High Acceptance and Completion of HIV Self-testing Among Diverse Populations of Young People in Kenya Using a Community-Based Distribution Strategy

AIDS and Behavior https://doi.org/10.1007/s10461-021-03451-1 ORIGINAL PAPER High Acceptance and Completion of HIV Self‑testing Among Diverse Populations of Young People in Kenya Using a Community‑Based Distribution Strategy Kate S. Wilson1 · Cyrus Mugo2 · David A. Katz1 · Vivianne Manyeki2 · Carol Mungwala2 · Lilian Otiso7 · David Bukusi9 · R. Scott McClelland1,5,6 · Jane M. Simoni1,4 · Matt Driver10 · Sarah Masyuko8 · Irene Inwani2 · Pamela K. Kohler1,3 Accepted: 26 August 2021 © The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2021 Abstract Oral HIV self-testing (HIVST) may expand access to testing among hard-to-reach reach adolescents and young adults (AYA). We evaluated community-based HIVST services for AYA in an urban settlement in Kenya. Peer-mobilizers recruited AYA ages 15–24 through homes, bars/clubs, and pharmacies. Participants were offered oral HIVST, optional assistance and post-test counseling. Outcomes were HIVST acceptance and completion (self-report and returned kits). Surveys were given at enrollment, post-testing, and 4 months. Log-binomial regression evaluated HIVST preferences by venue. Among 315 reached, 87% enrolled. HIVST acceptance was higher in bars/clubs (94%) than homes (86%) or pharmacies (75%). HIVST completion was 97%, with one confirmed positive result. Participants wanted future HIVST at multiple locations, include PrEP, and cost ≤ $5USD. Participants from bars/clubs and pharmacies were more likely to prefer unassisted testing and peer-distributers compared to participants from homes. This differentiated community-based HIVST strategy could facilitate engagement in HIV testing and prevention among AYA. Keywords HIV self-testing · Adolescents and young adults · Community-based testing · Differentiated HIV testing · SubSaharan Africa Introduction Adolescents and young adults (AYA) in sub-Saharan Africa (SSA) accounted for 33% of all new infections in 2019 [1], and AIDS remains the leading cause of death in this population [2]. HIV testing is the entry point into prevention and treatment. However, HIV testing among AYA is lower * Kate S. Wilson 1 Department of Global Health, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359931, Seattle, WA 98104, USA than any other age group [3]. Common barriers for AYA to accessing provider-directed HIV testing services (HTS) include wait time, cost, stigma, and local consent laws [4–7]. Oral HIV self-testing (HIVST) is a convenient, safe, and accurate alternative to standard provider-directed HIV testing that can increase access and improve health system efficiencies, especially with service disruptions from 5 Department of Epidemiology, University of Washington, Seattle, USA 6 Department of Medicine, University of Washington, Seattle, USA 7 LVCT Health, Nairobi, Kenya 2 University of Nairobi/Kenyatta National Hospital, Nairobi, Kenya 8 National AIDS and STI Control Program (NASCOP), Nairobi, Kenya 3 Department of Child, Family, and Population Health, Nursing, University of Washington, Seattle, USA 9 Kenyatta National Hospital, Nairobi, Kenya 10 Department of Cardiology, Cedar Sinai Medical Center, Los Angeles, USA 4 Department of Psychology, University of Washington, Seattle, USA 13 Vol.:(0123456789) AIDS and Behavior COVID-19 [8–13]. Since the World Health Organization (WHO) recommended adopting HIVST in 2016, most countries in SSA have included HIVST into national HIV testing guidelines and differentiated service delivery strategies [14, 15]. Community-based HIVST distribution is especially promising to increase testing and linkage to care and prevention among hard-to-reach populations [16, 17] and people who decline standard testing [18]. Secondary distribution through sexual partners or peers also improves routine testing among people with ongoing HIV exposure [19–21]. Recent studies show that HIVST is acceptable among AYA in SSA [7, 22]. In randomized trials of HIVST in Southern Africa, HIVST completion was higher among AYA than among older age groups [7, 23, 24]. However, there is limited evidence on how best to implement HIVST services to AYA in real-world settings [25, 26]. It is also unclear whether AYA want independent self-testing options or provider-support models [27]. A study that included options of HIVST or provider-directed testing to support linkage to care among adolescent girls and young women (AGYW) in Kenya [28] found that a lower proportion of AGYW chose HIVST compared to provider-directed testing. Because AYA represent a heterogeneous population with diverse social contexts, preferences, and risk of HIV acquisition [29], it is important to evaluate multiple distribution points, including homes, pharmacies, and bars or bus stands, to reach distinct AYA where they are [18, 30]. To address these gaps, we evaluated an HIVST model using three different communitybased distribution strategies on HIVST acceptance, completion, and preferences among AYA in Kenya. Methods Setting and Population This cohort study was conducted in Kawangware, an informal settlement in Nairobi selected because it was a National AIDS and STD Control Programme priority area and had community-based HIV testing infrastructure and outreach programs for priority populations. Eligible AYA were ages 15–24 years, reported unknown or HIV-negative status, had access to a cell phone, and could provide written informed consent. We purposefully selected three non-contiguous wards in Kawangware, one for each distribution channel: homebased testing (HBT), pharmacies, and ‘hotspots’ (bars/ nightclubs) hypothesized to reach different sub-groups of AYA. Recruitment varied by channel because of differences in when AYA were present. In HBT, we visited every fifth residence at different times and days during the week and approached all potentially eligible AYA present. Of 30 pharmacies visited, three were chosen based on ≥ 50 customers 13 per day, managers’ willingness to refer clients to the study, and access to a private space. Pharmacy staff referred potentially eligible AYA customers to peer mobilizers. Of 20 hotspots where we had an established relationship, three were selected based on manager willingness to refer potential participants and provide a private space for study activities. Peer mobilizers approached all potentially eligible AYA and invited those interested to learn more about the study to a designated private room. Study Procedures Participants had three contacts with study staff: at enrollment, immediately after test completion, and at 4 months after enrollment. Peer mobilizers conducted recruitment and offered HIVST information, while HTS counselors performed study consent, screening, data collection, and HIVST services. At enrollment, participants completed an interviewer-administered survey in Kiswahili or English. Counselors provided pre-test counseling according to 2017 national self-testing (...truncated)