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ABSTRACTJustice-impacted persons may inconsistently access HIV testing. This cross-sectional secondary analysis investigates lifetime HIV testing prevalence among adults with prior histories of incarceration in Southern California, United States, participating in health-focused programming (n = 3 studies). Self-reported demographic and lifetime HIV testing data were collected between 2017-2023; descriptive analyses were conducted. Across the three samples, at least 74% of participants were male; Latino and African American individuals accounted for nearly two-thirds of participants. Lifetime HIV testing ranged from 72.8% to 84.2%. Males were significantly more likely than females to report never being tested in two samples and accounted for >95% of those never tested. No statistically significant differences in testing were observed by race/ethnicity. Single young adults (ages 18-26) were less likely than their partnered peers to report testing. HIV testing is critical for ensuring that individuals access prevention and treatment. HIV testing among justice-impacted adults in this study was higher than in the general population, potentially due to opt-out testing in correctional settings. Nevertheless, these findings underscore the importance of implementing targeted interventions to reduce structural (e.g., health insurance, access to self-testing kits) and social barriers (e.g., HIV stigma) to increase HIV testing among justice-impacted males and single young adults.

BackgroundHIV testing rates among South African men lag behind rates for women and national targets. Community-based HIV self-screening (HIVSS) distribution and follow-up by community health workers (CHWs) is a scalable option to increase testing coverage, diagnosis, and treatment initiation. We provided HIVSS and assisted linkage to care to men not recently tested (within the past 12 months) residing in high-HIV-burden areas of Johannesburg.MethodsCHWs distributed HIVSS in 6 clinic catchment areas. Follow-up to encourage confirmatory testing and antiretroviral therapy initiation was conducted through personal support (PS) or an automated short message service (SMS) follow-up and linkage system in 3 clinic areas each. Using a quasi-experimental pre-post design, we compared differences in the proportion of men testing in the clinic catchment areas during the HIVSS campaign (June-August 2019) to the 3 months prior (March-May 2019) and compared treatment initiations by assisted linkage strategy.ResultsAmong 4793 participants accepting HIVSS, 62% had never tested. Among 3993 participants with follow-up data, 90.6% reported using their HIVSS kit. Testing coverage among men increased by 156%, from under 4% when only clinic-based HIV testing services were available to 9.5% when HIVSS and HIV testing services were available (z = -11.6; P < 0.01). Reported test use was higher for men followed through PS (99% vs. 68% in SMS); however, significantly more men reported reactive self-test results in the SMS group compared with PS (6.4% vs. 2.0%), resulting in more antiretroviral therapy initiations in the SMS group compared with PS (23 vs. 9; P < 0.01).ConclusionsCHW HIVSS distribution significantly increases testing among men. While PS enabled personalized follow-up, reporting differences indicate SMS is more acceptable and better aligned with expectations of privacy associated with HIVSS.

Across sub-Saharan Africa, men are less likely to know their HIV status than women, leading to later treatment initiation. Little is known about how experiences with general health services affect men's use of HIV testing. We used data from a 2019 community-representative survey of men in Malawi to understand frequency and cause of men's negative health service experiences (defined as men reporting they "would not recommend" a facility) and their association with future HIV testing. We conducted univariable and multivariable logistic regressions to determine which aspects of health facility visits were associated with would-not-recommend experiences and to determine if would-not-recommend experiences 12-24 months prior to the survey were associated with HIV testing in the 12 months prior to the survey. Among 1,098 men eligible for HIV testing in the 12 months prior to the survey, median age was 34 years; 9% of men reported at least one would-not-recommend experience, which did not differ by sociodemographics, gender norm beliefs, or HIV stigma beliefs. The factors most strongly associated with would-not-recommend experiences were cost (aOR 5.8, 95%CI 2.9-11.4), cleanliness (aOR 4.2, 95%CI 1.8-9.9), medicine availability (aOR 3.3, 95%CI 1.7-6.4), and wait times (aOR 2.7, 95%CI 1.5-5.0). Reporting a would-not-recommend experience 12-24 months ago was associated with a 59% decrease in likelihood of testing for HIV in the last 12 months (aOR 0.41; 95% CI:0.17-0.96). Dissatisfaction with general health services was strongly associated with reduced HIV testing. Coverage of high-priority screening services like HIV testing may benefit from improving overall health system quality.

IntroductionGlobally, transgender ('trans') women experience extreme social and economic marginalisation due to intersectional stigma, defined as the confluence of stigma that results from the intersection of social identities and positions among those who are oppressed multiple times. Among trans women, gender-based stigma intersects with social positions such as engagement in sex work and substance use, as well as race-based stigma to generate a social context of vulnerability and increased risk of HIV acquisition. In Brazil, trans women are the 'most at-risk' group for HIV, with 55 times higher estimated odds of HIV infection than the general population; further, uptake of HIV testing and pre-exposure prophylaxis (PrEP) among trans women is significantly lower than other at-risk groups. Through extensive formative work, we developed Manas por Manas, a multilevel intervention using HIV prevention strategies with demonstrated feasibility and acceptability by trans women in Brazil, to address intersectional stigma and increase engagement in the HIV prevention continuum.Methods and analysisWe are conducting a two-arm randomised wait-list controlled trial of the intervention's efficacy in São Paulo, Brazil, to improve uptake of HIV testing and PrEP among transgender women (N=400). The primary outcomes are changes in HIV testing (self-testing and clinic based), changes in PrEP uptake and changes in PrEP persistence at baseline and follow-up assessment for 12 months at 3-month intervals.Ethics and disseminationThis study was approved by University of California, San Francisco Institutional Review Board (15-17910) and Comissão Nacional de Ética em Pesquisa (Research Ethics National Commission, CAAE: 25215219.8.0000.5479) in Brazil. Participants provided informed consent before enrolment. We are committed to collaboration with National Institutes of Health officials, other researchers, and health and social services communities for rapid dissemination of data and sharing of materials. The results will be published in peer-reviewed academic journals and scientific presentations.Trial registration numberNCT03081559.

Developmental assets are critical to the health and wellbeing of youth. The current study examines the influence of developmental assets on PrEP use and HIV testing among YBMSM ages 18-24. Using a cross-sectional survey of YBMSM (N = 225), this study explored the role of external (e.g., family support, other adult support) and internal (e.g., personal responsibility) assets in explaining HIV prevention behaviors. Participants were recruited from Mechanical Turk (M-Turk) internet-based platform, social media sites, and community-based organizations. A path analysis was conducted to investigate the direct/indirect effects of internal and external assets on PrEP use and HIV testing. Family support (β = 0.40, p

BACKGROUND: Prior research has consistently shown that the involvement of families plays a vital role in reducing risk behaviors, such as engaging in condomless sex, and promoting HIV prevention behaviors among young Black men who have sex with men (YBMSM). With the aim of expanding the existing knowledge, this study aimed to examine the specific influence of families and other supportive adults in facilitating casual condom use, partner condom use, HIV testing, and preexposure prophylaxis (PrEP) utilization among young Black MSM. METHODS: A sample of YBMSM aged 18-29 years (N = 400) was collected online. We used a path analysis to examine the influence of family factors on PrEP stigma and PrEP use. Respondents were recruited from December 1, 2021, to January 31, 2022. We used a path analysis to examine the direct and indirect effects of family factors on PrEP use through HIV testing and encouraging condom use. RESULTS: Among BMSM, other adult support was positive and directly associated with condom use by both casual partners (β = 0.04, p

BACKGROUND: Cost-effectiveness analysis of HIV self-testing using patient-level data from a randomized clinical trial can inform HIV prevention funding decisions. Cost-effectiveness analysis using net-benefit regression addresses the sampling uncertainty in the trial data and the variability of policymakers willingness to pay (WTP). METHODS: We used published data from a 12-month longitudinal randomized clinical trial that enrolled 2665 men who had sex with men randomly assigned to the self-testing arm (participants receiving self-test kits) and control arm (participants receiving standard-of-care), and the self-testing arm identified 48 additional new HIV cases. We used net-benefit regression to investigate the cost-effectiveness of an HIV self-testing intervention, which compared the incremental cost per new HIV diagnosis with policymakers WTP thresholds. We addressed the uncertainties in estimating the incremental cost and the policymakers WTP per new diagnosis through the incremental net-benefit (INB) regression and cost-effectiveness acceptability curve (CEAC) analyses. RESULTS: From the health care providers perspective, the INB analysis showed a positive net benefit of HIV self-testing compared with standard-of-care when policymakers WTP per new HIV diagnosis was $9365 (95% confidence interval: $5700 to $25,500) or higher. The CEAC showed that the probability of HIV self-testing being cost-effective compared with standard-of-care was 58% and >99% at a WTP of $10 000 and $50 000 per new HIV diagnosis, respectively. CONCLUSION: The INB and CEAC analyses suggest that HIV self-testing has the potential to be cost-effective for relatively low values of policymakers WTP.

