Summary
A study that gave HIV self-testing kits out to 127 mainly young men who have sex with men (MSM) in two regions in north-east South Africa found that they much preferred using them than going to a clinic for a test. Of the 127 recruited, 116 (91.3%) used the self-test kit at least once and nearly half used the test twice during the six-month study period (there were three visits altogether, at baseline, month three and month six). It also found that the proportion of men who had tested for HIV in the last six months greatly increased during the follow-up period and that the proportion who anticipated testing frequently from then on also increased.
The study also asked participants to give out test kits to sexual partners and friends and most participants did so. The researchers were surprised at the high proportion of participants who gave out test kits to family members. The study provided both oral fluid and fingerprick tests and found that, in this population at least, fingerprick testing was preferred because participants trusted it more.
There were six new HIV infections diagnosed in the 127 participants. Although the study was not designed or powered to determine HIV incidence, these six infections within 55 person-years would equate to a very high annual incidence of 10.9%.
Even more impressively perhaps, there were 40 new diagnoses detected among trial participants’ contacts, among a total of 728 test kits being given out or one diagnosis per 18 test kits. As the researchers point out, given that this total was a figure reported second-hand to the researchers by participants, it is likely to represent a minimum number.
Trial participants
The self-testing trial was conducted in two Districts in Mpumalanga Province, Gert Sibande and Ehlanzeni. The former is rural, encompassing a cluster of farming towns on the High Veldt. The latter is urban, including Nelspruit, the Provincial Capital, which is a tourist hub for visitors to Kruger National Park.
The majority of participants (69) were re-contacted from a previous behavioural MSM survey, the 2012-2015 Mpumulanga Men’s Study. However, while 86% of those re-contacted from Gert Sibande were enrolled in the self-testing study, only a small proportion of participants in the 2015 study in Ehlanzeni could be contacted and only 44% (14 men) were enrolled. It was therefore decided to do a second wave of so-called Respondent-Driven Sampling (RDS) in Ehlanzeni. (In RDS, volunteers called ‘seeds’ from the local MSM community undertake to recruit others.) In the end 54 men and one transgender woman from Gert Sibande and 72 men from Ehlanzeni took part.
There were interesting similarities and differences between the two groups. They were on average young, with two-thirds of them in both areas under 25. Less than a third had had paid work in the last six months.
The majority identified as bisexual (68%) rather than gay (29%), with even fewer identifying as gay (14.5%) in Gert Sibande. Nonetheless, 80% had a regular male sexual partner in Gert Sibande and 86% in Ehlanzeni. Sixty-nine per cent also reported a regular female sexual partner in Gert Sibande, though only 37.5% in Ehlanzeni. Despite this, only minorities (31% in Gert Sibande and 39% in Ehlanzeni) said they had had more than one sexual partner in the last six months.
In Gert Sibande, most had been tested for HIV in the last six months and none had never tested, because of participation in the previous study. In Ehlanzeni 54% had tested in the last six months and 7% had never tested.
Trial results
As reported above, 91.3% of participants, with similar proportions in both areas, used the self-test kits they were given; most tested themselves once or twice though 17% in Ehlanzeni tested three or more times.
When asked at six months whether they preferred self-testing or testing with a healthcare worker at a clinic, 83% said they preferred self-testing and 11% clinic testing. Reasons for preferring self-testing included convenience, privacy and finding it more self-empowering. The minority who preferred clinic testing said they missed the counselling and support they got there.
Fingerprick blood tests were more popular than oral fluid tests, with, at both the initial and the three-month follow-up visit, 55% choosing the blood tests and about 17.5% choosing the oral tests. The remainder changed from one kind of test to the other at the three-month visit, most from oral to blood. At the end of the study two-thirds said they preferred the blood test. When asked why, the main reason was that its results were trusted more. Several participants said they did not understand why if a test could detect HIV in saliva, HIV was not transmissible through saliva. The researchers comment that more education is needed on the difference between testing for HIV antibodies and testing for the virus itself.
Nearly all participants (112 out of 116, 97%) also distributed self-test kits to others: two-thirds gave them to sexual partners, nearly everyone to friends and 84% to family members.
This latter finding surprised researchers, as did the fact that – even though self-testers said they valued privacy – 24% actually took their test at the same time as another person they gave a test kit to, and 40% had been present as a sex partner or friend took their test (49% in Gert Sibande). Even with family members, 33% of study participants were present when they tested (39% in Gert Sibande). As the researchers comment, it was not known which family members they gave test kits to.
As reported above, there were six participant seroconversions during the study, two in Gert Sibande and four in Ehlanzeni, and 40 seroconversions among contacts given test kits, ten in Gert Sibande and 30 in Ehlanzeni. This represents 5.5% of all test kits distributed. There were also 3.7% invalid results and in 19% of cases, participants did not know their contacts’ test results.
Improvements in testing rates
Before the study, 38% of participants had tested less than six months ago and 34% more than a year ago. After the study, 86% said they anticipated testing within the next six months and only 1% in more than a year’s time even if only clinic-based testing was available, and 100% said they’d within six months if self-tests were available.
These figures were reliable: in the event 84% did re-test within six months of the six-month visit and only 2.6% waited more than a year.
This is not the first time a study has found that offering gay men self-test kits results in improved testing rates: similar results have been reported from Australia and Seattle in the US. What this study finds new is that MSM in the generalised epidemic conditions of South Africa prefer self-testing to clinic testing by 8 to 1 and find it much easier to use in what can be a stigmatising clinical environment for MSM.
As the researchers point out, what needs to be tackled is the cost: with test kits costing the equivalent of US$6-12 each, they are too expensive for most individuals to pay for in a lower-income setting like South Africa, and self-testing needs to be provided and scaled up as part of national HIV prevention programming.
Lippman SA et al. High acceptability and increased self-testing frequency after introduction of HIV self-testing and network distribution among South African MSM. JAIDS 77(3):279-287. 2018.