South African men who have sex with men (MSM) have a high burden of undiagnosed HIV infection and HIV-testing rates incommensurate with their risk. HIV self-testing (HIVST) may increase testing uptake, frequency, and earlier HIV detection and treatment. We implemented a longitudinal HIVST study among South African MSM in Mpumalanga Province, in order to explore acceptability, feasibility, utilization and distribution patterns, and to understand how HIVST might expand testing frequency in this high prevalence area.
We recruited 127 HIV-negative MSM between June 2015 and May 2017 in Gert Sibande and Ehlanzeni districts. Participants received 5 self-test kits of their choice – oral fluid or blood fingerstick – at baseline and an additional 4 kits at a three month visit. Participants were asked to use the kits themselves at least one time and to distribute the other kits to their networks. Surveys were conducted at baseline, three months, and six months post-enrollment to elicit information on HIVST experiences, preferences, acceptability, utilization of HIVST and clinic-based testing, and test distribution to others. We used generalized estimating equations to assess changes in regular (every six months or more frequent) testing.
Ninety-one percent of all participants self-tested, all of whom reported being likely to self-test again, with over 80% preferring HIVST to clinic-based testing. Fingerstick tests were preferred: 45% ever choose oral fluid tests and 80% ever choose blood. Returning participants distributed 728 tests to sexual partners (18.5% of kits), friends (51.6%), and family (29.8%). Among those testing, 32% of the cohort reported testing with someone else present and 24% reported concurrent testing (testing at the same time as another). Six participants (5% of those returning for follow-up) seroconverted during the study; 40 new diagnoses were reported among network test recipients. Regular testing increased from 37.8% prior to the study to 84.5% at follow-up (p<0.1), and participants reported anticipated regular testing of 100% if HIVST were available compared to 84% if only clinic-testing were available in the coming year (p<.01). (Figure 1)
HIVST is highly acceptable and feasible to distribute through MSM networks in South Africa. Newly quarterly testing guidelines are unlikely feasible in a clinic-based environment alone, however our data suggest that HIVST is key to meeting regular testing goals and improving early detection.