BackgroundFacility HIV self-testing (HIVST) in outpatient departments can dramatically increase testing among adult outpatients. However, it is still unclear why populations opt out of facility HIVST and reasons for opt outing. Using data from a parent facility HIVST trial, we sought to understand individual characteristics associated with opting out of facility HIVST and reported reasons for not testing.MethodsExit surveys were conducted with outpatients aged ≥15 years at 5 facilities in Central and Southern Malawi randomized to the facility HIVST arm of the parent trial. Outpatients were eligible for our substudy if they were offered HIVST and eligible for HIV testing (ie, never previously tested HIV positive and tested ≥12 months ago or never tested). Summary statistics and multivariate regression models were used.ResultsSeven hundred seventy-one outpatients were included in the substudy. Two hundred sixty-three (34%) opted out of HIVST. Urban residency (adjusted risk ratios [aRR] 3.48; 95% CI: 1.56 to 7.76) and self-reported poor health (aRR 1.86; 95% CI: 1.27 to 2.72) were associated with an increased risk of opting out. Male participants had a 69% higher risk of opting out (aRR 1.69; 95% CI: 1.14 to 2.51), with risk being 38% lower among working male participants. Primary reasons for not testing were feeling unprepared to test (49·4%) and perceived low risk of HIV infection (30·4%)-only 2.6% believed that HIVST instructions were unclear, and 1.7% were concerned about privacy.ConclusionWorking, risky sexual behavior, rural residence, and good self-rated health were positively associated with opting out of HIVST among outpatients. Strategies to address internalized barriers, such as preparedness to test and perceived need to test, should be incorporated into facility HIVST interventions.

IntroductionOptimizing HIV prevention may require structured approaches for providing client-centred choices as well as community-based entry points and delivery. We evaluated the effect of a dynamic choice model for HIV prevention, delivered by community health workers (CHWs) with clinician support, on the use of biomedical prevention among persons at risk of HIV in rural East Africa.MethodsWe conducted a cluster randomized trial among persons (≥15 years) with current or anticipated HIV risk in 16 villages in Uganda and Kenya (SEARCH; NCT04810650). The intervention was a client-centred HIV prevention model, including (1) structured client choice of product (pre-exposure prophylaxis [PrEP] or post-exposure prophylaxis [PEP]), service location (clinic or out-of-clinic) and HIV testing modality (self-test or rapid test), with the ability to switch over time; (2) a structured assessment of patient barriers and development of a personalized support plan; and (3) phone access to a clinician 24/7. The intervention was delivered by CHWs and supported by clinicians who oversaw PrEP and PEP initiation and monitoring. Participants in control villages were referred to local health facilities for HIV prevention services, delivered by Ministry of Health staff. The primary outcome was biomedical prevention coverage: a proportion of 48-week follow-up with self-reported PrEP or PEP use.ResultsFrom May to July 2021, we enrolled 429 people (212 intervention; 217 control): 57% women and 35% aged 15-24 years. Among intervention participants, 58% chose PrEP and 58% chose PEP at least once over follow-up; self-testing increased from 52% (baseline) to 71% (week 48); ≥98% chose out-of-facility service delivery. Among 413 (96%) participants with the primary outcome ascertained, average biomedical prevention coverage was 28.0% in the intervention versus 0.5% in the control: a difference of 27.5% (95% CI: 23.0-31.9%, p

Depression is associated with key HIV-related prevention and treatment behaviors in sub-Saharan Africa. We aimed to identify the association of depressive symptoms with HIV testing, linkage to care, and ART adherence among a representative sample of 18-49 year-olds in a high prevalence, rural area of South Africa. Utilizing logistic regression models (N = 1044), depressive symptoms were inversely associated with reported ever HIV testing (AOR 0.92, 95% CI 0.85-0.99; p = 0.04) and ART adherence (AOR 0.82, 95% CI: 0.73-0.91; p

BACKGROUND: Most people who inject drugs (PWID) in Iran have not undergone recent HIV testing. While PWID face barriers when seeking HIV testing at health facilities, HIV self-testing (HIVST) could be a promising approach to improve HIV testing uptake. We examined the awareness and willingness to use HIVST among PWID in Iran. We also identified participants characteristics associated with a higher willingness to use HIVST. METHODS: PWID were recruited in 11 cities using a respondent-driven sampling method. Willingness to use HIVST was defined as a binary variable (very low/low willingness vs. high/very high willingness). We performed multivariable modified Poisson regression to examine associated factors and report adjusted prevalence ratios (aPR) and 95% confidence intervals (CI). RESULTS: Of 2,252 PWID, 362 (16.2%; 95% CI 14.7, 17.8) had ever heard of HIVST; however, 1,658 (73.6%; 95% CI 71.7, 75.4) reported high/very high willingness to use HIVST. Willingness to use HIVST was higher among PWID who reported having a high/moderate HIV risk perception (aPR 1.22; 95% CI 1.09, 1.37), ever experiencing homelessness (aPR 1.15; 95% CI 1.03, 1.28), > 10 years of injecting history (aPR 1.16; 95% CI 1.00, 1.34), and high injection frequency in the last three months (aPR 1.18; 95% CI 1.05, 1.32). CONCLUSION: Most PWID in Iran, particularly those experiencing homelessness, have a longer injecting history, engage in more frequent injection practices, and possess a heightened perception of HIV risk would be willing to adopt HIVST. Enhancing HIVST awareness through increased access to HIVST and health education programs are needed. Additionally, conducting implementation science studies to effectively design and run HIVST programs in Iran can also increase PWIDs access to HIV testing.

We assess the accuracy of self-reported testing, HIV status, and treatment responses compared to clinical records in Ehlanzeni District, South Africa. We linked a 2018 population-based survey of adults 18-49 years old with clinical data at local primary healthcare facilities from 2014 to 2018. We calculated self-reported testing, HIV status, and treatment, and triangulated findings with clinic record data. We adjusted testing estimates for known gaps in HIV test documentation. Of 2089 survey participants, 1657 used a study facility and were eligible for analysis. Half of men and 84% of women reported an HIV test in the past year. One third of reported tests could be confirmed in clinic data within 1 year and an additional 13% within 2 years; these fractions increased to 57% and 22% respectively limiting to participants with a verified clinic file. After accounting for gaps in clinic documentation, we found that prevalence of recent HIV testing was closer to 15% among men and 51% in women. Estimated prevalence of known HIV was 16.2% based on self-report vs. 27.6% with clinic documentation. Relative to clinical records among confirmed clinic users, self report of HIV testing and of current treatment were highly sensitive but non-specific (sensitivity 95.5% and 98.8%, specificity 24.2% and 16.1% respectively), while self report of HIV status was highly specific but not sensitive (sensitivity 53.0%, specificity 99.3%). While clinical records are imperfect, survey-based measures should be interpreted with caution in this rural South African setting.

ObjectivesDetermine whether patient-centered, streamlined HIV care achieves higher antiretroviral therapy (ART) uptake and viral suppression than the standard treatment model for people with HIV (PWH) reporting hazardous alcohol use.DesignCommunity cluster-randomized trial.MethodsThe Sustainable East Africa Research in Community Health trial (NCT01864603) compared an intervention of annual population HIV testing, universal ART, and patient-centered care with a control of baseline population testing with ART by country standard in 32 Kenyan and Ugandan communities. Adults (15 years or older) completed a baseline Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) and were classified as no/nonhazardous (AUDIT-C 0-2 women/0-3 men) or hazardous alcohol use (≥3 women/≥4 men). We compared year 3 ART uptake and viral suppression of PWH reporting hazardous use between intervention and control arms. We compared alcohol use as a predictor of year 3 ART uptake and viral suppression among PWH, by arm.ResultsOf 11,070 PWH with AUDIT-C measured, 1723 (16%) reported any alcohol use and 893 (8%) reported hazardous use. Among PWH reporting hazardous use, the intervention arm had higher ART uptake (96%) and suppression (87%) compared with control (74%, adjusted risk ratio [aRR] = 1.28, 95% CI: 1.19 to 1.38; and 72%, aRR = 1.20, 95% CI: 1.10 to 1.31, respectively). Within arm, hazardous alcohol use predicted lower ART uptake in control (aRR = 0.86, 95% CI: 0.78 to 0.96), but not intervention (aRR = 1.02, 95% CI: 1.00 to 1.04); use was not predictive of suppression in either arm.ConclusionsThe Sustainable East Africa Research in Community Health intervention improved ART uptake and viral suppression among PWH reporting hazardous alcohol use and eliminated gaps in ART uptake between PWH with hazardous and no/nonhazardous use. Patient-centered HIV care may decrease barriers to HIV care for PWH with hazardous alcohol use.

Studies on HIV self-testing (HIV-ST) have been limited to adults (age 18+). The study assessed use of HIV-ST among a diverse group of young men who have sex with men (YMSM) in the United States (US) and assessed differences in uptake by demographic characteristics and requirements for parental consent. This study demonstrated feasibility of HIV-ST for YMSM as young as 14 years of age, which suggests potential for increasing HIV testing in this young age group and promoting health equity.

