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Peer-distributed HIV self-test kits to increase demand for HIV prevention and care services in rural KwaZulu-Natal, South Africa: a three-armed cluster-randomised trial comparing social-networks versus direct delivery

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BACKGROUND: HIV elimination in South Africa calls for innovative approaches. We investigated HIV self-testing (HIVST) for increasing demand for HIV care and prevention services, comparing two peer-distribution approaches (direct distribution and an incentivized social-network approach) against peer-navigators providing information and referrals only.
METHODS: Restricted randomisation (1:1:1) allocated 24 peer-navigator pairs in rural Kwa-Zulu Natal into: (1) incentivized-peer-networks (IPN): peer-navigators recruited 'seeds' to distribute 5 packs to 18-30 year olds within their social networks. Packs contained 2 HIVST kits (OraQuick) and standard of care (SOC) materials. 'Seeds' received 20 Rand (US$1.5) for each recipient who went on to distribute packs themselves; (2) peer-navigator-distribution (PND): peer-navigators distributed HIVST packs and SOC materials directly; (3) SOC: peer-navigators distributed barcoded clinic referral slips and sexual health information promoting HIV testing, pre-exposure prophylaxis (PrEP) and antiretroviral therapy (ART). PrEP/ART linkage rates were defined as numbers screened for PrEP eligibility or starting ART within 90 days of referral slip distribution per peer-navigator outreach month (pnm). The primary outcome compared PrEP/ART linkage rates between arms for women aged 18-24 years. Secondary outcomes included linkage rates for youth (18-30 years). Intention to treat analysis was used. Investigators and statisticans were blinded to allocation.
RESULTS: Between March and December 2019, 7563 (2055 IPN, 2069 PND, 2539 SOC) packs were distributed during 144 peer-navigator outreach months, with 272 young adults linked to PrEP/ART (1.9/pnm). Linkage rates for women aged 18-24 years were lower for IPN (n=26, 0.54/pnm) than PND (n=45, 0.80/pnm) and SOC n=49, 0.85/pnm), although not significantly so (rate ratios [RR] 0.68, 95%CI 0.28-1.66 and 0.64, 95%CI 0.38-2.36, respectively). Adding HIVST kits to peer-navigator distribution (PND vs SOC) did not change linkage rates (RR 0.95, 95% CI 0.38-2.36). Youth (18-30 years), results were similar but with stronger evidence of lower linkage rates (0.88/pnm) for IPN than PND (2.11/pnm, RR 0.42, 95%CI 0.18-0.98) and SOC (2.07/pnm, RR 0.42 95%CI 0.18-1.02).
CONCLUSIONS: Peer-based HIVST distribution reached large numbers of young men and women, but did not increase demand for PrEP/ART, unless combined with peer-navigator PrEP/ART promotion. Incentivized peer network models resulted in fewer linkages compared to direct peer-navigator mobilization with or without HIVSTs.

Registration: NCT03751826.