Facility HIV Self-Testing in Outpatient Departments: An Assessment of Characteristics and Concerns of Outpatients Who Opt Out of Testing in Malawi.

BACKGROUND: Facility HIV self-testing (HIVST) in outpatient departments can dramatically increase testing among adult outpatients. However, it is still unclear why populations opt out of facility HIVST and reasons for opt outing. Using data from a parent facility HIVST trial, we sought to understand individual characteristics associated with opting out of facility HIVST and reported reasons for not testing. METHODS: Exit surveys were conducted with outpatients aged ≥15 years at 5 facilities in Central and Southern Malawi randomized to the facility HIVST arm of the parent trial. Outpatients were eligible for our substudy if they were offered HIVST and eligible for HIV testing (ie, never previously tested HIV positive and tested ≥12 months ago or never tested). Summary statistics and multivariate regression models were used. RESULTS: Seven hundred seventy-one outpatients were included in the substudy. Two hundred sixty-three (34%) opted out of HIVST. Urban residency (adjusted risk ratios [aRR] 3.48; 95% CI: 1.56 to 7.76) and self-reported poor health (aRR 1.86; 95% CI: 1.27 to 2.72) were associated with an increased risk of opting out. Male participants had a 69% higher risk of opting out (aRR 1.69; 95% CI: 1.14 to 2.51), with risk being 38% lower among working male participants. Primary reasons for not testing were feeling unprepared to test (49·4%) and perceived low risk of HIV infection (30·4%)-only 2.6% believed that HIVST instructions were unclear, and 1.7% were concerned about privacy. CONCLUSION: Working, risky sexual behavior, rural residence, and good self-rated health were positively associated with opting out of HIVST among outpatients. Strategies to address internalized barriers, such as preparedness to test and perceived need to test, should be incorporated into facility HIVST interventions.

Effect of index HIV self-testing for sexual partners of clients enrolled in antiretroviral therapy (ART) programs in Malawi: A randomized controlled trial.

BACKGROUND: HIV testing among the sexual partners of HIV-positive clients is critical for case identification and reduced transmission in southern and eastern Africa. HIV self-testing (HIVST) may improve uptake of HIV services among sexual partners of antiretroviral therapy (ART) clients, but the impact of HIVST on partner testing and subsequent ART initiation remains unclear. METHODS AND FINDINGS: We conducted an individually randomized, unblinded trial to assess if an index HIVST intervention targeting the partners of ART clients improves uptake of testing and treatment services in Malawi. The trial was conducted at 3 high-burden facilities in central and southern Malawi. ART clients attending HIV treatment clinics were randomized using simple randomization 1:2·5 to: (1) standard partner referral slip (PRS) whereby ART clients were given facility referral slips to distribute to their primary sexual partners; or (2) index HIVST whereby ART clients were given HIVST kits + HIVST instructions and facility referral slips to distribute to their primary sexual partners. Inclusion criteria for ART clients were: ≥15 years of age, primary partner with unknown HIV status, no history of interpersonal violence (IPV) with partner, and partner lives in facility catchment area. The primary outcome was partner testing 4-weeks after enrollment, reported by ART clients using endline surveys. Medical chart reviews and tracing activities with partners with a reactive HIV test measured ART initiation at 12 months. Analyses were conducted based on modified intention-to-treat principles, whereby we excluded individuals who did not have complete endline data (i.e., were loss to follow up from the study). Adjusted models controlled for the effects of age and marital status. A total of 4,237 ART clients were screened and 484 were eligible and enrolled (77% female) between March 28, 2018 and January 5, 2020. A total of 365 participants completed an endline survey (257/34 index HIVST arm; 107/13 PRS arm) and were included in the final analysis (78% female). Testing coverage among sexual partners was 71% (183/257) in the index HIVST arm and 25% (27/107) in the PRS arm (aRR: 2·77, 95% CI [2·56 to 3·00], p ≤ 0.001). Reported HIV positivity rates did not significantly differ by arm (16% (30/183) in HIVST versus 15% (4/27) in PRS; p = 0.99). ART initiation at 12 months was 47% (14/30) in HIVST versus 75% (3/4) in PRS arms; however, index HIVST still resulted in a 94% increase in the proportion of all partners initiating ART due to higher HIV testing rates in the HIVST arm (5% partners initiated ART in HVIST versus 3% in PRS). Adverse events including IPV and termination of the relationship did not vary by arm (IPV: 3/257 index HIVST versus 4/10 PRS; p = 0.57). Limitations include reliance on secondary report by ART clients, potential social desirability bias, and not powered for sex disaggregated analyses. CONCLUSIONS: Index HIVST significantly increased HIV testing and the absolute number of partners initiating ART in Malawi, without increased risk of adverse events. Additional research is needed to improve linkage to HIV treatment services after HIVST use. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03271307, and Pan African Clinical Trials, PACTR201711002697316.

