Impact of Neighborhood Social Cohesion and Rodent Sightings on Mental Health among Residents of New York City During the COVID-19 Pandemic.

Common mental disorders such as depression and anxiety are prevalent globally, and rates are especially high in New York City (NYC) since the COVID-19 pandemic. Neighborhood social and physical environments have been found to influence mental health. We investigated the impact of neighborhood social cohesion and neighborhood rodent sightings (as an indicator of neighborhood cleanliness) on nonspecific serious psychological distress (NSPD) status using 2020 NYC Community Health Survey data from 8781 NYC residents. Multivariable logistic regression was used to evaluate the relationships among social cohesion, rodent sightings, and NSPD adjusted for confounders and complex sampling and weighted to the NYC population. Effect measure modification of rodent sightings on the effect of social cohesion on NSPD was evaluated on the multiplicative scale by adding the interaction term to the multivariable model and, if significant, stratifying on the effect modifier, and on the additive scale using the relative excess risk due to interaction (RERI). Social cohesion was found to decrease the odds of NSPD, and rodent sightings were found to increase the odds of NSPD. We found significant evidence of effect measure modification on the multiplicative scale. In the stratified models, there was a protective effect of social cohesion against NSPD among those not reporting rodent sightings, but no effect among those reporting rodent sightings. Our findings suggest that both neighborhood social cohesion and rodent sightings impact the mental health of New Yorkers and that rodent infestations may diminish the benefit of neighborhood social cohesion.

Impact of the First Year of the COVID-19 on Unmet Healthcare Need among New York City Adults: a Universal Healthcare Experiment.

We examined the impact of the first year of the COVID-19 pandemic on unmet healthcare need among New Yorkers and potential differences by race/ethnicity and health insurance. Data from the Community Health Survey, collected in 2018, 2019, and 2020, were merged to compare unmet healthcare need within the past 12 months during the pandemic versus the 2 years prior to 2020. Univariate and multivariable logistic regression models evaluated change in unmet healthcare need overall, and we assessed whether race/ethnicity or health insurance status modified the association. Overall, 12% of New Yorkers (N = 27,660) experienced unmet healthcare during the 3-year period. In univariate and multivariable models, the first year of the pandemic (2020) was not associated with change in unmet healthcare need compared with 2018-2019 (OR = 1.04, p = 0.548; OR = 1.03, p = 0.699, respectively). There was no statistically significant interaction between calendar year and race/ethnicity, but there was significant interaction with health insurance status (interaction p = 0.009). Stratifying on health insurance status, those uninsured had borderline significant lower odds of experiencing unmet healthcare need during 2020 compared to the 2 years prior (OR = 0.72, p = 0.051) while those with insurance had a slight increase that was not significant (OR = 1.12, p = 0.143). Unmet healthcare need among New Yorkers during the first year of the pandemic did not differ significantly from 2018-2019. Federal pandemic relief funding, which offered no-cost COVID-19 testing and care to all, irrespective of health insurance or legal status, may have helped equalized access to healthcare.

Disparities in Dolutegravir Uptake Affecting Females of Reproductive Age With HIV in Low- and Middle-Income Countries After Initial Concerns About Teratogenicity : An Observational Study.

BACKGROUND: The transition to dolutegravir-containing antiretroviral therapy (ART) in low- and middle-income countries (LMICs) was complicated by an initial safety signal in May 2018 suggesting that exposure to dolutegravir at conception was possibly associated with infant neural tube defects. On the basis of additional evidence, in July 2019, the World Health Organization recommended dolutegravir for all adults and adolescents living with HIV. OBJECTIVE: To describe dolutegravir uptake and disparities by sex and age group in LMICs. DESIGN: Observational cohort study. SETTING: 87 sites that began using dolutegravir in 11 LMICs in the Asia-Pacific; Caribbean, Central and South America network for HIV epidemiology (CCASAnet); and sub-Saharan African regions of the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. PATIENTS: 134 672 patients aged 16 years or older who received HIV care from January 2017 through March 2020. MEASUREMENTS: Sex, age group, and dolutegravir uptake (that is, newly initiating ART with dolutegravir or switching to dolutegravir from another regimen). RESULTS: Differences in dolutegravir uptake among females of reproductive age (16 to 49 years) emerged after the safety signal. By the end of follow-up, the cumulative incidence of dolutegravir uptake among females 16 to 49 years old was 29.4% (95% CI, 29.0% to 29.7%) compared with 57.7% (CI, 57.2% to 58.3%) among males 16 to 49 years old. This disparity was greater in countries that began implementing dolutegravir before the safety signal and initially had highly restrictive policies versus countries with a later rollout. Dolutegravir uptake was similar among females and males aged 50 years or older. LIMITATION: Follow-up was limited to 6 to 8 months after international guidelines recommended expanding access to dolutegravir. CONCLUSION: Substantial disparities in dolutegravir uptake affecting females of reproductive age through early 2020 are documented. Although this disparity was anticipated because of country-level restrictions on access, the results highlight its extent and initial persistence. PRIMARY FUNDING SOURCE: National Institutes of Health.

