Background

BackgroundHIV pre-exposure prophylaxis (PrEP) is highly effective for prevention of HIV acquisition, but requires HIV testing at regular intervals. Female sex workers (FSWs) are a priority population for HIV prevention interventions in many settings, but face barriers to accessing healthcare. Here, we assessed the acceptability of HIV self-testing for regular HIV testing during PrEP implementation among FSWs participating in a randomized controlled trial of HIV self-testing delivery models.MethodsWe used data from two HIV self-testing randomized controlled trials with identical protocols in Zambia and in Uganda. From September–October 2016, participants were randomized in groups to: (1) direct delivery of an HIV self-test, (2) delivery of a coupon, exchangeable for an HIV self-test at nearby health clinics, or (3) standard HIV testing services. Participants completed assessments at baseline and 4 weeks. Participants reporting their last HIV test was negative were asked about their interest in various PrEP modalities and their HIV testing preferences. We used mixed effects logistic regression models to measure differences in outcomes across randomization arms at four weeks.ResultsAt 4 weeks, 633 participants in Zambia and 749 participants in Uganda reported testing negative at their last HIV test. The majority of participants in both studies were “very interested” in daily oral PrEP (91% Zambia; 66% Uganda) and preferred HIV self-testing to standard testing services while on PrEP (87% Zambia; 82% Uganda). Participants in the HIV self-testing intervention arms more often reported preference for HIV self-testing compared to standard testing services to support PrEP in both Zambia (P = 0.002) and Uganda (P < 0.001).ConclusionPrEP implementation programs for FSW could consider inclusion of HIV self-testing to reduce the clinic-based HIV testing burden.Trial registrationClinicalTrials.gov NCT02827240 and NCT02846402.

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When I launched the 90-90-90 targets three years ago, many people thought they were impossible to reach. Today, the story is very different. Families, communities, cities and countries have witnessed a transformation, with access to HIV treatment accelerating in the past three years. A record 19.5 million people are accessing antiretroviral therapy, and for the first time more than half of all people living with HIV are on treatment. More countries are paying for HIV treatment themselves. More people living with HIV are employed, more girls are in school, there are fewer orphans, there is less ill health and less poverty. Families and communities are feeling more secure. With science showing that starting treatment as early as possible has the dual benefit of keeping people living with HIV healthy and preventing HIV transmission, many countries have now adopted the gold-standard policy of treat all. Our efforts are bringing a strong return on investment. AIDS-related deaths have been cut by nearly half from the 2005 peak. We are seeing a downward trend in new HIV infections, especially in eastern and southern Africa, where new HIV infections have declined by a third in just six years. This good news is a result of the combined effect of a rapid scale-up of treatment and existing HIV prevention interventions. Moving forward, every additional dollar invested in AIDS will deliver a US$ 8 return. But our quest to end AIDS has only just begun. We live in fragile times, where gains can be easily reversed. The biggest challenge to moving forward is complacency. Global solidarity and shared responsibility has driven the success we have achieved so far. This must be sustained. But for several years now, resources for AIDS have remained stagnant, and we are not on track to reach the US$ 26 billion of investment we need by 2020. Without more domestic investments and international assistance, we cannot push faster on the Fast-Track. More people will become infected with HIV and lives will be lost. Without more community health workers, health systems will remain stretched. Without changing laws, key populations will be left behind. We must not fail children, women and girls, young people and key populations. We must engage with men differently. Men are being left behind in the push to 90-90-90, in turn affecting the lives of women and children. I remain optimistic. This report clearly demonstrates the power of the 90-90-90 targets and what can be achieved in a short time. It shows that innovations are possible at every level-from communities to research laboratories, from villages to cities. It illustrates the power of political leadership to make the impossible possible.

HIV self-testing increases recent and frequent HIV testing among female sex workers (FSWs) in urban Uganda. Using results from a randomized controlled trial, we aim to establish the effect of HIV self-testing delivery models on FSWs’ sexual behaviors in this setting. Clusters of one peer educator and eight participants were 1:1:1 randomized to: (1) direct provision of an HIV self-test, (2) provision of a coupon for facility collection of an HIV self-test, or (3) referral to standard-of-care HIV testing services. Sexual behaviors were self-reported at 1 and 4 months. From October to November 2016, 960 participants were enrolled and randomized. At 4 months, there were no statistically significant differences in participants’ sexual behaviors, including inconsistent condom use, across study arms. We do not find any changes in sexual risk-taking among FSWs in response to the delivery of HIV self-tests. Routine policies for HIV self-testing are likely a behaviorally safe component of comprehensive HIV prevention strategies.