The uptake of HIV testing and linkage to care remains low among men, contributing to continued high HIV incidence in women and HIV-related mortality in men in South Africa.
The ‘Home-Based Trial to Test and Start’ (HITS) is a cluster-randomized controlled trial of 45 communities (clusters) in the Umkhanyakude district of KwaZulu-Natal (ClinicalTrials.gov # NCT03757104). It is based in the Africa Health Research Institute (AHRI)’s population-based HIV testing platform, which offers home-based rapid HIV testing to all adults. In a 2×2 factorial design, we randomly assigned all men aged ≥15 years living in the 45 clusters to one of four arms: (i) a financial micro-incentive for HIV testing (R50 [$3] food voucher) (n=8), (ii) male-targeted counseling (n=8), (iii) both the micro-incentive and male-targeted counseling (n=8), and (iv) standard of care (SoC). The male-targeted counseling application, called EPIC-HIV, was a tablet-delivered theoretically-informed application, developed iteratively, to encourage HIV testing and individually offered to men. Here we report the effect of the interventions on the first registered primary endpoint of the HITS trial: uptake of home-based HIV testing among men. Intention-to-treat (ITT) analysis was performed using modified Poisson regression with adjustment for clustering of standard errors at the cluster level.
Among all men ≥15 years living in the 45 communities who were eligible for HIV testing based on registration in AHRI’s population-based HIV testing in 2018 (n=13,838), HIV testing uptake was 28% (683/2481) in the micro-incentive arm, 17% (433/2534) in the EPIC arm, 27% (568/2120) in the arm receiving both interventions, and 18% in the SoC arm. The HIV testing uptake among those men who could be located and approached for testing was 68% (micro-incentive), 56% (EPIC-HIV), 70% (both interventions), and 52% (SoC). In ITT analysis, compared to men in the SoC arm, the probability of HIV testing was 55% higher in the micro-incentive only arm (risk ratio (RR)=1.55, 95% CI: 1.31-1.82, p<0.001) and 50% higher in the arm with both interventions (RR=1.50, 95% CI: 1.21-1.87, p<0.001). The probability of HIV testing was not significantly different in the EPIC-HIV only arm (RR=0.96, 95% CI: 0.76-1.21, p=0.72).
Micro-incentives significantly increased the uptake of home-based HIV testing among men in rural South Africa and should thus be considered as a policy option where HIV testing rates are low.