Viral Load Status Before Switching to Dolutegravir-Containing Antiretroviral Therapy and Associations With Human Immunodeficiency Virus Treatment Outcomes in Sub-Saharan Africa.

BACKGROUND: Dolutegravir is being rolled out globally as part of preferred antiretroviral therapy (ART) regimens, including among treatment-experienced patients. The role of viral load (VL) testing before switching patients already on ART to a dolutegravir-containing regimen is less clear in real-world settings. METHODS: We included patients from the International epidemiology Databases to Evaluate AIDS consortium who switched from a nevirapine- or efavirenz-containing regimen to one with dolutegravir. We used multivariable cause-specific hazards regression to estimate the association of the most recent VL test in the 12 months before switching with subsequent outcomes. RESULTS: We included 36 393 patients at 37 sites in 5 countries (Democratic Republic of the Congo, Kenya, Rwanda, Tanzania, Uganda) who switched to dolutegravir from July 2017 through February 2020, with a median follow-up of approximately 11 months. Compared with those who switched with a VL <200 copies/mL, patients without a recent VL test or with a preswitch VL ≥1000 copies/mL had significantly increased hazards of an incident VL ≥1000 copies/mL (adjusted hazard ratio [aHR], 2.89; 95% confidence interval [CI], 1.99-4.19 and aHR, 6.60; 95% CI, 4.36-9.99, respectively) and pulmonary tuberculosis or a World Health Organization clinical stage 4 event (aHR, 4.78; 95% CI, 2.77-8.24 and aHR, 13.97; 95% CI, 6.62-29.50, respectively). CONCLUSIONS: A VL test before switching to dolutegravir may help identify patients who need additional clinical monitoring and/or adherence support. Further surveillance of patients who switched to dolutegravir with an unknown or unsuppressed VL is needed.

Identification of Legacy and Active Sources of Metal Contamination in Soils in Brooklyn, NY.

The purpose of this study was to examine the spatial distribution and potential anthropogenic sources of lead (Pb), zinc (Zn), copper (Cu), manganese (Mn), and iron (Fe) in surface soils throughout Brooklyn, NY. We collected soil samples (n = 1,373) from 176 different New York City parks. Samples were analyzed ex-situ using a portable X-ray fluorescence with a subset of samples laboratory confirmed. The effect of multiple sources on concentrations were determined by multivariable linear regression with generalized estimating equations. Median concentrations of Pb, Zn, Cu, Fe, and Mn were 108 ppm, 145 ppm, 49 ppm, 14,034 ppm, and 279 ppm, respectively. All metals were significantly correlated with one another (p < 0.001), with the strength of the correlation ranging from a low of approximately ρ = 0.3 (Pb-Mn and Zn-Mn) to a high of ρ = 0.7 (Pb-Cu). In final multivariate modeling significant association were observed between scrap yards and Mn concentration (ß = 0.075, 0.019), National Priorities List (NPL) sites and Pb, Fe and Mn (ß = 0.134, p = 0.004; ß = 0.038, p = 0.014; ß = 0.057, p = 0.037, respectively), and bridges nearby and Pb and Zn (ß = 0.106, p = 0.003; ß = 0.076, p = 0.026, respectively). Although manufacturing and industry have mostly left the area, smaller scrap metal recyclers are abundant and associated with increased Cu and Mn soil concentrations. In addition, NPL sites contributed to increased concentrations of all five metals within 800 m. Roadways have long been established to be sources of urban pollution; however, in our study we also found the presence of bridges within 800 m were also strongly predictive of increased Pb, Cu, and Zn concentrations.