Barriers and facilitators to facility HIV self-testing in outpatient settings in Malawi: a qualitative study.

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.

Effect of facility-based HIV self-testing on uptake of testing among outpatients in Malawi: a cluster-randomised trial.

BACKGROUND: HIV self-testing increases testing uptake in sub-Saharan Africa but scale-up is challenging because of resource constraints. We evaluated an HIV self-testing intervention integrated into high-burden outpatient departments in Malawi. METHODS: In this cluster-randomised trial, we recruited participants aged 15 years or older from 15 outpatient departments at high-burden health facilities (including health centres, mission hospitals, and district hospitals) in central and southern Malawi. The trial was clustered at the health facility level. We used constrained randomisation to allocate each cluster (1:1:1) to one of the following groups: standard provider-initiated testing and counselling with no intervention (provider offered during consultations), optimised provider-initiated testing and counselling (with additional provider training and morning HIV testing), and facility-based HIV self-testing (Oraquick HIV self-test, group demonstration and distribution, and private spaces for interpretation and counselling). The primary outcome was the proportion of outpatients tested for HIV on the day of enrolment, measured through exit surveys with a sample of outpatients. Analyses were on an intention-to-treat basis. The trial is registered with ClinicalTrials.gov, NCT03271307, and Pan African Clinical Trials, PACTR201711002697316. FINDINGS: Between Sept 12, 2017, and Feb 23, 2018, 5885 outpatients completed an exit survey-2097 in the HIV self-testing group, 1951 in the standard provider-initiated testing and counselling group, and 1837 in the optimised provider-initiated testing and counselling group. 1063 (51%) of 2097 patients in the HIV self-testing group had HIV testing on the same day as enrolment, compared with 248 (13%) of 1951 in the standard provider-initiated testing and counselling group and 261 (14%) of 1837 in the optimised provider-initiated testing and counselling group. The odds of same-day HIV testing were significantly higher in the facility-based HIV self-testing group compared with either standard provider-initiated testing and counselling (adjusted odds ratio 8·52, 95% CI 3·98-18·24) or optimised provider-initiated testing and counselling (6·29, 2·96-13·38). Around 4% of those tested in the standard provider-initiated testing and counselling and optimised provider-initiated testing and counselling groups felt coerced to test, and around 1% felt coerced to share test results. No coercion was reported in the facility-based HIV self-testing group. INTERPRETATION: Facility-based HIV self-testing increased HIV testing among outpatients in Malawi, with a minimal risk of adverse events. Facility-based HIV self-testing should be considered for scale-up in settings with a high unmet need for HIV testing. FUNDING: United States Agency for International Development.

High rates of STD and sexual risk behaviors among Garífunas in Honduras.

BACKGROUND: Honduras has the highest concentration of HIV and AIDS cases in Central America, with an estimated adult HIV prevalence of 1.5%. Prevalence is higher among certain ethnic groups such as the Garífuna with a reported HIV prevalence of 8%. METHODS: A biological and behavioral survey was conducted on a stratified random sample of the Garífuna population in Honduras, using computer-assisted interviews. Blood was tested for HIV, herpes simplex type 2 (HSV-2), and syphilis; urine was tested for Chlamydia trachomatis, Neisseria gonorrhoea, Trichomonas vaginalis, and Mycoplasma genitalum. RESULTS: We enrolled a total of 817 participants, 41% female and 51% male. Estimated prevalences and 95% confidence intervals (CI) were: HIV, 4.5% (95% CI: 3.0 to 6.6), HSV-2, 51.1% (95% CI: 46.7 to 55.6), and syphilis seropositivity, 2.4% (95% CI: 1.4 to 4.0). Sexually transmitted infections in urine were: chlamydia, 6.8% (95% CI: 4.7 to 9.7), gonorrhea, 1.1% (95% CI: 0.4 to 2.9), trichomoniasis, 10.5% (95% CI: 8.1 to 13.6), and Mycoplasma genitalium, 7.1% (95% CI: 5.1 to 9.9). Consistent condom use was low with stable (10.6%) and casual (41.4%) partners. In multivariate analysis, HIV was associated with rural residence. HSV-2 was associated with female sex, older age, and syphilis seropositivity. CONCLUSIONS: We found a moderate prevalence of HIV and a high prevalence of HSV-2 among the Garífunas. HSV-2 may increase the vulnerability of these populations to HIV in the future. Intervention strategies should emphasize sexually transmitted infection control and condom promotion, specifically targeting the Garífuna population.

