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Introduction: HIV self‐testing (HIVST) is a discreet and convenient way to reach people with HIV who do not know their status, including many who may not otherwise test. To inform World Health Organization (WHO) guidance, we assessed the effect of HIVST on uptake and frequency of testing, as well as identification of HIV‐positive persons, linkage to care, social harm, and risk behaviour. Methods: We systematically searched for studies comparing HIVST to standard HIV testing until 1 June 2016. Meta‐analyses of studies reporting comparable outcomes were conducted using a random‐effects model for relative risks (RR) and 95% confidence intervals. The quality of evidence was evaluated using GRADE. Results: After screening 638 citations, we identified five randomized controlled trials (RCTs) comparing HIVST to standard HIV testing services among 4,145 total participants from four countries. All offered free oral‐fluid rapid tests for HIVST and were among men. Meta‐analysis of three RCTs showed HIVST doubled uptake of testing among men (RR = 2.12; 95% CI: 1.51, 2.98). Meta‐analysis of two RCTs among men who have sex with men showed frequency of testing nearly doubled (Rate ratio = 1.88; 95% CI: 1.17; 3.01), resulting in two more tests in a 12–15‐month period (Mean difference = 2.13; 95% CI: 1.59, 2.66). Meta‐analysis of two RCTs showed HIVST also doubled the likelihood of an HIV‐positive diagnosis (RR = 2.02; 95% CI: 0.37, 10.76, 5.32). Across all RCTs, there was no indication of harm attributable to HIVST and potential increases in risk‐taking behaviour appeared to be minimal. Conclusions: HIVST is associated with increased uptake and frequency of testing in RCTs. Such increases, particularly among those at risk who may not otherwise test, will likely identify more HIV‐positive individuals as compared to standard testing services alone. However, further research on how to support linkage to confirmatory testing, prevention, treatment and care services is needed. WHO now recommends HIVST as an additional HIV testing approach.

Introduction HIV self‐testing (HIVST) provides couples and individuals with a discreet, convenient and empowering testing option. As with all HIV testing, potential harms must be anticipated and mitigated to optimize individual and public health benefits. Here, we describe social harms (SHs) reported during HIVST implementation in Malawi, and propose a framework for grading and responding to harms, according to their severity. Methods We report findings from six HIVST implementation studies in Malawi (2011 to 2017) that included substudies investigating SH reports. Qualitative methods included focus group discussions, in‐depth interviews and critical incident interviews. Earlier studies used intensive quantitative methods (post‐test questionnaires for intimate partner violence, household surveys, investigation of all deaths in HIVST communities). Later studies used post‐marketing reporting with/without community engagement. Pharmacovigilance methodology (whereby potentially life‐threatening/changing events are defined as “serious”) was used to grade SH severity, assuming more complete passive reporting for serious events. Results During distribution of 175,683 HIVST kits, predominantly under passive SH reporting, 25 serious SHs were reported from 19 (0.011%) self‐testers, including 15 partners in eight couples with newly identified HIV discordancy, and one perinatally infected adolescent. There were no deaths or suicides. Marriage break‐up was the most commonly reported serious SH (sixteen individuals; eight couples), particularly among serodiscordant couples. Among new concordant HIV‐positive couples, blame and frustration was common but rarely (one episode) led to serious SHs. Among concordant HIV‐negative couples, increased trust and stronger relationships were reported. Coercion to test or disclose was generally considered “well‐intentioned” within established couples. Women felt empowered and were assertive when offering HIVST test kits to their partners. Some women who persuaded their partner to test, however, did report SHs, including verbal or physical abuse and economic hardship. Conclusions After more than six years of large‐scale HIVST implementation and in‐depth investigation of SHs in Malawi, we identified approximately one serious reported SH per 10,000 HIVST kits distributed, predominantly break‐up of married serodiscordant couples. Both “active” and “passive” reporting systems identified serious SH events, although with more complete capture by “active” systems. As HIVST is scaled‐up, efforts to support and further optimize community‐led SH monitoring should be prioritized alongside HIVST distribution.