BackgroundPeople with schizophrenia experience unique barriers to routine HIV testing, despite increased risk of HIV compared with the general US population. Little is known about how health care delivery system factors affect testing rates or whether there are testing differences for people with schizophrenia.SettingNationally representative sample of Medicaid enrollees with and without schizophrenia.MethodsUsing retrospective longitudinal data, we examined whether state-level factors were associated with differences in HIV testing among Medicaid enrollees with schizophrenia compared with frequency-matched controls during 2002-2012. Multivariable logistic regression estimated testing rate differences between and within cohorts.ResultsHigher HIV testing rates for enrollees with schizophrenia were associated with higher state-level Medicaid spending per enrollee, efforts to reduce Medicaid fragmentation, and higher federal prevention funding. State-level AIDS epidemiology predicted more frequent HIV testing for enrollees with schizophrenia versus controls. Living in rural settings predicted lower HIV testing, especially for people with schizophrenia.ConclusionOverall, state-level predictors of HIV testing rates varied among Medicaid enrollees, although rates were generally higher for those with schizophrenia than controls. Increased HIV testing for people with schizophrenia was associated with coverage of HIV testing when medically necessary, higher Centers for Disease Control and Prevention prevention funding, and higher AIDS incidence, prevalence, and mortality when compared with controls. This analysis suggests that state policymaking has an important role to play in advancing that effort. Overcoming fragmented care systems, sustaining robust prevention funding, and consolidating funding streams in innovative and flexible ways to support more comprehensive systems of care delivery deserve attention.

BACKGROUND: The 95-95-95 UNAIDS global strategy was adapted to end the AIDS epidemic by 2030. The target is based on the premise that early detection of HIV-infected persons and linking them to treatment regardless of their CD4 counts will lead to sustained viral suppression. HIV testing strategies to increase uptake of testing in Western and Central Africa remain inadequate. Hence, a high proportion of people living with HIV in this region do not know their status. This report describes the implementation of a community based multi-disease health screening (also known as Know Your Status -KYS), as part of basic science research, in a way that contributed to achieving public health goals. METHODS: A community based multi-disease health screening was conducted in 7 communities within the Eastern region of Ghana between November 2017 and April 2018, to recruit and match HIV seronegative persons to HIV seropositive persons in a case-control HIV gut microbiota study. Health assessments included blood pressure, body mass index, blood sugar, Hepatitis B virus, syphilis, and HIV testing for those who consented. HIV seronegative participants who consented were consecutively enrolled in an ongoing HIV gut microbiota case-control study. Descriptive statistics (percentages) were used to analyze data. RESULTS: Out of 738 people screened during the exercise, 700 consented to HIV testing and 23 (3%) were HIV positive. Hepatitis B virus infection was detected in 4% (33/738) and Syphilis in 2% (17/738). Co-infection of HIV and HBV was detected in 4 persons. The HIV prevalence of 3% found in these communities is higher than both the national prevalence of 1.7% and the Eastern Regional prevalence of 2.7 in 2018. CONCLUSION: Community based multi-disease health screening, such as the one undertaken in our study could be critical for identifying HIV infected persons from the community and linking them to care. In the case of HIV, it will greatly contribute to achieving the first two 95s and working towards ending AIDS by 2030.

Adolescents comprise approximately 15% of new HIV infections in Kenya. Impoverished living conditions in informal settlements place residents at high risk for HIV infection. We assessed factors associated with HIV infection among adolescents residing in urban informal settlements in Kisumu. We recruited 3,061 adolescent boys and girls aged 15-19. HIV prevalence was 2.5% overall, all newly identified cases were among girls and infection was positively associated with not completing a secondary education (p < .001). Girls who had ever been pregnant (p < .001) or out-of-school without completing a secondary education (p < .001) were more likely to be HIV-positive. Our findings of higher HIV prevalence among adolescent girls who had been pregnant or did not complete secondary school highlight the need to facilitate access to HIV testing, HIV pre-exposure prophylaxis, and sexual and reproductive health services as components of a comprehensive prevention strategy to decrease HIV infections in this priority population.

BackgroundSoutheast Asian countries have been trying to increase HIV testing coverage of women since awareness of HIV status is essential to eliminate mother-to-child transmission of HIV. This study determined factors related to lifetime HIV testing uptake among women aged 15-49 years in four Southeast Asian countries: Myanmar, Cambodia, the Philippines and Timor-Leste.MethodsThis study used cross-sectional data from the 2015-16 Myanmar Demographic and Health Survey (DHS), the 2014 Cambodia DHS, the 2017 Philippines National DHS and the 2016 Timor-Leste DHS. We conducted multivariable logistic regression analyses to identify factors associated with lifetime HIV testing among women aged 15-49 years who completed the surveys in each country and ran a fixed effects logistic regression model using pooled data.ResultsThe proportions of lifetime HIV testing uptake among women aged 15-49 years were 42.1% in Cambodia, 19.5% in Myanmar, 4.6% in the Philippines, and 3.7% in Timor-Leste. Marital status, age, education, and wealth were significantly associated with lifetime HIV testing uptake among women in all four countries. Other factors (e.g., comprehensive knowledge of HIV, rural/urban residence, positive attitudes towards negotiation for safer sex) were also significant determinants of HIV testing uptake among women in some of these countries.ConclusionsA multi-sectoral collaboration of related sectors and organizations is necessary to increase access to HIV testing and HIV knowledge of women to overcome the barriers to HIV testing. It is critical to make HIV testing services available and accessible to women, especially in rural areas.

BACKGROUND: Fishing exposes fishermen to schistosomiasis-infested fresh water and concurrently through precarious livelihoods to risky sexual behaviour, rendering these two infections occupational hazards for fishermen. This study aimed to characterize the knowledge of the two conditions to obtain necessary data for a subsequent cluster randomized trial designed to investigate demand creation strategies for joint HIV-schistosomiasis service provision in fishing villages on the shores of southern Lake Malawi. METHODS: Enumeration of all resident fishermen in 45 clusters (fishing communities) was carried out between November 2019 and February 2020. In a baseline survey, fishermen reported their knowledge, attitudes and practices in the uptake of HIV and schistosomiasis services. Knowledge of HIV status and previous receipt of praziquantel were modelled using random effects binomial regression, accounting for clustering. Prevalence of willingness to attend a beach clinic was computed. RESULTS: A total of 6,297 fishermen were surveyed from the 45 clusters with harmonic mean number of fishermen per cluster of 112 (95% CI: 97; 134). The mean age was 31.7y (SD: 11.9) and nearly 40% (2,474/6,297) could not read or write. Overall, 1,334/6,293 (21.2%) had never tested for HIV, with 64.4% (3,191/4,956) having tested in the last 12 months, and 5.9% (373/6290) taking antiretroviral therapy (ART). In adjusted analyses, being able to read and write (adjusted risk ratio [aRR: 1.91, 95% CI: 1.59-2.29, p

Human Immunodeficiency Virus (HIV) continues to be a significant public health problem, with ~1.2 million Americans living with HIV and ~14% unaware of their infection. The Centers for Disease Control and Prevention recommends that patients 13 to 64 years of age get screened for HIV at least once, and those with higher risk profiles screen at least annually. Unfortunately, screening rates are below recommendations for high-risk populations, leading to problems of delayed diagnosis. Novel technologies have been applied in HIV research to increase prevention, testing and treatment. Conversational agents, with potential for integrating artificial intelligence and natural language processing, may offer an opportunity to improve outreach to these high-risk populations. The feasibility, accessibility and acceptance of using conversational agents for HIV testing outreach is important to evaluate, especially amidst a global coronavirus disease 2019 pandemic when clinical services have been drastically affected. This viewpoint explores the application of a conversational agent in increasing HIV testing among high-risk populations.

Black men who have sex with men (BMSM) and transgender women (BTW) are disproportionately affected by incarceration and HIV. We assessed factors associated with HIV testing and viral suppression among 176 incarcerated BMSM and BTW in Chicago, IL; Los Angeles, CA; and Houston, TX. In multivariable logistic regression, having a sexual orientation of bisexual, heterosexual, or other vs. gay or same-gender loving was associated with higher odds of testing in custody (aOR 8.97; 95% CI 1.95 - 41.24). Binge drinking (aOR 0.19; 95% CI 0.04 - 0.92) and being unemployed prior to incarceration (aOR 0.03; 95% CI 0.00 - 0.23) were associated with lower odds of testing; participants in Los Angeles were also more likely to be tested than those in Chicago. Being housed in protective custody (aOR 3.12; 95% CI 1.09-9.59) and having a prescription for ART prior to incarceration (aOR 2.58; 95% CI 1.01-6.73) were associated with higher odds of viral suppression when adjusted for site and duration of incarceration, though the associations were not statistically significant in the full multivariable model. Future research should examine structural and process level factors that impact engagement in HIV testing and treatment among detained BMSM and BTW.

