Despite progress toward controlling the human immunodeficiency virus (HIV) epidemic, testing gaps remain, particularly among men and young persons in sub-Saharan Africa (1). This observational study used routinely collected programmatic data from 20 African countries reported to the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) from October 2018 to September 2019 to assess HIV testing coverage and case finding among adults (defined as persons aged ≥15 years). Indicators included number of HIV tests conducted, number of HIV-positive test results, and percentage positivity rate. Overall, the majority of countries reported higher HIV case finding among women than among men. However, a slightly higher percentage positivity was recorded among men (4.7%) than among women (4.1%). Provider-initiated counseling and testing (PITC) in health facilities identified approximately two thirds of all new cases, but index testing had the highest percentage positivity in all countries among both sexes. Yields from voluntary counseling and testing (VCT) and mobile testing varied by sex and by country. These findings highlight the need to identify and implement the most efficient strategies for HIV case finding in these countries to close coverage Continuing Education examination available at https://www.cdc.gov/mmwr/mmwr_continuingEducation.html INSIDE

Background: Many southern African countries are nearing the global goal of diagnosing 90% of people with HIV by 2020. In 2016, 84 and 86% of people with HIV knew their status in Malawi and Zimbabwe, respectively. However, gaps remain, particularly among men. We investigated awareness and use of, and willingness to self-test for HIV and explored sociodemographic associations before large-scale implementation. Methods: We pooled responses from two of the first cross-sectional Demographic and Health Surveys to include HIV self-testing (HIVST) questions in Malawi and Zimbabwe in 2015-16. We investigated sociodemographic factors and sexual risk behaviours associated with previously testing for HIV, and past use, awareness of, and future willingness to self-test using univariable and multivariable logistic regression, adjusting for the sample design and limiting analysis to participants with a completed questionnaire and valid HIV test result. We restricted analysis of willingness to self-test to Zimbabwean men, as women and Malawians were not systematically asked this question. Results: Of 31,385 individuals, 31.2% of men had never tested compared with 16.5% of women (p < 0.001). For men, the likelihood of having ever tested increased with age. Past use and awareness of HIVST was very low, 1.2 and 12.6%, respectively. Awareness was lower among women than men (9.1% vs 15.3%, adjusted odds ratio [aOR] = 1.55; 95% confidence interval [CI]: 1.37-1.75), and at younger ages, and lower education and literacy levels. Willingness to self-test among Zimbabwean men was high (84.5%), with greater willingness associated with having previously tested for HIV, being at high sexual risk (highest willingness [aOR = 3.74; 95%CI: 1.39-10.03, p < 0.009]), and being ≥25 years old. Wealthier men had greater awareness of HIVST than poorer men (p < 0.001). The highest willingness to self-test (aOR = 3.74; 95%CI: 1.39-10.03, p < 0.009) was among men at high HIV-related sexual risk.

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Objective Rezūm vapor ablation is a minimally invasive treatment for benign prostatic hyperplasia (BPH) that uses injections of sterile water vapor directly into the prostate for tissue ablation. Although Rezūm is currently indicated for use in men with prostate sizes ≥30 and ≤80 ml, it is unclear how effective Rezūm is for men in urinary retention. We sought to determine whether Rezūm is effective in the treatment of catheter‐dependent urinary retention secondary to BPH. Methods A retrospective chart review was conducted on consecutive patients who presented for urinary retention and subsequently treated with Rezūm. We evaluated procedural details and examined variables pre‐ and post‐Rezūm (at 6 months) including International Prostate Symptom Score (IPSS), IPSS quality of life (IPSS–QOL), maximum flow (Qmax), post void residual volume (PVR), prostate specific antigen, rate of retention, and use of alpha blockers and 5‐alpha reductase inhibitor (5ARI). Results Of the 49 patients included in this study, median age of was 73 years, median prostate volume was 73cc (Interquartile range [IQR]: 50, 103) and a median lobe was present in 80% of patients. All patients were in urinary retention before treatment with a median PVR of 900 ml (IQR: 566, 1146). Following Rezum, IPSS (17 pre‐Rezūm, 4 post‐Rezūm) and IPSS–QOL (4 pre‐Rezūm, 1 post‐Rezūm) both improved at 6 months (p < 0.01). Qmax increased from 3 to 6 ml/s (p = 0.03) and PVR decreased from 900 to 78 ml (p < 0.01). Only 17/38 patients taking alpha‐blockers and 7/15 patients on 5ARIs continued therapy at 6 months following Rezūm (p < 0.01). Of the 49 patients treated, 10 (20.4%) remained in catheter dependent urinary retention following the procedure, and 6 remained in retention at 6 months (12.2%) even after further surgical therapies for BPH (p < 0.01). Conclusion Rezūm is a safe and effective therapy for treating catheter dependent urinary retention in patients with BPH, including those with median lobes. As a minimally invasive therapy, it is a promising option in patient, particularly those who are not suitable for prolonged anesthesia.