Introduction The ability to achieve an accurate test result and interpret it correctly is critical to the impact and effectiveness of HIV self‐testing (HIVST). Simple and easy‐to‐use devices, instructions for use (IFU) and other support tools have been shown to be key to good performance in sub‐Saharan Africa and may be highly contextual. The objective of this study was to explore the utility of cognitive interviewing in optimizing the local understanding of manufacturers’ IFUs to achieve an accurate HIVST result. Methods Functionally literate and antiretroviral therapy‐naive participants were purposefully selected between May 2016 and June 2017 to represent intended users of HIV self‐tests from urban and rural areas in Malawi and Zambia. Participants were asked to follow IFUs for HIVST. We then conducted cognitive interviews and observed participants while they attempted to complete the HIVST steps using a structured guide, which mirrored the steps in the IFU. Qualitative data were analysed using a thematic approach. Results Of a total of 61 participants, many successfully performed most steps in the IFU. Some had difficulties in understanding these and made errors, which could have led to incorrect test results, such as incorrect use of buffer and reading the results prematurely. Participants with lower levels of literacy and inexperience with standard pictorial images were more likely to struggle with IFUs. Difficulties tended to be more pronounced among those in rural settings. Ambiguous terms and translations in the IFU, unfamiliar images and symbols, and unclear order of the steps to be followed were most commonly linked to errors and lower comprehension among participants. Feedback was provided to the manufacturer on the findings, which resulted in further optimization of IFUs. Conclusions Cognitive interviewing identifies local difficulties in conducting HIVST from manufacturer‐translated IFUs. It is a useful and practical methodology to optimize IFUs and make them more understandable.

Introduction The South and Southeast Asia region has the second‐highest number of people living with HIV globally. Despite progress in reducing HIV incidence and AIDS‐related deaths, the region still has a long way to go in achieving the Joint United Nations Programme on HIV and AIDS (UNAIDS) 95‐95‐95 HIV testing, treatment and viral suppression targets. HIV self‐testing (HIVST) is recommended by the World Health Organization as an additional approach to HIV testing. This paper provides a commentary on the implementation status, benefits, barriers and recommendations for HIVST implementation in South and Southeast Asia. Additionally, it presents perspectives from HIV testing service experts from 11 countries in the region to put forth recommendations to accelerate the implementation of HIVST in South and Southeast Asia. Discussion There is uneven progress in national HIVST policy development and implementation across the region. HIVST, as an additional testing approach, can help to enhance testing coverage, frequency and demand for follow‐up HIV services among key populations. Key factors influencing the implementation and scale‐up of HIVST include the degree of awareness of HIVST among general and key populations, the development and implementation of supportive national HIVST policies and the availability of public funding for HIVST. To address barriers and leverage enablers to HIVST implementation, generating evidence on cost‐effectiveness and budget impact, developing multisectoral partnerships for market shaping, promoting differentiated and decentralized delivery models, and optimizing linkage to further testing and care are recommended. Conclusions It is crucial to accelerate the implementation and scale‐up of HIVST to differentiate and decentralize the delivery of HIV testing services in South and Southeast Asian countries. Sharing experiences among country experts is vital to foster the adoption of best practices and facilitate the trial‐and‐error process of HIVST implementation. Such collaborative approaches can help South and Southeast Asian countries attain the UNAIDS 95‐95‐95 targets, especially the first 95 on HIV diagnosis, and play a significant role in ending the global AIDS epidemic.

