Determinants of Recent HIV Self-Testing Uptake Among Men Who Have Sex With Men in Jiangsu Province, China: An Online Cross-Sectional Survey

Coronavirus disease 2019 (COVID-19) has spread rapidly around the world since the first reports from Wuhan in China in December, 2019, and the outbreak was characterised as a pandemic by WHO on March 12, 2020. 1 Approximately 37·9 million people living with HIV 2 are at risk of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes COVID-19. Although some international institutions, in collaboration with governments and community partners, are working to sustain HIV service provision for people living with HIV, the COVID-19 pandemic presents several barriers and challenges to the HIV care continuum. 3 First, implementation of quarantine, social distancing, and community containment measures have reduced access to routine HIV testing, which challenges completion of UNAIDS' first 90-90-90 target globally, that 90% of all people living with HIV will know their HIV status. HIV testing is the vital first step towards initiation into the HIV care continuum. 3 Even with availability of HIV self-testing kits in some areas, 4 testing remains a big challenge in settings with scarce access to these kits. Therefore, increased efforts are needed to augment access and to facilitate testing. Second, timely linkage to HIV care could be hindered during the COVID-19 pandemic. People living with HIV who should have initiated antiretroviral therapy (ART) in hospital might be deterred or delayed because hospitals are busy treating patients with COVID-19. Furthermore, because many public health authorities globally are focused on COVID-19 control, allocation of resources for HIV care could be diminished, and circumstances surrounding the HIV care continuum could worsen. Third, the COVID-19 pandemic might also hinder ART continuation. Hospital visits could be restricted because of implementation of city lockdowns or traffic controls. UNAIDS and the BaiHuaLin alliance of people living with HIV, with support of the Chinese National Center for AIDS/STD Control and Prevention, did a survey among people living with HIV in China in February, 2020.5, 6 Among this population, 32·6% were at risk of ART discontinuation and about 48·6% did not know where to get antiviral drugs in the near future.5, 6 People living with HIV who are faced with ART discontinuation not only could undergo physical health deterioration but also might suffer great psychological pressure. In response to these challenges, WHO, UNAIDS, and the Global Network of People Living With HIV are working together to ensure continued provision of HIV prevention, testing, and treatment services.6, 7, 8 The Chinese National Center for AIDS/STD Control and Prevention issued a notice guaranteeing free antiviral drugs for selected treatment management agencies in China, and released a list of ART clinics. 6 People living with HIV can refill antiviral drugs either at the nearest local Center for Disease Control and Prevention or by post, to maintain enrolment in treatment programmes and to continue ART. 6 Hospitals in Thailand are to dispense antiviral drugs in 3–6-month doses to meet the needs of people living with HIV and reduce facility visits. 9 The US Department of Health and Human Services released interim guidance for COVID-19 and people living with HIV on March 20, 2020, 10 which emphasised that people living with HIV should maintain at least a 30-day supply and ideally a 90-day supply of ART and all other drugs, by mail-order delivery if possible. Community-based organisations have also played an important part in maintaining HIV services. UNAIDS is working with the BaiHuaLin alliance of people living with HIV and other community partners to reach and help those who will run out of antiviral drugs in the near future. 6 Since the lock down of Wuhan on Jan 23, 2020, a community-based organisation (Wuhan TongZhi Center) has dedicated resources to ensure the supply of antiviral drugs and opened a hotline to provide consultations. As of March 31, 2020, this organisation has had more than 5500 consultations with people living with HIV and has helped more than 2664 individuals obtain antiviral drugs. The Thai Red Cross AIDS Research Centre set up a visible platform outside their anonymous clinic with a screening system for every client, providing HIV testing and prevention supplies (eg, condoms, postexposure prophylaxis, and pre-exposure prophylaxis). 9 As COVID-19 continues to spread around the world, many locations are facing the risk of SARS-CoV-2 infection and barriers and challenges for maintaining the HIV care continuum. The situation could be worse in places with weak health-care systems. We recommend that governments, community-based organisations, and international partners should work together to maintain the HIV care continuum during the COVID-19 pandemic, with particular efforts made to ensure timely access to, and to avoid disruption of, routine HIV services.

Background Home-based HIV testing and counselling (HTC) achieves high uptake, but is difficult and expensive to implement and sustain. We investigated a novel alternative based on HIV self-testing (HIVST). The aim was to evaluate the uptake of testing, accuracy, linkage into care, and health outcomes when highly convenient and flexible but supported access to HIVST kits was provided to a well-defined and closely monitored population. Methods and Findings Following enumeration of 14 neighbourhoods in urban Blantyre, Malawi, trained resident volunteer-counsellors offered oral HIVST kits (OraQuick ADVANCE Rapid HIV-1/2 Antibody Test) to adult (≥16 y old) residents (n = 16,660) and reported community events, with all deaths investigated by verbal autopsy. Written and demonstrated instructions, pre- and post-test counselling, and facilitated HIV care assessment were provided, with a request to return kits and a self-completed questionnaire. Accuracy, residency, and a study-imposed requirement to limit HIVST to one test per year were monitored by home visits in a systematic quality assurance (QA) sample. Overall, 14,004 (crude uptake 83.8%, revised to 76.5% to account for population turnover) residents self-tested during months 1–12, with adolescents (16–19 y) most likely to test. 10,614/14,004 (75.8%) participants shared results with volunteer-counsellors. Of 1,257 (11.8%) HIV-positive participants, 26.0% were already on antiretroviral therapy, and 524 (linkage 56.3%) newly accessed care with a median CD4 count of 250 cells/μl (interquartile range 159–426). HIVST uptake in months 13–24 was more rapid (70.9% uptake by 6 mo), with fewer (7.3%, 95% CI 6.8%–7.8%) positive participants. Being “forced to test”, usually by a main partner, was reported by 2.9% (95% CI 2.6%–3.2%) of 10,017 questionnaire respondents in months 1–12, but satisfaction with HIVST (94.4%) remained high. No HIVST-related partner violence or suicides were reported. HIVST and repeat HTC results agreed in 1,639/1,649 systematically selected (1 in 20) QA participants (99.4%), giving a sensitivity of 93.6% (95% CI 88.2%–97.0%) and a specificity of 99.9% (95% CI 99.6%–100%). Key limitations included use of aggregate data to report uptake of HIVST and being unable to adjust for population turnover. Conclusions Community-based HIVST achieved high coverage in two successive years and was safe, accurate, and acceptable. Proactive HIVST strategies, supported and monitored by communities, could substantially complement existing approaches to providing early HIV diagnosis and periodic repeat testing to adolescents and adults in high-HIV settings.