BackgroundHIV testing among the sexual partners of HIV-positive clients is critical for case identification and reduced transmission in southern and eastern Africa. HIV self-testing (HIVST) may improve uptake of HIV services among sexual partners of antiretroviral therapy (ART) clients, but the impact of HIVST on partner testing and subsequent ART initiation remains unclear.Methods and findingsWe conducted an individually randomized, unblinded trial to assess if an index HIVST intervention targeting the partners of ART clients improves uptake of testing and treatment services in Malawi. The trial was conducted at 3 high-burden facilities in central and southern Malawi. ART clients attending HIV treatment clinics were randomized using simple randomization 1:2·5 to: (1) standard partner referral slip (PRS) whereby ART clients were given facility referral slips to distribute to their primary sexual partners; or (2) index HIVST whereby ART clients were given HIVST kits + HIVST instructions and facility referral slips to distribute to their primary sexual partners. Inclusion criteria for ART clients were: ≥15 years of age, primary partner with unknown HIV status, no history of interpersonal violence (IPV) with partner, and partner lives in facility catchment area. The primary outcome was partner testing 4-weeks after enrollment, reported by ART clients using endline surveys. Medical chart reviews and tracing activities with partners with a reactive HIV test measured ART initiation at 12 months. Analyses were conducted based on modified intention-to-treat principles, whereby we excluded individuals who did not have complete endline data (i.e., were loss to follow up from the study). Adjusted models controlled for the effects of age and marital status. A total of 4,237 ART clients were screened and 484 were eligible and enrolled (77% female) between March 28, 2018 and January 5, 2020. A total of 365 participants completed an endline survey (257/34 index HIVST arm; 107/13 PRS arm) and were included in the final analysis (78% female). Testing coverage among sexual partners was 71% (183/257) in the index HIVST arm and 25% (27/107) in the PRS arm (aRR: 2·77, 95% CI [2·56 to 3·00], p ≤ 0.001). Reported HIV positivity rates did not significantly differ by arm (16% (30/183) in HIVST versus 15% (4/27) in PRS; p = 0.99). ART initiation at 12 months was 47% (14/30) in HIVST versus 75% (3/4) in PRS arms; however, index HIVST still resulted in a 94% increase in the proportion of all partners initiating ART due to higher HIV testing rates in the HIVST arm (5% partners initiated ART in HVIST versus 3% in PRS). Adverse events including IPV and termination of the relationship did not vary by arm (IPV: 3/257 index HIVST versus 4/10 PRS; p = 0.57). Limitations include reliance on secondary report by ART clients, potential social desirability bias, and not powered for sex disaggregated analyses.ConclusionsIndex HIVST significantly increased HIV testing and the absolute number of partners initiating ART in Malawi, without increased risk of adverse events. Additional research is needed to improve linkage to HIV treatment services after HIVST use.Trial registrationClinicalTrials.gov, NCT03271307, and Pan African Clinical Trials, PACTR201711002697316.

HIV testing uptake was around 70% among female sex workers (FSWs) in Iran in 2015. Due to the recognized importance of HIV testing in prevention, care, and treatment among FSWs, this study aimed to provide an update and also an improvement as it uses respondent-driven sampling (RDS) for the frequency and the correlates of HIV testing among FSWs in Iran. A total of 1,515 FSWs were recruited from eight cities in Iran between 2019-2020 using RDS. Data were collected using face-to-face interviews. Also, rapid diagnostic tests (RDT) were used to determine HIV and syphilis status as per national guidelines. We used multivariable logistic regression to explore correlates of HIV testing in the last 12 months. Of 1,399 FSWs who had data for HIV testing, 44.7% (95% Confidence Intervals (CI): 40.7; 48.7) reported HIV testing in the last 12 months. The odds of HIV testing in the last 12 months was higher among FSWs who used a condom at last sex with a non-paying partner (Adjusted OR = 1.78; 95% CI: 1.39; 2.27), never used alcohol (Adjusted OR = 1.72; 95% CI: 1.33; 2.23), ever used drug (Adjusted OR = 1.60; 95% CI: 1.22; 2.08). HIV testing among FSWs in Iran is considerably low. It is necessary to know the barriers to HIV testing to improve the cascade of HIV treatment in the country.

BackgroundFour large community-randomized trials examining universal testing and treatment (UTT) to reduce HIV transmission were conducted between 2012-2018 in Botswana, Kenya, Uganda, Zambia and South Africa. In 2014, the UNAIDS 90-90-90 targets were adopted as a useful metric to monitor coverage. We systematically review the approaches used by the trials to measure intervention delivery, and estimate coverage against the 90-90-90 targets. We aim to provide in-depth understanding of the background contexts and complexities that affect estimation of population-level coverage related to the 90-90-90 targets.MethodsEstimates were based predominantly on "process" data obtained during delivery of the interventions which included a combination of home-based and community-based services. Cascade coverage data included routine electronic health records, self-reported data, survey data, and active ascertainment of HIV viral load measurements in the field.ResultsThe estimated total adult populations of trial intervention communities included in this study ranged from 4,290 (TasP) to 142,250 (Zambian PopART Arm-B). The estimated total numbers of PLHIV ranged from 1,283 (TasP) to 20,541 (Zambian PopART Arm-B). By the end of intervention delivery, the first-90 target (knowledge of HIV status among all PLHIV) was met by all the trials (89.2%-94.0%). Three of the four trials also achieved the second- and third-90 targets, and viral suppression in BCPP and SEARCH exceeded the UNAIDS target of 73%, while viral suppression in the Zambian PopART Arm-A and B communities was within a small margin (~ 3%) of the target.ConclusionsAll four UTT trials aimed to implement wide-scale testing and treatment for HIV prevention at population level and showed substantial increases in testing and treatment for HIV in the intervention communities. This study has not uncovered any one estimation approach which is superior, rather that several approaches are available and researchers or policy makers seeking to measure coverage should reflect on background contexts and complexities that affect estimation of population-level coverage in their specific settings. All four trials surpassed UNAIDS targets for universal testing in their intervention communities ahead of the 2020 milestone. All but one of the trials also achieved the 90-90 targets for treatment and viral suppression. UTT is a realistic option to achieve 95-95-95 by 2030 and fast-track the end of the HIV epidemic.

BackgroundNearly 50% of men living with HIV in many countries are unaware of their HIV status; men also have lower uptake of HIV treatment and pre-exposure prophylaxis (PrEP). In SSA, highly mobile men such as those working in fishing communities alongside Lake Victoria have low uptake of HIV testing and low rates of linkage to HIV treatment and PrEP, despite increasing availability of these services. HIV self-testing (HIVST) kits hold promise for overcoming barriers to HIV testing and linkage to services for HIV-positive and HIV-negative men. We describe here a protocol for an HIV status-neutral, social network-based approach to promote HIV testing, linkage to care and prevention, and better health outcomes, including adherence, in fishermen around Lake Victoria.MethodsUtilizing beach management unit (BMU) registries of fishermen operating in three Lake Victoria fishing communities in Siaya County, Kenya, we completed a census and social network mapping to identify close social networks of men. Network clusters identified by a socially-central lead ("promotor") and selected to ensure maximal separation between treatment and control will be randomized. Promotors in both arms will receive basic HIV training; intervention promotors are further trained in HIVST to distribute kits to their cluster, while control promotors will distribute to their cluster vouchers for free HIVST at nearby clinics. We will test whether these promoters can enhance linkage to ART and PrEP after self-testing, thereby addressing a key limitation of HIVST. We will also measure 6- and 12-month viral load in those living with HIV and PrEP adherence among those without HIV via urine tenofovir levels as objective markers of adherence.DiscussionThis study has the potential to improve HIV health and promote HIV prevention among a hard to reach, at-risk, and highly mobile population of men in Western Kenya-a critical population in Kenya's HIV prevention and treatment program. Further, if successful, this innovative social networks-based model could be scaled at the regional level to address HIV prevention and care among similarly at-risk populations of men in eastern Africa and inland fisheries settings across the continent.Trial registrationSelf-Test Strategies and Linkage Incentives to Improve ART and PrEP Uptake in Men, registered on February 26, 2021, registration # NCT04772469 .