Exploration of the Complex Relationships Among Multilevel Predictors of PrEP Use Among Men Who Have Sex with Men in the United States.

To explore the relationships among individual-, social-, and contextual- (state-level characteristics, including LBGTQ + and racial inequality) level factors and PrEP use. A cross-sectional survey was conducted in 2015-2016 among a geographically diverse group of men who have sex with men (MSM). Survey data was linked to publicly available state-level data based on participant zip code. Multivariable multilevel logistic regression was used to explore the association between multilevel variables and PrEP use. Of 4165 HIV-negative MSM, 13.4% were taking PrEP. In the regression analysis, several demographic and behavioral factors were associated with higher odds of PrEP use. Importantly, after adjusting for individual- and social-level factors, residents of states with high LGBTQ + equality had significantly higher odds of taking PrEP (OR 1.57; 95% CI 1.119, 2.023) compared to low equality states. LGBTQ + inequality between states may hinder PrEP use. States may need to take proactive measures to reduce LGBTQ + inequality as this may negatively impact the ability to reach the federal administration's stated goal to end the HIV epidemic in the US.

Estimating aerosol transmission risk of SARS-CoV-2 in New York City public schools during reopening.

The objective of this study was to estimate the risk of SARS-CoV-2 transmission among students and teachers in New York City public schools, the largest school system in the US. Classroom measurements conducted from December 2017 to September 2018 were used to estimate risk of SARS-CoV-2 transmission using a modified Wells-Riley equation under a steady-state conditions and varying exposure scenarios (infectious student versus teacher, susceptible student versus teacher, with and without masks). We then used multivariable linear regression with GEE to identify school and classroom factors that impact transmission risk. Overall, 101 classrooms in 19 schools were assessed, 86 during the heating season, 69 during cooling season, and 54 during both. The mean probability of transmission was generally low but varied by scenario (range: 0.0015-0.81). Transmission rates were higher during the heating season (beta=0.108, p=0.010), in schools in higher income neighborhoods (>80K versus 20K-40K beta=0.196, p<0.001) and newer buildings (<50 years beta=0.237, p=<0.001; 50-99 years beta=0.230, p=0.013 versus 100+ years) and lower in schools with mechanical ventilation (beta=0.141, p=0.057). Surprisingly, schools located in older buildings and lower-income neighborhoods had lower transmission probabilities, likely due to the greater outdoor airflow associated with an older, non-renovated buildings that allow air to leak in (i.e. drafty buildings). Despite the generally low risk of school-based transmission found in this study, with SARS-CoV-2 prevalence rising in New York City this risk will increase and additional mitigation steps should be implemented in schools now.

The Evidence for HIV Self-Testing to Increase HIV Testing Rates and the Implementation Challenges that Remain.

PURPOSE OF REVIEW: We describe the evidence regarding the impact of offering HIV self-testing (HIVST) and explore the gaps that need to be filled to design and implement HIVST programs. RECENT FINDINGS: Numerous randomized controlled trials found that offering HIVST increases HIV testing rates. However, these trials used an oral HIVST that was provided for free and there is no research examining the impact of offering blood-based (finger prick) kits or charging for HIVST kits. The trials also used various methods for distributing the HIVST kits, but there is little research comparing distribution methods. Study participants varied in the HIV testing method they chose when given choices, suggesting that offering multiple HIV testing options may be needed to maximize testing rates. Despite the consistent finding that offering HIVST increases HIV testing rates, questions remain that need to be answered in order to maximize the potential of this new biomedical technology.

A multistate joint model for interval-censored event-history data subject to within-unit clustering and informative missingness, with application to neurocysticercosis research.

