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Review 3: "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"

The majority of reviewers found this preprint potentially informative, but recommend that the authors include more clarification on specific sections. 

Published onJun 14, 2024
Review 3: "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"
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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
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
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:

  • Potentially informative. The main claims made are not strongly justified by the methods and data, but may yield some insight. The results and conclusions of the study may resemble those from the hypothetical ideal study, but there is substantial room for doubt. Decision-makers should consider this evidence only with a thorough understanding of its weaknesses, alongside other evidence and theory. Decision-makers should not consider this actionable, unless the weaknesses are clearly understood and there is other theory and evidence to further support it.

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Review: This analysis examines the association between community cohesion and the identification of new HIV diagnoses (after community-led distribution of HIV self-test (HIVST) kits occurred) among rural communities in Zimbabwe using mixed effects linear regression. They found that HIVST kit distribution among high-cohesion communities was associated with an increase in the odds of identifying people with new HIV diagnoses.

The present study aimed to explore the effects of different HIVST kit distribution models, levels of community involvement in planning distribution programs and community cohesion on HIVST uptake, linkage to post-test services (confirmatory testing, VMMC and PrEP) and HIV-related outcomes (new HIV diagnoses and undetectable viral load). The authors report a positive association between new HIV diagnoses and social cohesion and suggest that such an association may arise due to more cohesive communities being better at identifying those most at risk of undiagnosed HIV.

While the results of this analysis are potentially informative, the cross-sectional nature of the study limit the authors’ ability to draw more substantive conclusions. Additionally, more details are needed on certain aspects of the study to help determine the overall reliability and strength of the findings. For example, underlying differences in the distribution of PLHIV across communities could potentially bias results related specifically to “new” HIV diagnoses – could high levels of new diagnoses be indicative of other factors, for example, lower access to healthcare? As participation/kit distribution was not necessarily limited to individuals without a known HIV diagnosis, and presumably, PLHIV were still included in the denominator for the assessment looking at new HIV diagnoses, it would be informative to look at how these results compare to one that excludes PLHIV, as they could not, by definition, be among those reporting a new HIV diagnosis.

It would also be useful to know whether there is any variation in the distribution/social cohesion of PLHIV vs those presumed to be negative prior to kit distribution. Despite some of the inherent limitations of the cross-sectional study design, as well as the current exclusion of some additional information that would be helpful in assessing potential pre-existing differences between communities, this study provides evidence of a positive relationship between communities with higher social cohesion and new HIV diagnoses after community led HIVST kit distribution. Further analysis is needed to determine whether this could potentially be a causal relationship and/or whether other underlying factors could be at play.

This study suggests a positive association between community social cohesion levels and new HIV diagnoses after community led HIVST kit distribution. One potential explanation for such a finding is that more cohesive communities being better at identifying those most at risk of undiagnosed HIV. Further analysis is needed to determine whether this is the case, and/or whether other underlying factors could be at play.

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