The chulli water purifier: acceptability and effectiveness of an innovative strategy for household water treatment in Bangladesh.

To evaluate the effectiveness of the chulli water purifier, a new household water treatment strategy in Bangladesh that relies on passing water through a stove, we interviewed persons who had this water purifier. From households using it regularly, we tested untreated water, sand-filtered water without heat pasteurization, sand-filtered and heat pasteurized water, and household stored, treated water. Reasons for discontinuing use among 80 of 101 persons included mechanical problems (49%), inconvenience (35%), and high cost (10%). Only four households were regularly using the purifier. Three (19%) of 16 heat-treated samples were positive for Escherichia coli. The median log reduction from source water was > 5. Nine (56%) stored water samples were positive for E. coli, indicating recontamination. Poor durability, inconvenience, high cost, and post-treatment contamination limit the usefulness of the purifier. These issues, which are relevant for other household water treatment strategies, should be resolved before further implementation.

Laboratory-based surveillance of paratyphoid fever in the United States: travel and antimicrobial resistance.

BACKGROUND: The incidence of paratyphoid fever, including paratyphoid fever caused by antimicrobial-resistant strains, is increasing globally. However, the epidemiologic and laboratory characteristics of paratyphoid fever in the United States have never been studied. METHODS: We attempted to interview all patients who had been infected with laboratory-confirmed Salmonella serotypes Paratyphi A, Paratyphi B, or Paratyphi C in the United States with specimens collected from 1 April 2005 through 31 March 2006. At the Centers for Disease Control and Prevention (CDC), isolates underwent serotype confirmation, antimicrobial susceptibility testing, and pulsed-field gel electrophoresis typing. RESULTS: Of 149 patients infected with Salmonella Paratyphi A, we obtained epidemiologic information for 89 (60%); 55 (62%) of 86 were hospitalized. Eighty-five patients (96%) reported having travel internationally, and 80 (90%) had traveled to South Asia. Of the 146 isolates received at the CDC, 127 (87%) were nalidixic acid resistant; nalidixic acid resistance was associated with travel to South Asia (odds ratio, 17.0; 95% confidence interval, 3.8-75.9). All nalidixic acid-resistant isolates showed decreased susceptibility to ciprofloxacin (minimum inhibitory concentration, > or = 0.12 microg/mL). Of 49 patients infected with Salmonella Paratyphi B, only 12 (24%) were confirmed to have Paratyphi B when tested at the CDC. Four (67%) of 6 patients were hospitalized, and 5 (83%) reported travel (4 to the Andean region of South America). One case of Salmonella Paratyphi C infection was reported in a traveler to West Africa with a urinary tract infection. CONCLUSIONS: Physicians should be aware of the increasing incidence of infection due to Salmonella Paratyphi A and treatment options given its widespread antimicrobial resistance. A paratyphoid fever vaccine is urgently needed. Continued surveillance for paratyphoid fever will help guide future prevention and treatment recommendations.

Factors associated with E. coli contamination of household drinking water among tsunami and earthquake survivors, Indonesia.

The December 2004 tsunami in Sumatra, Indonesia, destroyed drinking water infrastructure, placing over 500,000 displaced persons at increased risk of waterborne disease. In June 2005, we assessed the relationship of water handling behaviors to household water quality in three districts: Aceh Besar, Simeulue, and Nias. We surveyed 1,127 households from 21 communities and tested stored drinking water. Factors associated with a reduced likelihood of having contaminated stored drinking water included obtaining water from improved sources (Aceh Besar, adjusted odds ratio (aOR) 0.41, P < 0.01; Simeulue, aOR 0.48, P = 0.02), using chlorine solution (Simeulue, aOR 0.41, P < 0.01), and having free chlorine in stored water (Aceh Besar, aOR 0.42, P < 0.01; Nias, aOR 0.28, P < 0.01). Reported boiling, even among those who could describe correct practice, was not associated with improved water quality. Water source improvement and household water chlorination appear to be useful strategies to improve household stored drinking water quality in post-disaster situations.

Emergence of Shiga toxin 1 genes within Shigella dysenteriae type 4 isolates from travelers returning from the Island of Hispañola.

Shiga toxins are produced by Shigella dysenteriae type 1 and certain strains of Escherichia coli. Three cases of Shiga toxin-producing S. dysenteriae type 4 were identified among travelers to the island of Hispañola between 2002 and 2005. Clinical and public health practitioners should be aware of this newly identified strain.