INTRODUCTION: Malawi is rapidly closing the gap in achieving the UNAIDS 95-95-95 targets, with 90% of people living with HIV in Malawi aware of their status. As we approach epidemic control, interventions to improve coverage will become more costly. There is, therefore, an urgent need to identify innovative and low-cost strategies to maintain and increase testing coverage without diverting resources from other HIV services. The objective of this study is to model different combinations of facility-based HIV testing modalities and determine the most cost-effective strategy to increase the proportion of men and youth testing for HIV. METHODS: A data-driven individual-based model was parameterized with data from a community-representative survey (socio-demographic, health service utilization and HIV testing history) of men and youth in Malawi (data collected August 2019). In total, 79 different strategies for the implementation of HIV self-testing (HIVST) and provider-initiated-testing-and-counselling at the outpatient department (OPD) were evaluated. Outcomes included percent of men/youth tested for HIV in a 12-month period, cost-effectiveness and human resource requirements. The testing yield was assumed to be constant across the scenarios. RESULTS: Facility-based HIVST offered year-round resulted in the greatest increase in the proportion of men and youth tested in the OPD (from 45% to 72%-83%), was considered cost-saving for HIVST kit priced at $1.00, and generally reduced required personnel as compared to the status quo. At higher HIVST kit prices, and more relaxed eligibility criteria, all scenarios that considered year-round HIVST in the OPD remained on the cost-effectiveness frontier. CONCLUSIONS: Facility-based HIVST is a cost-effective strategy to increase the proportion of men/youth tested for HIV in Malawi and decreases the human resource requirements for HIV testing in the OPD-providing additional healthcare worker time for other priority healthcare activities.

BackgroundCommunity mobilisation, engaging communities in a process to collectively enact change, could improve HIV testing and care engagement. In South Africa, current rates fall below those needed for epidemic control. We assessed whether community mobilisation increased HIV testing, linkage to care, and retention in care over time in intervention relative to control communities.MethodsWe conducted a cluster-randomised controlled trial in villages in the Agincourt sub-district of the rural Mpumalanga Province in South Africa. 15 villages were randomly assigned to either a community mobilisation intervention engaging residents to address social barriers to HIV testing and treatment (intervention arm) or to a control arm using balanced randomisation. Villages were eligible if they had been fully enumerated in 2014, had not been included in previous mobilisation activities, and included over 500 permanent adult residents aged 18-49 years. Primary outcomes included quarterly rates of HIV testing, linkage to care, and retention in care documented from health facility records among residents of the intervention and control communities over the 3-year study period. Intention-to-treat analyses employed generalised estimating equations stratified by sex. This trial is registered with ClinicalTrials.gov, NCT02197793.FindingsBetween Aug 1, 2015, and July 31, 2018, residents in eight intervention communities (n=20 544 residents) and seven control communities (n=17 848) contributed data; 92 residents contributed to both arms. Among men, HIV testing increased quarterly by 12·1% (relative change [RC] 1·121, 95% CI 1·099 to 1·143, p

Community-based rapid HIV testing is effective for reaching racial-ethnically diverse men who have sex with men (MSM), offering an opportunity for bundled health promotion interventions. Given MSM experience a heightened prevalence of human papillomavirus (HPV) and meningococcal disease, we examined their preferences for bundling rapid HIV testing with an intervention to promote vaccination against these infections. In 2020, we conducted five virtual focus groups (N = 25 participants) in English and Spanish with MSM in Southern California's Inland Empire. Participants discussed their knowledge about HPV and meningitis vaccination and attitudes toward receiving vaccination information and referrals during rapid HIV tests. We used the rigorous and accelerated data reduction technique to systematically analyse the data. Participants had a mean age of 30, were socioeconomically diverse, and predominantly (68%) Hispanic. 96% had ever been tested for HIV, while only 28% were vaccinated against HPV and/or meningitis. Most participants were unaware of MSM's elevated risk for HPV and meningitis and were eager to receive vaccination information from LGBTQ+-friendly providers. However, many participants emphasised rapid HIV testing was stressful and anticipated feeling overwhelmed if presented with vaccination information in this setting. Preferred formats for vaccine promotion included pamphlets and resources that could be discretely accessed online, supported by broader advertising featuring diverse MSM on social media, dating apps, and posters in the community. Overall, our findings suggest that bundling health promotion messages with rapid HIV testing may be ineffective, as the anxiety associated with taking an HIV test may interfere with such messages and their impact.

ObjectivesIn late 2014, an HIV outbreak occurred in rural Cambodia among villagers who received medical injections from unlicensed medical providers, justifying the need to assess medical injection practices among those who are at risk of acquiring and/or transmitting HIV. This study examined medical injection/infusion behaviours among people living with HIV (PLWH) and those who were HIV negative in Cambodia. These behaviours should be properly assessed, especially among PLWH, as their prevalence might influence a future risk of other outbreaks.DesignA cross-sectional survey was conducted in order to examine injection behaviours and estimate injection prevalence and rates by HIV status. Unsafe injections/infusions were those received from village providers who do not work at a health centre or hospital, or traditional providers at the participant's (self-injection included) or provider's home. Logistic regression was performed to examine the relationship between unsafe injection/infusion and HIV, adjusting for sex, age, education, occupation, residence location and other risk factors.SettingThe survey was conducted in 10 HIV testing and treatment hospitals/clinics across selected provinces in Cambodia, from February to March 2017.ParticipantsA total number of 500 volunteers participated in the survey, 250 PLWH and 250 HIV-negative individuals.Outcome measuresMeasures of injection prevalence and other risk behaviours were based on self-reports.ResultsBoth groups of participants reported similar past year's injection/infusion use, 47% (n=66) among PLWH and 54% (n=110) HIV-negative participants (p=0.24). However, 15% (n=11) of PLWH reported having received unsafe last injection compared with only 7% (n=11) of HIV-negative participants. In logistic regression, this association remained numerically positive, but was not statistically significant (adjusted OR 1.84 (95% CI: 0.71 to 4.80)).ConclusionsThe inclination for medical injections and infusions (unsafe at times) among PLWH and the general population in Cambodia was common and could possibly represent yet another opportunity for parenteral transmission outbreak.

BackgroundLatino men who have sex with men (MSM) in San Diego have poor HIV testing and prevention outcomes compared with non-Latino White men. Peer navigation (PN) is a promising evidence-based intervention to reduce disparities but needs tailoring for Latino MSM.SettingsHealth centers near the US-Mexico border.MethodsUsing the Exploration, Preparation, Implementation, Sustainment Framework, we conducted mixed-methods implementation science study. In phase I, we conducted interviews with Latino men (n = 15), focus groups with staff (n = 7), and surveys with all to understand the Exploration, Preparation, Implementation, Sustainment factors associated with HIV testing and care linkage. In phase II, we conducted 31 web-based surveys with Latino men and staff to rank intervention and implementation strategies from phase I. Quantitative data were analyzed descriptively, integrated with qualitative data, and reviewed by our community-academic partnership to develop an implementation model.ResultsLatino men (N = 15) were 94% Spanish speaking, 67% gay identified, 27% US born, and their suggestions were to have navigators use peer referral to address barriers such as stigma; use the Latino social network to expand reach, leverage social media for peer-led intervention, and disseminate HIV information. Staff (N = 26) were 77% Spanish speaking, 35% gay-identified, 96% trained in cultural competency, and suggested including culturally appropriate HIV educational materials in Spanish, status and identity neutral programs, administrative/supervisorial/training structure for PNs, and PN compensation and team integration. Overall, results emphasized a need for a formalized PN model centered on referrals and using existing Latino community social networks.ConclusionsFindings can be packaged for future implementation of PN programs for Latino MSM.

IntroductionSouth African men are underrepresented in HIV testing and treatment services. Secondary distribution of oral HIV self-test (HIVST) kits by women living with HIV (WLHIV) to their male partners (i.e. index partner HIVST) may increase men's testing and treatment but has been understudied.MethodsBetween March and July 2021, we evaluated the effectiveness of index partner HIVST versus the standard of care (SOC) (invitations for men's facility-based testing) on men's testing in a 1:1 randomized control trial. Eligibility criteria included: WLHIV; ≥18 years of age; attending one of four high-density rural clinics; have a working cell phone; and self-reported having a primary male partner of unknown serostatus. The primary outcome was the proportion of WLHIV reporting that her partner tested for HIV within 3 months after enrolment.ResultsWe enrolled 180 WLHIV and 176 completed an endline survey (mean age = 35 years, 15% pregnant, 47% unmarried or non-cohabiting). In the HIVST arm, 78% of male partners were reported to have tested for HIV versus 55% in SOC (RR = 1.41; 95% CI = 1.14-1.76). In the HIVST arm, nine men were reactive with HIVST (14% positivity), six were confirmed HIV positive with standard testing (67%) and all of those started antiretroviral therapy (ART), and four HIV-negative men started pre-exposure prophylaxis (PrEP) (5%). In SOC, six men were diagnosed with HIV (12% positivity), 100% started ART and seven HIV-negative men started PrEP (16%). One case of verbal intimate partner violence was reported in the HIVST arm.ConclusionsSecondary distribution of HIVST to partners of WLHIV was acceptable and effective for improving HIV testing among men in rural South Africa in our pilot study. Interventions are needed to link reactive HIVST users to confirmatory testing and ART.

