HIV self-testing in Senegal reaches first-time testers
HIV self-testing can help existing programmes to reach populations reporting barriers to engagement with existing and routine HIV testing services.
A pilot HIV self-testing (HIVST) project in Senegal was highly successful at reaching first-time testers and people who hadn’t tested in the last year. Among 1,144 people who took a pre-test questionnaire, 46.9% (536/1144) of the participants were first-time testers, and 26.9% (308/1144) had ever tested for HIV but not within the last 12 months.
The pilot was conducted in two cities, Dakar and Ziguinchor, through venue and social network-based distribution with the hope of reaching key affected populations with HIV testing for whom stigma and criminalisation often impede access to HIV testing.
In Senegal, HIV disproportionately affects men who have sex with men, female sex workers and people who inject drugs, with prevalence estimates of 23.5%, 3.3% and 10.2%, respectively. Here same-sex practices are criminalised and sex work for cisgender women is legal but highly regulated.
A local community partner already working with key populations in Senegal helped to identify places where tests could be distributed, including sex work venues, bars, nightclubs, hot spots, and mobile clinics, as well as health facilities that provide services to key populations.
In these settings, ‘directly assisted distribution’ of HIVST followed World Health Organization (WHO) guidelines and was led by the community partner. They were led by trained distributors who provided pre-test instructions, test information, demonstration of proper HIVST use, and education on the importance for confirmatory testing, irrespective of a test reactivity. Participants were then given the choice to self-test with a trained distributer in a private room, or they could take the test home to do it themselves.
A small number of tests were also distributed through social network-based unassisted distribution, where those who received a test in a venue could take HIVST kits away for two additional people.
Between April 2017 and Jun 2018, 1,839 HIVST kits were distributed with 1,149 (62.5%) individuals participating in a pre-test questionnaire. Of this group, 817 (71.1%) also participated in a post-test questionnaire.
Around one-third (32.3%) of pre-test respondents reported being a member of a key affected population. Most (18.8%) reported being a sex worker (18.8%), or a female sex worker specifically (14.3%), while 15.1% defined themselves as men who have sex with men, 3.7% were people who inject drugs, and 1.7% were transgender women.
Among key affected populations more specifically, 36.8% of the pre-test group were first-time testers. Among sex workers of all genders, 26.5% were first-time testers. 46.0% (80/174) of men who have sex with men, 59.5% (25/42) of people who inject drugs, and 55.0% (11/20) of transgender women were first-time testers.
Age was associated with HIV testing history, with younger participants more likely to never have tested for HIV when compared to their older counterparts aged 31 and over. People assigned as male at birth were also associated with a lower odds of ever testing for HIV.
Uptake of the HIV self-test was high among those who participated in the post-test survey, with 94.3% indicating that they used the test. Just over half (54.3%) of the participants chose to use the HIVST at the distribution site and the rest (45.7%) used it at home, with a high number (88.9%) using the test within two days.
Of the small number of people who received a reactive result, meaning they needed further confirmatory testing, 63.2% of these were first-time testers. Unfortunately, confirmatory testing was low, with only approximately two-thirds of those with reactive results reporting confirmatory testing. None of the people with invalid results - meaning their tests came back in error - reported confirmatory testing.
In this study, the HIVST was found to be highly acceptable among the participants with nearly two-thirds reporting being comfortable using the test. Instructions were easy to follow and they felt that their family or friends could also benefit from a test. After receiving the HIVST, 30.6% discussed HIV testing with a sexual partner or friend. Most of the participants said they would feel comfortable asking a primary sexual partner or a casual partner to test.
“These data suggest the potential impact that HIVST could have in complementing existing HIV testing services by reaching a diverse group of first-time HIV-testers as well as those who have not tested recently in Senegal,” noted the authors in their conclusion.
“This small-scale implementation further suggested the importance of leveraging existing structures and programs for distribution. Moreover, since HIVST has the potential to disrupt traditional testing approaches, sustained engagement with government and community stakeholders is needed to inform optimal implementation strategies of HIVST.”