We propose a multistate joint model to analyze interval-censored event-history data subject to within-unit clustering and nonignorable missing data. The model is motivated by a study of the neurocysticercosis (NC) cyst evolution at the cyst-level, taking into account the multiple cysts phases with intermittent missing data and loss to follow-up, as well as the intra-brain clustering of observations made on a predefined data collection schedule. Of particular interest in this study is the description of the process leading to cyst resolution, and whether this process varies by antiparasitic treatment. The model uses shared random effects to account for within-brain correlation and to explain the hidden heterogeneity governing the missing data mechanism. We developed a likelihood-based method using a Monte Carlo EM algorithm for the inference. The practical utility of the methods is illustrated using data from a randomized controlled trial on the effect of antiparasitic treatment with albendazole on NC cysts among patients from six hospitals in Ecuador. Simulation results demonstrate that the proposed methods perform well in the finite sample and misspecified models that ignore the data complexities could lead to substantial biases.

Linkage to Care Following an HIV Diagnosis in Three Public Sector Clinics in eThekwini (Durban), South Africa: Findings from a Prospective Cohort Study.

Linkage to care following an HIV diagnosis remains an important HIV care continuum milestone, even in the era of universal ART eligibility. In an 8-month prospective cohort study among 459 (309 women, 150 men) newly-diagnosed HIV-positive individuals in three public-sector clinics in Durban metropolitan region, South Africa, from 2010 to 2013, median time to return to clinic for CD4+ results (linkage) was 10.71 weeks (95% CI 8.52-12.91), with 54.1% 3-month cumulative incidence of linkage. At study completion (9.23 months median follow-up), 26.2% had not linked. Holding more positive outcome-beliefs about enrolling in care was associated with more rapid linkage [adjusted hazard ratio (AHR)each additional belief 1.31; 95% CI 1.05-1.64] and lower odds of never linking [adjusted odds ratio (AOR) 0.50; 95% CI 0.33-0.75]. Holding positive ARV beliefs was strongly protective against never linking to care. Age over 30 years (AHR 1.59; 95% CI 1.29-1.97) and disclosing one's HIV-positive status within 30 days of diagnosis (AHR 1.52; 95% CI 1.10-2.10) were associated with higher linkage rates and lower odds of never linking. Gender was not associated with linkage and did not alter the effect of other predictors. Although expanded access to ART has reduced some linkage barriers, these findings demonstrate that people's beliefs and social relations also matter. In addition to structural interventions, consistent ART education and disclosure support, and targeting younger individuals for linkage are high priorities.

Applying a social-ecological lens to opinions about HIV self-testing among Kenyan truckers who declined to test: a qualitative study.

HIV prevalence among truckers in Africa is high and testing rates suboptimal. With numerous African countries having approved HIV self-testing kits, more information on how to design acceptable and accessible self-testing programs for high-risk populations is necessary. We explored views about self-testing via in-depth interviews with 24 truckers participating in a randomised controlled trial who refused HIV testing. A social-ecological lens was used to guide data analysis and frame study findings. While most participants said that they would use an HIV self-test, perceived barriers and facilitators were identified at multiple levels. Many participants noted lack of time to test or obtain a self-test kit as a major barrier (intrapersonal) and varied in their views about self-testing with a partner (interpersonal). Participants offered programmatic/policy recommendations, suggesting that they preferred accessing self-test kits in settings where training could be provided. Participants believed they should be able to pick up multiple test kits at the same time and that the test kits should be free or low cost. These study findings will help guide the design of self-testing programs for truckers and other mobile populations.

Exploring the complex associations over time among albendazole treatment, cyst evolution, and seizure outcomes in neurocysticercosis.

OBJECTIVE: To develop a causal model for the occurrence of neurocysticercosis (NC)-related seizures and test hypotheses generated from the model. METHODS: We used data from a randomized controlled trial comparing albendazole with placebo among patients newly diagnosed with NC. Based on our causal model, we explored the associations among albendazole treatment, NC cyst evolution, and seizure outcomes over 24 months of follow-up using generalized linear mixed effect models. RESULTS: We included 153 participants, of whom 51% received albendazole. The association between seizure outcomes and treatment over time demonstrated lack of linearity and heterogeneity, requiring the inclusion of time-treatment interaction terms for valid modeling. Participants in the albendazole group had fewer seizures overall and of partial onset at all time points compared with the placebo group, but the difference increased over the first few months following treatment, then decreased over time. Generalized seizures exhibited a more complex association; those in the albendazole group had fewer seizures compared with those in the placebo group for the first few months after treatment, and then the association reversed and those in the placebo arm had fewer seizures. Adjusting for the number of NC cysts in each phase resulted in an attenuation of the strength of association between albendazole and seizure outcomes, consistent with mediation. Among participants in whom all cysts had disappeared (n = 21), none continued to have seizures. SIGNIFICANCE: Albendazole treatment is associated with a possible reduction in focal seizures in the short term (3-6 months), perhaps by hastening the resolution of the cysts. However, the effect is not discernible over the long term, because most cysts either calcify or resolve completely, regardless of whether treated with albendazole. The stage of evolution of the cysticercus is an important consideration in the evaluation of albendazole effect on seizure outcome.