ObjectivesPeople with severe mental illness are 10 times more likely to have HIV/ AIDS than the general population, yet little is known about the characteristics and frequency of recognition of pre-existing HIV/AIDS diagnoses among inpatients with severe mental illness. This study examines documentation rates of pre-existing HIV/ AIDS among inpatients within psychiatric hospitals in New York State.DesignRetrospective cohort study to examine recognition of pre-existing HIV/AIDS among psychiatric inpatients.MethodsPatient-level Medicaid claims records were linked with hospital and regional data for people admitted to psychiatric inpatient units in New York State. Presence of HIV/AIDS diagnoses prior to psychiatric hospitalization was coded for each inpatient (n = 14 602). Adjusted odds ratios of undocumented HIV/AIDS diagnoses at the time of discharge were calculated using logistic regression analyses.ResultsAbout 5.1% (741/14 602) of unique psychiatric inpatients had pre-existing HIV/AIDS diagnoses. Of these inpatients, 58.3% (432/741) were not coded as having HIV/AIDS upon discharge. Higher rates of missed detection were associated with younger age, non-Hispanic white race/ethnicity, shorter length of stay, more distal coding of an HIV/AIDS diagnosis, and fewer HIV/AIDS-related Medicaid claims in the past year. Hospitals with higher readmission rates also had higher rates of undetected HIV/AIDS diagnoses.ConclusionOver half of inpatients previously diagnosed with HIV/AIDS did not have their HIV-positive status noted upon discharge from psychiatric hospitalization. This finding underscores how frequently clinically significant medical comorbidities fail to be incorporated into psychiatric treatment and treatment planning. Inpatient clinicians are missing important opportunities to optimize HIV/AIDS treatment and reduce morbidity and mortality.

ObjectiveWe sought to assess the effectiveness of using a peer-led online community to increase HIV self-testing among Latinx and African American men who have sex with men (MSM).DesignRandomized controlled trial.MethodsThroughout 6 waves, between February 18, 2017, and January 8, 2021, 900 HIV negative and/or serostatus unknown Los Angeles-based MSM (68.9% Latinx, 16.0% African American, and 7.4% White) participated in an online 12-week HIV prevention randomized controlled trial. A total of 79 trained role models (peer leaders) were randomly assigned to participants within clusters to build trust and deliver HIV testing information on Facebook groups. Participants in control groups were assigned to groups without peer leaders. Participants were not required to respond to peer leaders or to remain group members. Participants completed self-report assessments at baseline and 12-week follow-up and could receive a free HIV self-testing kit during the study period.ResultsCompared with control group participants, intervention group participants were significantly more likely to accept the offer for the HIV self-testing kit (intervention 130 of 450, 29%; control 102 of 450, 22.7%; odds ratio = 1.43, 95% confidence interval: 1.04 to 1.95, P = 0.03), report having taken an HIV self-test within the past 3 months (odds ratio = 1.47, 95% confidence interval: 1.01 to 2.13, P = 0.04), and report drinking fewer glasses of alcohol in an average week (P = 0.01). Effects seemed concentrated within later study waves. Study retention was greater than 93%.ConclusionsA peer-led online community seems to be an effective method of increasing HIV self-testing among MSM of color. We discuss the implications of the wave effects on public health research and policy.

Youth aged 15-24 years comprise 48% of new HIV infections and 15% of persons living with HIV in Kisumu County, Kenya. We assessed factors associated with HIV infection among youth participating in the Community Health Initiative (CHI) implemented in an urban informal settlement in 2018. Predictors of HIV infection were assessed by multivariable logistic regression. CHI engaged 4,441 youth through community health campaigns and home-based HIV testing. HIV prevalence was 3.5% overall and 7.1% among young women aged 20-24. There were 24 youth newly identified as HIV-positive out of 157 total HIV-positive youth. HIV-positive status was positively associated with being female (aOR = 2.46; 95% CI 1.57, 3.84) and aged 20-24 (aOR = 2.40; 95% CI 1.52, 3.79), and inversely associated with secondary school education or higher (aOR = 0.27; 95% CI 0.16, 0.44). Our findings highlight the need for HIV prevention programs specially tailored for youth to further reduce new HIV infections in this priority population.

Social influences may create a barrier to couples HIV testing and counselling (CHTC) uptake in sub-Saharan Africa. This secondary analysis of data collected in the 'Uthando Lwethu' randomised controlled trial used discrete-time survival models to evaluate the association between within-couple average 'peer support' score and uptake of CHTC by the end of nine months' follow-up. Peer support was conceptualised by self-rated strength of agreement with two statements describing friendships outside of the primary partnership. Eighty-eight couples (26.9%) took up CHTC. Results tended towards a dichotomous trend in models adjusted only for trial arm, with uptake significantly less likely amongst couples in the higher of four peer support score categories (OR 0.34, 95% CI 0.18, 0.68 [7-10 points]; OR 0.53, 95% CI 0.28, 0.99 [≥ 11 points]). A similar trend remained in the final multivariable model, but was no longer significant (AOR 0.59, 95% CI 0.25, 1.42 [7-10 points]; AOR 0.88, 95% CI 0.36, 2.10 [≥ 11 points]). Accounting for social influences in the design of couples-focused interventions may increase their success.

Little is known about screening tools for adults in high HIV burden contexts. We use exit survey data collected at outpatient departments in Malawi (n = 1038) to estimate the sensitivity, specificity, negative and positive predictive values of screening tools that include questions about sexual behavior and use of health services. We compare a full tool (seven relevant questions) to a reduced tool (five questions, excluding sexual behavior measures) and to standard of care (two questions, never tested for HIV or tested > 12 months ago, or seeking care for suspected STI). Suspect STI and ≥ 3 sexual partners were associated with HIV positivity, but had weak sensitivity and specificity. The full tool (using the optimal cutoff score of ≥ 3) would achieve 55.6% sensitivity and 84.9% specificity for HIV positivity; the reduced tool (optimal cutoff score ≥ 2) would achieve 59.3% sensitivity and 68.5% specificity; and standard of care 77.8% sensitivity and 47.8% specificity. Screening tools for HIV testing in outpatient departments do not offer clear advantages over standard of care.

BackgroundSouth Los Angeles (SPA6), with mostly Black (27.4%) and Latinx (68.2%) residents, has the second highest rates of new HIV diagnoses (31 per 100,000) in Los Angeles County. However, there is limited understanding of the HIV testing-to-care continuum among newly diagnosed in this setting.MethodsWe conducted an exploratory study that analyzed de-identified data, including demographic characteristics and biomedical outcomes, from the electronic medical records of individuals newly diagnosed with HIV from 2016-2020 at the only public safety-net, county-run health department HIV clinic in SPA 6. We used Pearson Chi-square and Fisher's Exact test to explore associations with HIV outcomes and a Kaplan-Meier survival curve to assess the time to linkage to care.ResultsA total of 281 patients were identified. The majority (74.1%) presented with a baseline CD4

BackgroundIndividuals with serious mental illness often do not receive guideline-concordant metabolic screening and human immunodeficiency virus (HIV) testing, contributing to increased morbidity and premature mortality. This study evaluates the effectiveness of CRANIUM (Cardiometabolic Risk Assessment and treatment through a Novel Integration model for Underserved populations with Mental illness), an intervention to increase metabolic screening and HIV testing among patients with serious mental illness in a community mental health clinic compared to usual care.MethodsThe study used a quasi-experimental design, prospectively comparing a preventive care screening intervention at one community mental health clinic (n = 536 patients) to usual care at the remaining clinics within an urban behavioural health system (n = 4,847 patients). Psychiatrists at the intervention site received training in preventive health screening and had access to a primary care consultant, screening and treatment algorithms, patient registries, and a peer support specialist. Outcomes were the change in screening rates of A1c, lipid, and HIV testing post-intervention at the intervention site compared to usual care sites.ResultsRates of lipid screening and HIV testing increased significantly at the intervention site compared to usual care, with and without multivariable adjustment [Lipid: aOR 1.90, 95% CI 1.32-2.75, P = .001; HIV: aOR 23.42, 95% CI 5.94-92.41, P

HIV disproportionately affects Latinos versus Whites, with Latinos having higher rates of HIV. Additionally, many HIV-positive Latinos are unaware of their infection. Proyecto Protégete, an HIV prevention intervention developed for Latino men who have sex with men (MSM), used social and sexual networking mobile applications (apps) to recruit individuals for HIV testing and linkage to medical care and prevention services. This study occurred in Los Angeles County, California, USA from December 18, 2015 to April 22, 2017. The study's primary aim was to assess Proyecto Protégete's ability to successfully recruit Latino MSM involved in high-risk sexual activities. A secondary aim was to evaluate its capacity to promote HIV testing and linkage to HIV medical care and prevention services among this population by comparing it to two programs with similar samples. Comparisons using Fisher's Exact Test were conducted between Proyecto Protégete and the HIV testing program of the agency in which Proyecto Protégete was located and the County-funded HIV testing programs to compare the samples' rates of HIV-positive Latino MSM identified through HIV testing and linked to HIV medical care and prevention services. Participants were recruited through seven apps. In Proyecto Protégete, 9,573 individuals completed the screener, 4,657 were eligible, and 359 (7.7% of those eligible) enrolled. Among those enrolled, 79% reported anal sex without a condom in the previous twelve months; 51% reported anal sex under the influence of alcohol. The HIV positivity rates were as follows: Proyecto Protégete, 1.71%; the agency, 1.25% (p = .293, compared to Proyecto Protégete); and the County, 1.09% (p = .172, compared to Proyecto Protégete). The rates of those confirmed as new HIV-positives and linked to medical care within 30 days were as follows: Proyecto Protégete, 71.4%; the agency, 81.5% (p = .450, compared to Proyecto Protégete); and the County, 77.3% (p = .503, compared to Proyecto Protégete). Proyecto Protégete had a higher rate of linked referrals to prevention services than the agency's testing program (19.5% versus 8.3%, p < .001). Proyecto Protégete experienced successes in some areas but not in others. Future research should build on Proyecto Protégete's experiences to promote HIV-related services among Latino MSM.

