25:114 doi:
    1. Mountain E, Mishra S, Vickerman P, Pickles M, Gilks C, Boily M-C. Antiretroviral therapy uptake, attrition, adherence and outcomes among HIV-infected female sex workers: a systematic review and meta-analysis. PLoS ONE. 2014;9:e105645 doi:
    1. Choko AT, Kumwenda MK, Johnson CC, Sakala DW, Chikalipo MC, Fielding K, et al. Acceptability of woman-delivered HIV self-testing to the male partner, and additional interventions: a qualitative study of antenatal care participants in Malawi. J Int AIDS Soc. 2017;20:21610 doi:

Source: PubMed

Patrocinadores e Colaboradores

Condições médicas

Intervenções de drogas

3
Se inscrever