A Randomized Controlled Trial to Increase HIV Testing Demand Among Female Sex Workers in Kenya Through Announcing the Availability of HIV Self-testing Via Text Message.

We assessed whether informing female sex workers about the availability of HIV self-testing at clinics in Kenya using text messages would increase HIV testing rates. We selected a sample of 2196 female sex workers registered in an electronic health record system who were irregular HIV testers and randomized them to be sent a text message announcing the availability of (1) HIV self-test kits sent three times (intervention), (2) general HIV testing sent three times (enhanced standard of care [SOC]), or (3) general HIV testing sent one time (traditional SOC). Participants in the intervention arm were significantly more likely to test for HIV during 2-month follow-up compared to those in the enhanced SOC (OR 1.9, p = 0.001). There was no difference in HIV testing between those in the enhanced SOC and the traditional SOC arms. Announcing the availability of HIV self-testing via text message increased HIV testing among this high-risk group.

Announcing the availability of oral HIV self-test kits via text message to increase HIV testing among hard-to-reach truckers in Kenya: a randomized controlled trial.

BACKGROUND: Truckers in sub-Saharan Africa are at higher risk of contracting HIV than the general population. HIV self-testing may be a way to increase testing rates in this high-risk population. The objective of this randomized controlled trial was to assess whether informing truckers who do not test for HIV regularly about the availability of HIV self-testing kits at roadside wellness centers in Kenya using text messages would increase HIV testing rates compared to the current program in which they are sent text messages about the availability of HIV testing in general. METHODS: A sample of 2262 male truckers registered in the North Star Alliance electronic health record system who, based on these records, were not testing for HIV regularly were randomized to one of three study groups in which they were sent text messages about the availability of (1) oral HIV self-test kits at all 8 North Star Alliance Kenya clinics that was sent three times (intervention), (2) HIV testing in general (not self-testing) at all North Star Alliance clinics sent three times (enhanced standard of care [SOC]), or (3) HIV testing in general (not self-testing) at all North Star Alliance clinics sent one time (SOC). We looked at HIV testing over a 2-month study period following the first text. RESULTS: Truckers in the intervention group were significantly more likely to test for HIV compared to those in the enhanced SOC (OR = 2.7, p = 0.009). There was no difference in HIV testing between those in the enhanced SOC and the SOC groups. Of those in the intervention group who tested, 64.5% chose the self-test and 35.5% chose the standard provider-administered blood-based HIV test. Although the intervention more than doubled HIV testing rates, because HIV testing rates were so low in this population (by design as we selected irregular testers), even in the intervention group more than 96% of participants did not test. CONCLUSIONS: Announcing the availability of HIV self-testing via text message increased HIV testing rates among truckers who were not regularly accessing HIV testing. However, self-testing is only a partial solution to increasing testing rates in this hard to reach population. TRIAL REGISTRATION: This trial was registered prior to enrollment at the Registry for International Impact Evaluations (RIDIE STUDY ID: 582a2462ae2ab): http://ridie.3ieimpact.org/index.php?r=search/detailView&id=492 . It was also registered after completion at ClinicalTrials.gov ( ClinicalTrials.gov Identifier: NCT03662165): https://clinicaltrials.gov/ct2/show/NCT03662165?term=NCT03662165&type=Intr&cond=HIV&rank=1 .

Social Support and Violence-prone Relationships as Predictors of Disclosure of HIV Status Among Newly Diagnosed HIV-positive South Africans.

