Discussion
These results indicate that a community-led intervention may be more effective in high social cohesion communities and high problem solving communities compared to the paid distributor arm.In high social cohesion communities, the odds of new HIV diagnosis were over double in clusters with the community-led intervention (OR 2.08 95% CI 1.03–4.19). Notably, the proportion of new HIV diagnoses was considerably higher for the community-led intervention arm than the paid distribution intervention arm within high social cohesion communities, despite the fact that self-testing was not, which may indicate better targeting of self-tests to people who need to test [Unlike the paid distribution arm, the community led model also allowed for testing in other locations as well as door-to-door, those at higher risk of HIV and more likely to test positive would be more likely to be concerned about privacy and thus utilise the opportunities to test outside of the house. In addition, the community-led intervention may have fostered a sense of ownership, creating a more secure and enabling environment to test, compared to the paid distributor arm where the HIVST program was implemented by a paid distributor.This is reflected in the results which show that those in the community-led arm had over double (OR 2.08 95% CI 1.03–4.19) the odds of HIV self-testing compared to community-based arm in high social cohesion communities. This is aligned with previous research that has found higher social cohesion to increase HIV testing [Within low HIV awareness communities, clusters allocated to the community-led model had 0.41 (95% CI 0.24–0.69 Our results also indicated evidence of interaction between community problem solving and trial effectiveness. The results highlighted a dose response for self-testing, with the odds of reported self-testing increasing from low problem-solving communities (community-led OR 0.48 95% CI 0.28–0.84) to high community problem solving communities (community-led OR 1.17 95% CI 0.68–2.02). These results could be driven by some communities within this group that are better at problem solving being more proactive in running the community-led intervention, resulting in an increase in self testing.There is a growing body of evidence for the role of social cohesion and community ownership in promoting positive health outcomes [The results of this study need to be considered in context of its limitations. Due to the nature of the study design, temporality could have caused bias. Whilst the survey aimed to gather precisely when participants most recent HIVSTs were conducted, the date of the HIVST could have been recalled incorrectly. Therefore, it is difficult to be certain that the intervention occurred before participants had a new HIV diagnosis or linked to preventative care. Also, it is hard to disentangle whether the community measures were pre-existing and improved the effectiveness of the intervention or whether the intervention improved the community measures, particularly social cohesion. However, due to the short period of the intervention it is unlikely to have been able to improve community measures such as social cohesion enough to have influenced the intervention.Due to the number of statistical comparisons in the analyses of these results, it is possible some significant associations may have been obtained by chance. This paper describes an exploratory analyses of the data and therefore results have been interpreted with caution and indicate emerging patterns or areas of future research focus, as opposed to drawing conclusions.Despite the limitations, this study contributes to existing literature on the role of community-led interventions on HIV outcomes. Our results highlight that community-led interventions have the ability to reach high risk populations in communities that have stronger existing community measures. This study uses community measures validated for research purposes and also assesses these at the community-level as opposed to the individual level. This enables our findings to be more meaningful in understanding how the context of a community interacts with health outcomes.