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Introduction: Facility-based HIV testing services (HTS) have been less acceptable and accessible by adolescents, men and key populations in South Africa. Community-based HIV counselling and testing (CBCT) modalities, including mobile unit and home-based testing, have been proposed to decrease barriers to HIV testing uptake. CBCT modalities and approaches may be differentially acceptable to men and women based on age. Implementation of multimodal CBCT services may improve HIV testing rates among adolescents and men, and support the roll-out of prevention services. Methods: A cross-sectional analysis was conducted using aggregate, routine programmatic data collected from 1 October 2015 through 31 March 2017 from a multimodal, at-scale CBCT programme implemented in 12 high-burden districts throughout South Africa. Data collection tools were aligned to reporting standards for the National Department of Health and donor requirements. HIV testing rates (i.e. number of tests performed per 100,000 population using South African census data) and testing proportions by modality were stratified by sex, age groups and heath districts. Descriptive statistics were performed using STATA 13.0. Results: Overall, 944,487 tests were performed during the 1.5-year testing period reported. More tests were conducted among females than males (53.6% vs. 46.4%). Overall, 8206 tests per 100,000 population (95% CI: 8190.2 to 8221.9) were performed; female-to-male (F:M) testing ratio was 1.11. Testing rates were highest among young women age 20 to 24 years (16,328.4; 95% CI: 16,237.9 to 16,419.1) and adolescent girls aged 15 to 19 years (12,817.0; 95% CI: 12,727.9 to 12,906.6). Home-based testing accounted for 61.3% of HIV tests, followed by near-home mobile unit testing (30.2%) and workplace mobile unit testing (4.7%). More women received HTS via home-based testing (F:M ratio = 1.29), whereas more men accessed work-place mobile testing (M:F ratio = 1.35). No sex differential was observed among those accessing near-home mobile testing (F:M ratio = 0.98). Conclusions: Concurrent implementation of multiple, targeted CBCT modalities can reduce sex disparities in HIV testing in South Africa. Given the acceptability and accessibility of these CBCT services to adolescent girls and young women, evident from their high testing rates, leveraging community-based services delivery platforms to increase access to HIV prevention services, including pre-exposure prophylaxis (PrEP), should be considered. Keywords: HIV testing services; HIV testing uptake; community-based HIV counselling and testing; sex disparities; adolescent girls and young women; South Africa, 1 | INTRODUCTION South Africa has the largest HIV epidemic in the world, with an estimated 7.7 million people living with HIV (PLHIV) [1], and the highest incidence of new [...]

Introduction: Although HIV testing services (HTS) have been successfully task-shifted to lay counsellors, no model has tested the franchising of HTS to lay counsellors as independent small-scale business owners. This paper evaluates the effectiveness of a social franchisee (SF) HTS-managed pilot project compared to the Foundation for Professional Development (FPD) employee-managed HTS programme in testing and linking clients to care. Methods: Unemployed, formally employed or own business individuals were engaged as franchisees, trained and supported to deliver HTS services under a common brand in high HIV-prevalent communities in Tshwane district between 2016 and 2017. SFs were remunerated per-HIV test and received larger payments per-HIV-positive client linked to care. In the standard HTS, FPD employed counsellors received similar training and observed similar standards as in the SF HTS, but were remunerated through the normal payroll. We assessed the proportion of clients tested, HIV positivity, linkage to care and per-counsellor cost of HIV test and linkage to care in the two HTS groups. Results: The SF HTS had 19 HIV counsellors while FPD HTS employed 20. A combined total of 84,556 clients were tested by SFs (50.5%: 95% confidence interval (CI) 50.2 to 50.8)) and FPD (49.5%: 49.2 to 49.8). SFs tested more females than FPD (54.1%: 53.6 to 54.6 vs. 48%: 47.7 to 48.7). SFs identified more first-time testers than FPD (21.5%: 21.1 to 21.9 vs. 8.9%: 8.6 to 9.1). Overall, 8%: 7.9 to 8.2 tested positive with more clients testing positive in the SF (10.2%: 9.9 to 10.5) than FPD (5.9%: 5.6 to 6.1) group. The SFs identified more female HIV-positive clients (11.1%: 10.7 to 11.6) than FPD (6.5%: 6.2 to 6.9). The SFs linked fewer clients to HIV care and treatment (60.0%: 58.5 to 61.5) than FPD (80.3%: 78.7 to 81.9%). It cost four times less to conduct an HIV test using SFs ($3.90 per SF HIV test) than FPD ($13.98) and five times less to link a client to care with SFs ($62.74) than FPD ($303.13). Conclusions: SF HTS was effective in identifying more clients, first-time HIV testers and more HIV-positive people, but less effective in linking clients to care than FPD HTS. The SF HTS model was cheaper than the FPD-employee model. We recommend strengthening SFs particularly their linkage to care activities. Keywords: social franchising; HIV testing; HIV positivity; linkage to care; HIV testing and linkage cost; South Africa, 1 | INTRODUCTION With an estimated 7.1 million people living with HIV (PLHIV) and almost 270,000 people newly infected with HIV in 2016 [1-3] South Africa has a large HIV [...]