Despite the salience of social support and violence as potential outcomes of disclosure, how pre-existing social support and relationship violence among people living with HIV shapes and influences HIV status disclosure has received limited attention. Following the Disclosure Process Model, this study investigated pre-disclosure support and violence-prone relationships as predictors of disclosure using data from a prospective study of 459 newly diagnosed South African women and men. Most (88%) disclosed their status to at least one person by their 8-month interview. Level of social support was unrelated to disclosure to a partner. However, those with higher levels of support had higher odds of disclosing to family and to others. Women in violence-prone relationships were more likely to report disclosure to a partner than were those not in such relationships, counter to expectations. The findings suggest that the same mechanisms may not explain processes of disclosure across all relationship types.

Offering Self-administered Oral HIV Testing as a Choice to Truck Drivers in Kenya: Predictors of Uptake and Need for Guidance While Self-testing.

We assessed predictors of choosing self-administered oral HIV testing in the clinic with supervision versus the standard provider-administered blood test when offered the choice among 149 Kenyan truck drivers, described the types of guidance participants needed during self-testing and predictors of needing guidance. Overall, 56.38% of participants chose the self-test, 23.49% the provider-administered test, and 20.13% refused testing. In the adjusted regression models, each additional unit on the fatalism and self-efficacy scales was associated with 0.97 (p = 0.003) and 0.83 (p = 0.008) times lower odds of choosing the self-test, respectively. Overall, 52.38% of self-testers did so correctly without questions, 47.61% asked questions, and 13.10% required unsolicited correction from the provider. Each additional unit on the fatalism scale was associated with 1.07 times higher odds of asking for guidance when self-testing (p < 0.001). Self-administered oral HIV testing seems to be acceptable and feasible among Kenyan truck drivers, especially if given the opportunity to ask questions.

HIV testing preferences among long distance truck drivers in Kenya: a discrete choice experiment.

Providing HIV testing services to truck drivers in Africa is crucial but has proven challenging. The introduction of HIV self-testing promises to provide expanded service delivery options for clients, potentially increasing demand for services and expanding coverage - especially important for high-risk and difficult-to-reach populations. This study examines the preferences regarding HIV testing service delivery models, among long distance truck drivers to identify testing services that would appeal to this population. Using a discrete choice experiment, this study examines the drivers of choice regarding HIV counselling and testing among 305 truck drivers recruited from two roadside wellness clinics along major trucking routes in Kenya. Participants made trade-offs between characteristics of HIV testing service delivery models by making hypothetical choices in a series of paired HIV testing scenarios. Conditional logit models were used to identify the HIV testing characteristics driving the selection of preferred scenarios, as well as determine whether preferences interact with individual characteristics - especially HIV testing history. Participants preferred free, provider-administered HIV testing at a roadside clinic, using a finger-prick test, with in-person counselling, undertaken in the shortest possible time. The strongest driver of choice was the cost of the test. Those who had never tested previously preferred oral testing and telephonic counselling, while those who were not regular testers favoured clinic based - over self-testing. The results of this study indicate that for the majority of participants - most of whom had tested before - the existing services offered at roadside clinics were the preferred service delivery model. The introduction of oral self-testing increases the options available to truck drivers and may even improve testing uptake for some, especially among those who have never tested before. However, these findings suggest the impact on HIV testing uptake of introducing oral self-testing may be limited in this population.

Offering self-administered oral HIV testing to truck drivers in Kenya to increase testing: a randomized controlled trial.

We conducted a randomized controlled trial among 305 truck drivers from two North Star Alliance roadside wellness clinics in Kenya to see if offering HIV testing choices would increase HIV testing uptake. Participants were randomized to be offered (1) a provider-administered rapid blood (finger-prick) HIV test (i.e., standard of care [SOC]) or (2) a Choice between SOC or a self-administered oral rapid HIV test with provider supervision in the clinic. Participants in the Choice arm who refused HIV testing in the clinic were offered a test kit for home use with phone-based posttest counseling. We compared HIV test uptake using the Mantel Haenszel odds ratio (OR) adjusting for clinic. Those in the Choice arm had higher odds of HIV test uptake than those in the SOC arm (OR = 1.5), but the difference was not statistically significant (p = 0.189). When adding the option to take an HIV test kit for home use, the Choice arm had significantly greater odds of testing uptake (OR = 2.8, p = 0.002). Of those in the Choice arm who tested, 26.9% selected the SOC test, 64.6% chose supervised self-testing in the clinic, and 8.5% took a test kit for home use. Participants varied in the HIV test they selected when given choices. Importantly, when participants who refused HIV testing in the clinic were offered a test kit for home use, an additional 8.5% tested. Offering truck drivers a variety of HIV testing choices may increase HIV testing uptake in this key population.