Introduction Being aware of one's HIV‐positive status can help reduce unprotected sex and promote early treatment seeking. Therefore, HIV self‐test (HIVST) programs may help control the HIV epidemic by case finding. The aims of this study were to determine the effect of HIVST programs on HIV case finding, time to confirmatory diagnosis and factors associated with linkage to confirmatory diagnosis in Taiwan. Methods The Centers for Disease Control in Taiwan initiated HIVST programs and imported 78,000 self‐test kits in 2017 and 2019. Clients paid 7 US dollars for a self‐test kit at facilities, vending machines or online. The programs set up an HIVST logistics management system; each kit had a unique barcode for monitoring the programs because purchases were anonymous. When clients provided their test results with photo barcodes online or at HIV/AIDS‐designated hospitals, they received full monetary reimbursement. We conducted a quasi‐experimental interrupted time‐series (ITS) analysis that covered a period of 60 months from 2015 to 2019. We enrolled a retrospective cohort of reported HIV cases with initial positive results from HIVST programs between March 2017 and July 2020. Results The ITS analysis included data from 10,976 reported HIV cases from 2015 to 2019. The HIVST‐positive cohort included 386 reported HIV cases, of whom 99.7% were males and 97% were men who have sex with men (MSM); the median age was 28 years. The ITS analysis showed a positive slope change in the number of reported HIV cases immediately in the beginning implementation month (coefficient: 51.09 in 2017 and 3.62 in 2019), but there was a significant decrease over time. It was a negative slope change by 9.52 cases per month in 2017 and 5.56 cases per month in 2019. In the HIVST‐positive cohort, three of five individuals linked to HIV confirmatory diagnosis within 1 month after a positive self‐test result, and an early linkage to confirmatory diagnosis was associated with HIVST disclosure (adjusted OR = 6.5; 95% CI: 3.9–10.6). Conclusions HIVST programs were associated with an increase in HIV case finding. Our findings suggest that countries with a high incidence of HIV among MSM populations should offer multichannel HIVST services.

Introduction: Acceptability and willingness to both take and pay for HIV self‐tests (HIVSTs) in US neighbourhoods with high rates of HIV infection are not well understood. Methods: We surveyed 1,535 individuals about acceptability and willingness to take and pay for an HIVST in a predominately African American neighbourhood with 3% HIV seroprevalence. We recruited individuals presenting for HIV screening services in a community‐based programme. Latent class analysis (LCA) grouped individuals with similar patterns of HIV‐risk behaviours and determined which groups would be most willing to use and buy HIVSTs. Results: Nearly 90% of respondents were willing to use an HIVST; 55% were willing to buy HIVSTs, but only 23% were willing to pay the market price of US$40. Four distinct groups emerged and were characterized by risk behaviours: (1) low risk (N = 324); (2) concurrent partnerships (N = 346); (3) incarceration and substance use (N = 293); and (4) condomless sex/multiple partners (N = 538). Individuals in the low‐risk class were less willing to self‐test compared to concurrent sexual partners (OR = 0.39, p = .003) and incarceration and substance use (OR = 0.46, p = .011) classes. There were no significant differences across classes in the amount individuals were willing to pay for an HIVST. Conclusions: HIVSTs were overwhelmingly acceptable but cost prohibitive; most participants were unwilling to pay the market rate of US $ 40. Subsidizing and implementing HIVST programmes in communities with high rates of infection present a public health opportunity, particularly among individuals reporting condomless sex with multiple partners, concurrent sexual partnerships and those with incarceration and substance use histories.

Test-to-PrEP, a bundled HIV self-test (HIVST) and PrEP educational kit was distributed to the social networks (SN) of PrEP clients using social network strategies (SNS). PrEP clients ( n  = 100) distributed kits to their SN members ( n  = 415). Multilevel analysis assessed the relationship between demographic/network characteristics and likelihood of PrEP discussions. Higher network density (e.g., the level of linkage among network members) and daily contact were associated with having previously talked about PrEP. Networks that were denser (more ties/connections), more frequently in contact, and had a relationship type that assumes greater closeness (proximal relations) resulted in greater likelihood of having had PrEP conversations. This work demonstrates the feasibility of using SNS to increase routine HIV testing and PrEP knowledge. The Test-To-PrEP SNS strategy is a promising tool to increase HIV prevention and care access to all who may benefit. Resumen Test-to-PrEP, es un paquete que incluye una prueba de autodiagnóstico del VIH (HIVST) y un kit educativo sobre PrEP. Este paquete fue distribuido en las redes sociales (RS) de los clientes de PrEP utilizando estrategias de redes sociales (ERS). Los clientes de PrEP ( n  = 100) distribuyeron los paquetes a las personas de sus RS ( n  = 415). El análisis multinivel evaluó la relación entre las características demográficas de los usuarios de PrEP y de sus redes con la probabilidad de tener conversaciones sobre PrEP. Una mayor densidad de la red (por ejemplo, el nivel de conexión entre los miembros de la red) y el contacto diario estuvieron asociados con haber hablado previamente sobre PrEP. Las redes más densas (con más vínculos/conexiones), con contacto más frecuente y relaciones de mayor proximidad resultaron en una mayor probabilidad de haber tenido conversaciones sobre PrEP. Este trabajo demuestra la viabilidad de usar estrategias de SNS para aumentar las pruebas rutinarias de VIH y el conocimiento sobre PrEP. La estrategia SNS de Test-To-PrEP es una herramienta prometedora para ampliar la prevención del VIH y el acceso a la atención a todos aquellos que puedan beneficiarse.