BackgroundWorldwide, an estimated 38.0 million people lived with the human immunodeficiency virus in 2019, and 3.4 million young people aged 15~24 years were living with HIV. Sub-Saharan Africa carries a significant HIV burden with West and Central Africa most affected with HIV. Among the young people living with HIV in West and Central Africa, an estimated 810,000 were aged 15~24 years. This study aimed to assess predictors that influence the uptake of HIV testing among youth aged 15~24 years in The Gambia.MethodsThe 2013 Gambia Demographic and Health Survey data for youth aged 15~24 years was used. The Andersen behavioral model of health service use guided this study. A cross-sectional study design was used on 6194 subjects, among which 4730 were female. The analysis employed Chi-squared tests and hierarchical logistic regression.ResultsLess than one-quarter of the youth 1404 (22.6%) had ever been tested for HIV. Young people aged 20~24 years (adjusted odds ratio (aOR): 1.98), who were females (aOR: 1.13), married youth (aOR: 3.89), with a primary (aOR: 1.23), secondary or higher education (aOR: 1.46), and who were from the Jola/Karoninka ethnic group (aOR: 1.81), had higher odds of having been tested for HIV. Those with adequate HIV knowledge and those who were sexually active and had aged at first sex ≥15 years (aOR: 3.99) and those

BackgroundPublic health is increasingly turning to non-traditional digital data to inform HIV prevention and control strategies. We demonstrate a parsimonious method using both traditional survey and internet search histories to provide new insights into HIV testing and pre-exposure prophylaxis (PrEP) information seeking that can be easily extended to other settings.MethodWe modeled how US internet search volumes from 2019 for HIV testing and PrEP compared against expected search volumes for HIV testing and PrEP using state HIV prevalence and socioeconomic characteristics as predictors. States with search volumes outside the upper and lower bound confidence interval were labeled as either over or under performing. State performance was evaluated by (a) Centers for Disease Control and Prevention designation as a hotspot for new HIV diagnoses (b) expanding Medicaid coverage.ResultsTen states over-performed in models assessing information seeking for HIV testing, while eleven states under-performed. Thirteen states over-performed in models assessing internet searches for PrEP information, while thirteen states under-performed. States that expanded Medicaid coverage were more likely to over perform in PrEP models than states that did not expand Medicaid coverage. While states that were hotspots for new HIV diagnoses were more likely to over perform on HIV testing searches.ConclusionOur study derived a method of measuring HIV and PrEP information seeking that is comparable across states. Several states exhibited information seeking for PrEP and HIV testing that deviated from model assessments. Statewide search volume for PrEP information was affected by a state's decision to expand Medicaid coverage. Our research provides health officials with an innovative way to monitor statewide interest in PrEP and HIV testing using a metric for information-seeking that is comparable across states.

BackgroundHIV testing is the gateway to HIV treatment and prevention. HIV self-testing (HIVST) has potential to increase testing; however, the potential population-level impact of HIVST on the HIV epidemic and the best strategies for promoting HIVST are unknown. Our aim is to inform public health approaches for promoting HIVST as part of a comprehensive strategy to reduce HIV incidence.MethodsStochastic network-based HIV transmission models were used to estimate how different HIVST strategies would affect HIV incidence in Seattle and Atlanta over 10 years. We included four types of HIV testers and implemented nine replacement and eleven supplementation strategies for HIVST.ResultsReplacement of clinic-based tests with HIVST increased HIV incidence in Seattle and Atlanta. The benefits of supplementary strategies depended on the tester type using HIVST. Targeting non-testers averted the highest number of cases per test. In Seattle 2.2 (95%SI=-77, 100.4) and 4.7 (95%SI=-35.7, 60.1) infections were averted per 1000 HIVST when non-testers used HIVST once or twice per year respectively. In Atlanta the comparable rates were 8.0 (95%SI=-60.3 to 77.7) and 6.7 (95%SI=-37.7, 41.0). Paradoxically, increasing testing among risk-based testers using HIVST increased incidence.ConclusionsThe population-level impact of HIVST depends on who is reached with HIVST, how kits are used, and by characteristics of the underlying epidemic and HIV care infrastructure. Targeted HIVST can be an effective component of a comprehensive HIV testing strategy. More work is needed to understand how to identify and target non-testers for self-testing implementation.

ObjectiveThe objective of this study was to determine the availability and national distribution of HIV testing and counseling at substance use treatment facilities in the United States.MethodsAnalyses of data from the 2018 National Survey of Substance Abuse Treatment Services assessed HIV testing and counseling availability in U.S. substance use treatment facilities (excluding those in U.S. territories). Facilities were subcategorized by availability of mental health services and medication for opioid use disorders and compared by using logistic models. Descriptive statistics were calculated to characterize the availability of HIV testing and counseling by state, state HIV incidence, and facility characteristics.ResultsAmong U.S. substance use treatment facilities (N=14,691), 29% offered HIV testing, 53% offered HIV counseling, 23% offered both, and 41% offered neither. Across states, the proportions of facilities offering HIV testing ranged from 9.0% to 62.8%, and the proportion offering counseling ranged from 19.2% to 83.3%. In only three states was HIV testing offered by at least 50% of facilities. HIV testing was significantly more likely to be offered in facilities that offered medication for opioid use disorder (48.0% versus 16.0% in those not offering such medication) or mental health services (31.2% versus 24.1% in those not offering such services). Higher state-level HIV incidence was related to an increased proportion of facilities offering HIV testing.ConclusionsOnly three in 10 substance use treatment facilities offered HIV testing in 2018. This finding represents a missed opportunity for early identification of HIV among people receiving treatment for substance use disorders.

Uptake of HIV testing is suboptimal in Uganda, particularly in rural communities. Reaching UNAIDS 95-95-95 goals requires strategies to increase HIV testing among hard-to-reach populations. This cross-sectional study sought to characterize engagement with HIV testing among traditional healers and their clients in rural Uganda. We enrolled 175 traditional healers and 392 adult clients of healers in Mbarara District. The primary outcome for this study was having received an HIV test in the prior 12 months. Most clients (n = 236, 65.9%) had received an HIV test within 12 months, compared to less than half of healers (n = 75, 46.3%) who had not. In multivariate regression models, male clients of healers were half as likely to have tested in the past year, compared with female (adjusted odds ratios (AORs) = 0.43, 95% CI = 0.26-0.70). Increasing age negatively predicted testing within the past year (AOR = 0.95, 95% CI = 0.93-0.97) for clients. Among healers, more sexual partners predicted knowing ones serostatus (AOR = 1.6, 95% CI 1.03-2.48). Healers (AOR = 1.16, 95% CI 1.07-1.26) and clients (AOR = 1.28, 95% CI 1.13-1.34 for clients) with greater numbers of lifetime HIV tests were more likely to have tested in the past year. Traditional healers and their clients lag behind UNAIDS benchmarks and would benefit from programs to increase HIV testing uptake.

Since the beginning of the HIV epidemic, there have been more than 75 million cases. Currently, there about 1.2 million living with HIV in the USA. Despite current testing recommendations, test rates continue to be suboptimal. Investigators have studied the use of digital technology to promote HIV testing, especially among high-risk populations. PURPOSE OF REVIEW: This non-systematic review provides an overview of the scientific research between 2015 and 2020 focused on the use of digital technology to bolster HIV testing and suggests novel technologies for exploration. RECENT FINDINGS: A total of 40 studies were included in the review that span a wide range of available technology. Studies effectively increased HIV testing among study participants. Generally, participants in the intervention/exposure groups had significantly higher rates of HIV test uptake compared to participants in the comparison groups at study follow-up. For a variety of reasons (e.g., differences in ways the technologies were used and study design), no digital tool clearly performed better than others, but each have the capacity to increase outreach and self-testing. An exploration of the potential use of nascent technologies is also discussed, as well as the authors' experiences using a number of these technologies in our research.