Objective: To determine which of 3 HIV testing and counseling (HTC) models in outpatient departments (OPDs) increases HIV testing and entry of newly identified HIV-infected patients into care., Design: Randomized trial of HTC interventions., Methods: Thirty-six OPDs in South Africa, Tanzania, and Uganda were randomly assigned to 3 different HTC models: (A) health care providers referred eligible patients (aged 18-49, not tested in the past year, not known HIV positive) to on-site voluntary counseling and testing for HTC offered and provided by voluntary counseling and testing counselors after clinical consultation; (B) health care providers offered and provided HTC to eligible patients during clinical consultation; and (C) nurse or lay counselors offered and provided HTC to eligible patients before clinical consultation. Data were collected from October 2011 to September 2012. We describe testing eligibility and acceptance, HIV prevalence, and referral and entry into care. Chi-square analyses were conducted to examine differences by model., Results: Of 79,910 patients, 45% were age eligible and 16,099 (45%) age eligibles were tested. Ten percent tested HIV positive. Significant differences were found in percent tested by model. The proportion of age eligible patients tested by Project STATUS was highest for model C (54.1%, 95% confidence interval [CI]: 42.4 to 65.9), followed by model A (41.7%, 95% CI: 30.7 to 52.8), and then model B (33.9%, 95% CI: 25.7 to 42.1). Of the 1596 newly identified HIV positive patients, 94% were referred to care (96.1% in model A, 94.7% in model B, and 94.9% in model C), and 58% entered on-site care (74.4% in model A, 54.8% in model B, and 55.6% in model C) with no significant differences in referrals or care entry by model., Conclusions: Model C resulted in the highest proportion of all age-eligible patients receiving a test. Although 94% of STATUS patients with a positive test result were referred to care, only 58% entered care. We found no differences in patients entering care by HTC model. Routine HTC in OPDs is acceptable to patients and effective for identifying HIV-infected persons, but additional efforts are needed to increase entry to care.

Men may be key players in the transmission of sexually transmitted infections (STI), and it is important that STI/HIV health services reach men. The objective of this study was to explore sexual health care access and seeking behaviours in men. This study used focus groups to examine sexual health care access and seeking behaviours in men 5 years after implementation of free antiretroviral therapy (ART) in the South African public sector. Six focus groups (N=58) were conducted with men ≫18 years in an urban area of Gauteng province. Men were recruited from various locations throughout the community. Men reported several barriers and facilitators to the use of public and private clinics for sexual health services including HIV testing, and many men reported seeking care from traditional healers. Men often viewed public clinics as a place for women and reported experiences with some female nurses who were rude or judgmental of the men. Additionally, some men reported that they sought sexual health care services at public clinics; however, they were not given physical examinations by health care providers to diagnose their STI syndrome. Most men lacked knowledge about ART and avoided HIV testing because of fear of death or being abandoned by their families or friends. Study findings suggest that men still require better access to high-quality, non-judgmental sexual health care services. Future research is needed to determine the most effective method to increase men's access to sexual health care services.