Background The Ghana AIDS Commission reported in 2022 that out of 354,927 people living with HIV, 67.5% were females. While considerable progress has been made in expanding access to HIV testing services, a significant proportion of individuals remain unaware of their HIV status, presenting a significant barrier to effective prevention and treatment. Although HIV Self-Testing (HIVST) has emerged as a promising approach to increase the uptake of HIV testing, its adoption and utilisation have been limited by various sociodemographic factors. We investigated the knowledge of HIV Self-Testing Kit as well as prevalence of HIVST and their associated factors among Ghanaian women. Methods This was a cross-sectional study among 15,014 women of their reproductive age using data from the 2022 GDHS. The data were analysed using STATA version 17.0. Simple frequencies were used to summarise the data. A multilevel binary logistic regression using four models (Models I–IV) was used to examine the association between the two outcome variables and the explanatory variables, controlling for individual- and contextual-level factors. Statistical significance was set at p  < 0.05 at 95% CI. Results We discovered that only 18.2% [95% CI = 17.1–19.3] and 2.4% [95% CI = 2.1–2.8] of Ghanaian women in their reproductive age had adequate knowledge of HIV Self-Testing Kit (HIVSTK) and had used the HIVSTK for HIV testing respectively. The odds of knowledge of HIVSTK were higher among women aged 20–24 years (aOR = 1.33, 95% CI = 1.07, 1.64; p  = < 0.01), those with a higher level of education (aOR = 6.14, 95% CI = 4.41, 8.55; p  < 0.001), those who listen to radio (aOR = 1.41, 95% CI = 1.20, 1.65; p  < 0.001) and use the internet at least once a week (aOR = 1.49, 95% CI = 1.24, 1.78; p  < 0.001). The odds of knowing about HIVSTKs increased with higher levels of wealth distribution with the highest recorded among those in the wealthiest group (aOR = 1.85, 95% CI = 1.32, 2.58; p  < 0.001). Compared with women with no formal education, the odds of HIVST were higher among those with higher education (aOR = 20.29, 95% CI = 9.16, 44.97; p  < 0.001). The odds of HIVST were also higher among those who listen to radio (aOR = 1.51, 95% CI = 1.05, 2.17; p  < 0.05) and those who use the internet at least once a week [aOR = 1.80, 95% CI = 1.15, 2.83; p  < 0.001). Furthermore, the odds of self-testing for HIV were higher among women with a history of HIVST (aOR = 6.73, 95% CI = 3.34, 13.55; p  = < 0.001) and those with the wealthiest wealth quintiles (aOR = 4.31, 95% CI = 1.31, 13.02; p  = < 0.001). Conclusion Our study revealed a shallow knowledge of HIV Self-Testing Kit as well as a low prevalence of HIV self-testing among women in their reproductive age in Ghana. The evidence suggests that more than nine in ten women had never undertaken an HIV self-test. The observed HIVST in this study may have implications for achieving the objectives of the HIVST policy. This may impede the achievement of SDG 3.3 which seeks to end the AIDS epidemic by 2030. Practical strategies including education and awareness, may be utilized through electronic media as well as radio and television, especially among those with little or no education. Additionally, the government can subsidise testing kits to create opportunities for those in the low-wealth quintiles to purchase and self-test themselves.