ObjectiveTo examine the factors associated with recent HIV testing and to develop an HIV testing prevalence surface map using spatial interpolation techniques to identify geographical areas with low and high HIV testing rates in Ghana.DesignSecondary analysis of Demographic and Health Survey.SettingRural and urban Ghana PARTICIPANTS: The study sample comprised 9380 women and 3854 men of 15-49 years.ResultsWe found that 13% of women and 6% of men of Ghana had tested for HIV in the past 12 months. For women, being within the age groups of 15-39 years, being currently married, attainment of post-secondary education, having only one sexual partner and dwelling in certain regions with reference to greater Accra (Volta, Eastern, Upper West and Upper East) were associated with a higher likelihood of HIV testing. For men, being older than 19 years, attainment of post-secondary education and dwelling in the Upper East region with reference to the greater Accra region were significantly associated with a higher likelihood of HIV testing. The surface map further revealed intra-regional level differences in HIV testing estimates.ConclusionGiven the results, HIV testing must be expanded with equitable testing resource allocation that target areas within the regions in Ghana with low HIV testing prevalence. Men should be encouraged to be tested for HIV.

Justice-involved youth have a number of risk factors for HIV infection, including high rates of substance use, psychiatric comorbidities, and risky sexual behaviors. Although detained youth are likely to receive health care-which may include HIV testing-court-involved, non-incarcerated (CINI) youth may be unlikely to receive HIV testing services either before or during their justice involvement. However, the relationship between risk factors and HIV testing among CINI youth is largely unknown. We explored the association between HIV testing and factors commonly associated with both HIV testing and HIV risk among 173 CINI youth with identified behaviors that put them at risk for HIV acquisition. Only 15.6% of participants reported a lifetime history of HIV testing, despite high rates of sexual and substance use risk behaviors. Age (older), gender (female), sexual orientation (non-heterosexual), recent marijuana use, lifetime use of other drugs, history of a sexually transmitted infection, pap smear in the past year and history of mental health/substance use treatment were all significantly associated with lifetime HIV testing. The extremely low testing rates in this sample emphasize that the juvenile justice system outside of detention is not adequately addressing youths needs related to HIV testing or ensuring access to testing services for youth at risk of contracting HIV. Results suggest that additional efforts are needed to connect justice-involved youth to healthcare more broadly and HIV testing in particular.

BackgroundFrequent retesting for HIV among persons at increased risk of HIV infection is critical to early HIV diagnosis of persons and delivery of combination HIV prevention services. There are few evidence-based interventions for promoting frequent retesting for HIV. We sought to determine the effectiveness of financial incentives and deposit contracts in promoting quarterly HIV retesting among adults at increased risk of HIV.Methods and findingsIn peri-urban Ugandan communities from October to December 2018, we randomized HIV-negative adults with self-reported risk to 1 of 3 strategies to promote HIV retesting: (1) no incentive; (2) cash incentives (US$7) for retesting at 3 and 6 months (total US$14); or (3) deposit contracts: participants could voluntarily deposit US$6 at baseline and at 3 months that would be returned with interest (total US$7) upon retesting at 3 and 6 months (total US$14) or lost if participants failed to retest. The primary outcome was retesting for HIV at both 3 and 6 months. Of 1,482 persons screened for study eligibility following community-based recruitment, 524 participants were randomized to either no incentive (N = 180), incentives (N = 172), or deposit contracts (N = 172): median age was 25 years (IQR: 22 to 30), 44% were women, and median weekly income was US$13.60 (IQR: US$8.16 to US$21.76). Among participants randomized to deposit contracts, 24/172 (14%) made a baseline deposit, and 2/172 (1%) made a 3-month deposit. In intent-to-treat analyses, HIV retesting at both 3 and 6 months was significantly higher in the incentive arm (89/172 [52%]) than either the control arm (33/180 [18%], odds ratio (OR) 4.8, 95% CI: 3.0 to 7.7, p < 0.001) or the deposit contract arm (28/172 [16%], OR 5.5, 95% CI: 3.3 to 9.1, p < 0.001). Among those in the deposit contract arm who made a baseline deposit, 20/24 (83%) retested at 3 months; 11/24 (46%) retested at both 3 and 6 months. Among 282 participants who retested for HIV during the trial, three (1%; 95%CI: 0.2 to 3%) seroconverted: one in the incentive group and two in the control group. Study limitations include measurement of retesting at the clinic where baseline enrollment occurred, only offering clinic-based (rather than community-based) HIV retesting and lack of measurement of retesting after completion of the trial to evaluate sustained retesting behavior.ConclusionsOffering financial incentives to high-risk adults in Uganda resulted in significantly higher HIV retesting. Deposit contracts had low uptake and overall did not increase retesting. As part of efforts to increase early diagnosis of HIV among high-risk populations, strategic use of incentives to promote retesting should receive greater consideration by HIV programs.Trial registrationclinicaltrials.gov: NCT02890459.

BackgroundMen who have sex with men (MSM) in India are extremely marginalised and stigmatised, and therefore experience immense psychosocial stress. As current HIV prevention interventions in India do not address mental health or resilience to these stressors, we aimed to evaluate a resilience-based psychosocial intervention in the context of HIV and sexually transmitted infection (STI) prevention.MethodsWe did a multicity, randomised, clinical efficacy trial in Chennai (governmental tuberculosis research institute) and Mumbai (non-governmental organisation for MSM), India. Inclusion criteria were MSM, aged 18 years or older, who were at risk of HIV acquisition or transmission, defined as having any of the following in the 4 months before screening: anal sex with four or more male partners (protected or unprotected), diagnosis of an STI, history of transactional sex activity, or condomless anal sex with a man who was of unknown HIV status or serodiscordant. Participants were required to speak English, Tamil (in Chennai), or Hindi (in Mumbai) fluently. Eligible individuals were randomly assigned (1:1) to either a resilience-based psychosocial HIV prevention intervention, consisting of group (four sessions) and individual (six sessions) counselling alongside HIV and STI voluntary counselling and testing, or a standard-of-care control comprising voluntary counselling and testing alone. The primary outcomes were number of condomless anal sex acts with male partners during the past month (at baseline and 4 months, 8 months, and 12 months after randomisation), and incident bacterial STIs (at 12 months after randomisation). Resilience-related mediators included self-esteem, self-acceptance, and depression. Recruitment is now closed. This trial is registered with ClinicalTrials.gov, NCT02556294.FindingsBetween Sept 4, 2015, and June 28, 2018, we enrolled 608 participants; 305 (50%) were assigned to the psychosocial intervention condition and 303 (50%) were assigned to the control condition. 510 (84%) of 608 men completed an assessment at 4 months after randomisation, 483 (79%) at 8 months, and 515 (85%) at 12 months. 512 (99%) of 515 men had STI data from the 12-month assessment. The intervention condition had a 56% larger reduction in condomless anal sex acts (95% CI 35-71; p

BackgroundEfforts to increase HIV testing, diagnosis and care are critical to curbing HIV epidemics among cisgender men who have sex with men (MSM) and transgender women (TW) in low- and middle-income countries (LMIC). We compared the effectiveness of respondent-driven sampling (RDS) and venue-based sampling (VBS) for identifying previously undiagnosed HIV infection among MSM and TW in Tijuana, Mexico.MethodsBetween March 2015 and December 2018, we conducted RDS within the social networks of MSM and TW and VBS at venues frequented by MSM and TW to socialize and meet sexual partners. Those reached by RDS/VBS who reported at least 18 years of age, anal sex with MSM or TW, and no previous HIV diagnosis were eligible for HIV testing.ResultsOf those screened following recruitment via RDS (N = 1232; 98.6% MSM; 1.3% TW), 60.8% (749/1232) were eligible for HIV testing and 97.5% (730/749) were tested for HIV infection, which led to the identification of 36 newly diagnosed HIV infections (4.9%). Of those screened following recruitment via VBS (N = 2560; 95.2% MSM; 4.6% TW), 56.5% (1446/2560) were eligible for HIV testing and 92.8% (1342/1446) were tested for HIV infection, which led to the identification of 82 newly diagnosed HIV infections (6.1%). The proportion of new HIV diagnoses did not differ by recruitment method (ratio = 0.81, 95% confidence interval: 0.55 to 1.18). Compared to those recruited via RDS, those tested following recruitment via VBS were younger, more likely to identify as gay, and more likely to identify as TW. Compared to those recruited via VBS, those newly diagnosed with HIV infection following recruitment via RDS reported higher levels of internalized stigma and were more likely to report injection drug use and a history of deportation from the United States.ConclusionsDespite RDS and VBS being equally effective for identifying undiagnosed HIV infection, each recruitment method reached different subgroups of MSM and TW in Tijuana. Our findings suggest that there may be benefits to using both RDS and VBS to increase the identification of previously undiagnosed HIV infection and ultimately support HIV care engagement among MSM and TW in Mexico and other similar LMIC.