Background Facility HIV self-testing (HIVST) within outpatient departments can increase HIV testing coverage by facilitating HIVST use in outpatient waiting spaces while clients wait for routine care. Facility HIVST allows for the majority of outpatients to test with minimal health care worker time requirements. However, barriers and facilitators to outpatients’ use of facility HIVST are still unknown. Methods As part of a cluster randomized trial on facility HIVST in Malawi, we conducted in-depth interviews with 57 adult outpatients (> 15 years) who were exposed to the HIVST intervention and collected observational journals that documented study staff observations from facility waiting spaces where HIVST was implemented. Translated and transcribed data were analyzed using constant comparison analysis in Atlas.ti. Results Facility HIVST was convenient, fast, and provided autonomy to outpatients. The strategy also had novel facilitators for testing, such as increased motivation to test due to seeing others test, immediate support for HIVST use, and easy access to additional HIV services in the health facility. Barriers to facility HIVST included fear of judgment from others and unwanted status disclosure due to lack of privacy. Desired changes to the intervention included private, separate spaces for kit use and interpretation and increased opportunity for disclosure and post-test counseling. Conclusions Facility HIVST was largely acceptable to outpatients in Malawi with novel facilitators that are unique to facility HIVST in OPD waiting spaces. Trial registration The parent trial is registered with ClinicalTrials.gov, NCT03271307, and Pan African Clinical Trials, PACTR201711002697316.

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Background: HIV testing among the sexual partners of HIV-positive clients is critical for case identification and reduced transmission. Current strategies have limited reach. We evaluated an index HIV self-testing (HIVST) intervention among ART clients in Malawi, whereby clients were asked to distribute HIVST kits to their primary sexual partners. Methods: We conducted an individually randomized, unblinded trial at 3 district hospitals in Malawi between March 28 2018-January 5, 2020. Clients attending ART clinics were randomized 1:2.5 to: (1) standard partner referral slip (PRS); or (2) index HIVST. Inclusion criteria were: ART client is ≥15 years of age; primary partner with unknown HIV status; no history of interpersonal violence with that partner; and partner lives in facility catchment area. The primary outcome was completion of index partner testing, and, if positive, index partner ART initiation within 12-months. Baseline and follow-up surveys with ART clients measured the primary outcome and medical chart reviews measured ART initiation. Uni- and multivariate logistic regressions were conducted. Findings: A total of 4,043 ART clients were screened and 456 were eligible and enrolled. 365 completed a follow-up survey and were included in the final analysis (22% men). Testing coverage among partners was 71% in the HIVST arm and 25% in PRS (AOR:9.6; 95% CI: 6.45-12.82). HIV positivity rates did not differ by arm (19% in HIVST versus 16% in PRS; p=0.74). ART initiation at 12-months was 46% (14/30) in HIVST versus 75% (3/4) in PRS arms; however, HIVST still resulted in a 94% increase in the proportion of all partners initiating ART due to high testing rates. Adverse events did not vary by arm. Interpretation: Index HIVST significantly increased HIV testing and ART initiation among ART clients' sexual partners without increased risk of adverse events. Additional research is needed to understand and improve ART initiation within index HIVST.