Background Despite the aging HIV epidemic, increasing age can be associated with hesitancy to test. Addressing this gap is a critical policy concern and highlights the urgent need to identify the underlying factors, to improve knowledge of HIV-related risks as well as uptake of HIV testing and prevention services, in midlife-older adults. Methods We conducted five focus group discussions and 12 in-depth interviews between April 2013 and November 2016 among rural and urban Malawian midlife-older ( ≥ 30 years) men and women. Using a life-course theoretical framework we explored how age is enacted socially and its implications on HIV testing and sexual risk behaviours. We also explore the potential for HIV self-testing (HIVST) to be part of a broader strategy for engaging midlife-older adults in HIV testing, prevention and care. Thematic analysis was used to identify recurrent themes and variations. Results Midlife-older adults (30–74 years of age) associated their age with respectability and identified HIV as “a disease of youth” that would not affect them, with age protecting them against infidelity and sexual risk-taking. HIV testing was felt to be stigmatizing, challenging age norms, threatening social status, and implying “lack of wisdom”. These norms drove self-testing preferences at home or other locations deemed age and gender appropriate. Awareness of the potential for long-standing undiagnosed HIV to be carried forward from past relationships was minimal, as was understanding of treatment-as-prevention. These norms led to HIV testing being perceived as a threat to status by older adults, contributing to low levels of recent HIV testing compared to younger adults. Conclusions Characteristics associated with age-gender norms and social position encourage self-testing but drive poor HIV-risk perception and unacceptability of conventional HIV testing in midlife-older adults. There is an urgent need to provide targeted messages and services more appropriate to midlife-older adults in sub-Saharan Africa. HIVST which has often been highlighted as a tool for reaching young people, may be a valuable tool for engaging midlife-older age groups who may not otherwise test.

HIV testing is the cornerstone of strategies for achieving the fast-track target to end the AIDS epidemic by 2030. Self-testing has been proven to be an effective health intervention for men who have sex with men (MSM). While social network-based approaches for distributing HIV self-tests are recommended by the World Health Organization, their implementation consists of multiple steps that need to be properly evaluated. This study aimed to assess the implementation cascade of a social network-based HIV self-test approach for reaching MSM who had never undergone testing in Hong Kong. This is a cross-sectional study. Seed MSM participants were recruited through different web-based channels, who in turn invited their peers to participate in this study. A web-based platform was set up to support the recruitment and referral process. Participants could request for an oral fluid or a finger-prick HIV self-test, with or without real-time support, after completing a self-administered questionnaire. Referrals could be made upon uploading the test result and passing the web-based training. Characteristics of participants completing each of these steps and their preferences for the type of HIV self-test were evaluated. A total of 463 MSM were recruited, including 150 seeds. Participants recruited by seeds were less likely to have previously been tested for HIV (odds ratio [OR] 1.80, 95% CI 1.06-3.04, P=.03) and have lower confidence in performing self-tests (OR 0.66, 95% CI 0.45-0.99, P=.045). Almost all (434/442, 98%) MSM who completed the questionnaire requested a self-test, of whom 82% (354/434) had uploaded their test results. Participants requesting support were new to self-testing (OR 3.65, 95% CI 2.10-6.35, P<.001) and less confident in carrying out the self-test correctly (OR 0.35, 95% CI 0.22-0.56, P<.001). More than half (216/354, 61%) of the eligible participants initiated the referral process by attempting the web-based training with a passing rate of 93% (200/216). They were more likely to have sought sex partners (OR 2.20, 95% CI 1.14-4.25, P=.02), especially through location-based networking apps (OR 2.13, 95% CI 1.31-3.49, P=.002). They also gave higher usability scores along the implementation cascade (median 81 vs 75, P=.003). The social network approach was effective in diffusing HIV self-tests in the MSM community and reaching nontesters. Support and option to choose a preferable type of self-test are essential to address users' individual needs when delivering HIV self-tests. A positive user experience throughout the processes along the implementation cascade is vital to transform a tester into a promoter. ClinicalTrials.gov NCT04379206; https://clinicaltrials.gov/ct2/show/NCT04379206.