Discussion
PRS
ADVERSE EVENTS, SECONDARY
In this RCT, we found that index HIVST among the primary partners of ART clients dramatically increased the proportion of partners tested for HIV. The index HIVST arm showed a 167% increase in testing uptake as compared to standard PRSs, achieving testing coverage of 71% among sexual partners. Due to increased testing coverage, index HIVST resulted in a 211% increase in the number of partners identified as living with HIV as compared to PRS. After 12 months, 14/30 (47%) of those newly diagnosed in the HIVST arm and 3/4 (75%) of those in the PRS arm initiated ART. However, the HIVST arm also showed nearly double the proportion of total partners initiating ART—even with lower initiation rates—due to dramatic increases in testing coverage (5·4% of the total HIVST sample initiating ART versus 2·8% of the total PRS sample). Findings suggested that index HIVST can effectively increase testing uptake and ART coverage among partners of ART clients, although additional work is needed to improve linkage to ART after HIVST use. Routine testing for individuals at higher risk of HIV acquisition is important for both treatment and prevention efforts. Utilizing index HIVST approaches may be an important step to facilitating routine testing as part of individuals self-care practices [The intervention was cost-efficient for new diagnoses, and the cost per newly diagnosed individual was low compared to other testing modalities that target general populations (such as community screening, facility-based HIVST, among others) [A sub-analysis of our data showed large testing differences by sex—in the HIVST arm 89% of female partners tested versus 67% of male partners. This disparity is important as index testing represents a key strategy for reaching men, who comprised over 78% of eligible index partners and have few additional entry points into HIV services [Index HIVST was highly acceptable among ART clients, with no differences in adverse events reported by arm. Our findings are similar to other secondary HIVST distribution strategies with both HIV–negative and status unknown women in Kenya and Malawi [Eight percent of index partners who used HIVST were unable to interpret their test result. Understanding the usability of HIVST within index testing is critical to ensuring the strategy is effective and scalable in low-resource settings, particularly where health literacy is low. The limited data available on the usability of secondary HIVST show that most partners are able to complete an HIVST test successfully, but some require guidance, desire pre-test counseling, or mistrust HIVST results [We examined ART initiation among HIVST users longitudinally. Twelve months after enrollment, we found that only 47% of index partners who had a reactive HIVST kit initiated ART, and the vast majority of these individuals did so within the first 3 months after testing. Our experience is similar to other published data on secondary HIVST distribution, where linkage and initiation rates range from 23% to 68% [This study has several limitations. First, ART clients who did not complete a 4-week endline survey were excluded from the analyses because it was impossible to determine primary and secondary outcomes, which may result in bias if those retained were more likely to have used and be satisfied with the intervention. Second, we rely on secondary reports from ART clients to determine primary outcomes for their sexual partners. Secondary reports are likely to underestimate the impact of index HIVST since partners may use an HIVST kit, or receive additional HIV services, without the ART client’s knowledge. Third, our primary outcome (HIV testing) was measured 4 weeks after enrollment of the ART client, allowing only a short period for outcome attainment. Fourth, we did not collect data on linkage to prevention services for those who tested HIV–negative. It is critical that future HIV testing interventions take a status neutral approach [Index HIVST greatly increased HIV testing among sexual partners of ART clients without increasing adverse events. The intervention was cost-efficient for new diagnoses, but strategies to improve ART initiation after receiving reactive HIVST results are needed. Further research is needed to understand the role of index HIVST among non-stable partners and what strategies can optimize testing among male partners and ART initiation more broadly.