Stated and revealed preferences for HIV testing: can oral self-testing help to increase uptake amongst truck drivers in Kenya?

BACKGROUND: Long-distance truck drivers in Africa are particularly at risk of HIV acquisition and offering self-testing could help increase testing coverage in this hard-to-reach population. The aims of this study are twofold: (1) to examine the preference structures of truck drivers in Kenya regarding HIV testing service delivery models and what they mean for the roll-out of HIV self-testing, and (2) to compare the preference data collected from a hypothetical discrete choice experiment with the actual choices made by participants in the intervention arm of a randomised controlled trial (RCT) who were offered HIV testing choices. METHODS: Using data from 150 truck drivers, this paper examines whether the stated preferences regarding HIV testing in a discrete choice experiment predict the actual test selected when offered HIV testing choices. Conditional logit models were used for main effects analysis and stratified models were run by HIV testing choices made in the trial to assess if the attributes preferred differed by test chosen. RESULTS: The strongest driver of stated preference among all participants was cost. However, two preferences diverged between those who actually chose self-testing in the RCT and those who chose a provider administered test: the type of test (p < 0.001) and the type of counselling (p = 0.003). Self-testers preferred oral-testing to finger-prick testing (OR 1.26 p = 0.005), while non-self-testers preferred finger-prick testing (OR 0.56 p < 0.001). Non-self-testers preferred in-person counselling to telephonic counselling (OR 0.64 p < 0.001), while self-testers were indifferent to type of counselling. Preferences in both groups regarding who administered the test were not significant. CONCLUSIONS: We found stated preference structures helped explain the actual choices participants made regarding the type of HIV testing they accepted. Offering oral testing may be an effective strategy for increasing willingness to test among certain groups of truck drivers. However, the importance of in-person counselling and support, and concern that an oral test cannot detect HIV infection may mean that continuing to offer finger-prick testing at roadside wellness centres will best align with the preferences of those already attending these facilities. More research is needed to explore whether who administers the HIV test (provider versus self) makes any difference. TRIAL REGISTRATION: This trial is registered with the Registry for International Development Impact Evaluations ( RIDE ID#55847d64a454f ).

Psychosocial characteristics of primary care-seeking long-distance truck drivers in Kenya and associations with HIV testing.

The 90-90-90 strategy from the Joint United Nations Programme on HIV/AIDS (UNAIDS) to end the AIDS epidemic by 2020 includes, as its first goal, to have 90% of all people living with HIV to know their status. Achieving this goal will depend on effectively reaching high risk populations, which include mobile populations such as truck drivers. This study aimed to characterise a sample of 305 truck drivers recruited from 2 roadside wellness clinics in Kenya in terms of anticipated HIV stigma, self-efficacy, fatalism, gender equity, sensation seeking, and self-esteem, and then determine the association of these psychosocial characteristics with HIV testing behaviour. Greater general self-efficacy was associated with higher income and more years working as a truck driver. Greater fatalism was associated with non-Christian religion, being married, and having a lower income. Greater gender equity was associated with completing high school, being married, and having higher income. Greater sensation seeking was associated with lower income and fewer years employed as a truck driver. In multivariable logistic regression adjusted for demographic variables, anticipated HIV stigma was negatively associated with having ever tested for HIV (adjusted odds ratio [aOR] = 0.79; 95% confidence interval [CI] = 0.63-0.98; p = 0.034) and self-esteem was positively associated with testing (aOR = 1.06; 95% CI = 1.00-1.12; p = 0.038). Associations with HIV testing behaviour were not significant for self-efficacy, fatalism, gender equity, or sensation seeking. Public health interventions aiming to reduce anticipated stigma and increase self-esteem may potentially increase the uptake of HIV testing among truck drivers. Further research is needed to better understand the influence of these psychosocial characteristics on HIV testing.