Review 1: "What Role do Community-level Factors Play in HIV Self-testing Uptake, Linkage to Services and HIV-related Outcomes? A Mixed Methods Study of Community-led HIV Self-testing Programmes in Rural Zimbabwe"

Andrew Mujugira

doi:doi:10.1162/2e3983f5.5bb96890

What role do community-level factors play in HIV self-testing uptake, linkage to services and HIV-related outcomes? A mixed methods study of community-led HIV self-testing programmes in rural Zimbabwe

by Mary K Tumushime, Nancy Ruhode, Melissa Neuman, Constancia Watadzaushe, Miriam Mutseta, Miriam Taegtmeyer, Cheryl C. Johnson, Karin Hatzold, Elizabeth L. Corbett, Frances M. Cowan, and Euphemia L. Sibanda

Show Description
Published on Apr 19, 2024
www.medrxiv.org

Description

ABSTRACT Community-led interventions, where communities plan and lead implementation, are increasingly adopted in public health. We explore what factors may be associated with successful community-led distribution of HIV self-test (HIVST) kits to guide future service delivery.Twenty rural communities were supported to implement month-long HIVST kit distribution programmes from January-September/2019. Participant observation was conducted to document distribution models. Three months post-intervention, a population-based survey measured: self-reported new HIV diagnosis; self-reported HIVST uptake; self-reported linkage to post-test services; and viral load. The survey included questions for a composite measure of ‗community cohesion‘. Communities were grouped into low/medium/high based on community cohesion scores. We used mixed effect logistic regression to assess how outcomes differed by community cohesion. In total, 27,812 kits were distributed by 348 distributors. Two kit distribution models were implemented: door-to-door distribution only or distribution at venues/events within communities. Of 5,683 participants surveyed, 1,831 (32.2%) received kits and 1,229 (67.1%) reported using it; overall HIVST uptake was 1,229/5,683 (21.6%). Self-reported new HIV diagnosis increased with community cohesion, from 32/1,770 (1.8%) in the lowest cohesion group to 40/1,871 (2.1%) in the medium group, adjusted odds ratio (aOR) 2.94 (1.41-6.12, p=0.004) and 66/2,042 (3.2%) in the highest cohesion group, aOR 7.20 (2.31-22.50, p=0.001). Other outcomes did not differ by extent of cohesion.HIVST kit distribution in high-cohesion communities was associated with seven times higher odds of identifying people with new HIV diagnoses, suggesting more cohesive communities may better identify those most at risk of undiagnosed HIV. Communities can learn from and adopt these participatory community-led approaches to intervention planning and implementation, which may foster cohesion and benefit public health programmes.

RR:C19 Evidence Scale rating by reviewer:

Reliable. The main study claims are generally justified by its methods and data. The results and conclusions are likely to be similar to the hypothetical ideal study. There are some minor caveats or limitations, but they would/do not change the major claims of the study. The study provides sufficient strength of evidence on its own that its main claims should be considered actionable, with some room for future revision.

***************************************

Review: The study found low uptake (22%) of HIV self-testing (HIVST), regardless of the community-led distribution model used. There was no significant association between community cohesion and uptake of HIVST or confirmatory testing, voluntary medical male circumcision, pre-exposure prophylaxis, or viral load suppression. However, there was a significant association between community cohesion and new HIV diagnoses based on self-reporting.

The authors conducted a secondary analysis of data from a published cluster randomized trial. The study aimed to identify factors associated with successful community-led distribution of HIV self-test kits by paid distributors. The study revealed low uptake of HIV self-testing (HIVST) at approximately 22%, with no significant difference between distribution models. While community cohesion did not have an impact on some primary outcomes, including HIVST uptake and linkage to confirmatory testing, voluntary medical male circumcision (VMMC), pre-exposure prophylaxis (PrEP), or viral load suppression, it was significantly associated with new HIV diagnoses based on self-reporting. Overall, this well-written manuscript provides an important addition to existing literature. However, I have some suggestions for improving its quality.

Major Comments:

Incorporating a costing analysis would enhance the paper's impact by providing a comprehensive understanding of the intervention's budgetary implications. The study successfully distributed 27,812 HIVST kits through 348 distributors and surveyed 5,683 out of 6,748 participants (84%). Determining the cost per new HIV diagnosis and cost for each successful linkage to care would provide valuable information for both HIV programs and policymakers, aiding in resource allocation and decision-making. However, if these data are not currently available, including this as a recommendation for future research would be beneficial.
Methods, lines 170-172. The authors state that U=U results in “a greatly reduced risk of onward transmission” and cite reference 19. However, this wording implies that there may still be a residual risk of HIV transmission even with viral suppression, which could cause uncertainty for people with HIV and their sexual partners. In contrast, reference 19 defines U=U as meaning that “HIV-positive individuals with an undetectable viral load cannot transmit HIV to sexual partners.” The US National Institute of Allergy and Infectious Diseases also endorses U=U by stating there is “effectively no risk of sexual transmission of HIV when the partner living with HIV has a durably undetectable viral load.” Please consider revising the text to clarify the U=U message.
Abstract: It is recommended that the authors report all primary outcomes rather than just those that show a significant association with community cohesion.

Other revisions:

Results, lines 423-427: The data presentation format may cause confusion due to the use of nested parentheses. To improve readability, it is recommended to replace inner parentheses with square brackets or semi-colons and clearly indicate that values in nested parentheses represent 95% confidence intervals. For example, (aOR 0.70, [95% CI: 0.40-1.22], p=0.21) or (aOR 0.70; 95% CI: 0.40-1.22; p=0.21).
Discussion, lines 508-509: Please provide a reference for this sentence: “There is some evidence…”
Discussion. Lines 510 and 511: The preferred terminology is transitioning from "people living with HIV (PLHIV)" to "people with HIV" (PWH) as, by definition, individuals with HIV are living.

Community-driven distribution of HIV self-tests shows potential as an intervention to identify individuals with undiagnosed HIV and facilitate their access to care. Conducting cost-effective analyses can provide important insights for HIV programs and policymakers seeking to implement this approach.

Review 1: "What Role do Community-level Factors Play in HIV Self-testing Uptake, Linkage to Services and HIV-related Outcomes? A Mixed Methods Study of Community-led HIV Self-testing Programmes in Rural Zimbabwe"

Connections