Effectiveness of Linkage to Care and Prevention Interventions Following HIV Self-Testing: A Global Systematic Review and Meta-analysis.

Over 38.4 million people were living with HIV globally in 2021. The HIV continuum includes HIV testing, diagnosis, linkage to combined antiretroviral therapy (cART), and retention in care. An important innovation in the HIV care continuum is HIV self-testing. There is a paucity of evidence regarding the effectiveness of interventions aimed at linking self-testers to care and prevention, including pre-exposure prophylaxis (PrEP). To bridge this gap, we carried out a global systematic review and meta-analysis to ascertain the effectiveness of interventions post-HIV self-testing regarding: (1) linkage to care or ART, (2) linkage to PrEP, and (3) the impact of HIV self-test (HIVST) interventions on sexual behaviors. We searched PubMed, Web of Science, SCOPUS, Cochrane Library, CINAHL Plus (EBSCO), MEDLINE (Ovid), Google Scholar, and ResearchGate. We included only published randomized controlled trials (RCTs) and quasi-experiment that compared HIVST to the standard of care (SoC). Studies with sufficient data were aggregated using meta-analysis on RevMan 5.4 at a 95% confidence interval. Cochrane's Q test was used to assess heterogeneity between the studies, while Higgins and Thompson's I2 was used to quantify heterogeneity. Subgroup analyses were conducted to identify the source of heterogeneity. Of the 2669 articles obtained from the databases, only 15 studies were eligible for this review, and eight were included in the final meta-analysis. Overall, linkage to care was similar between the HIVST arm and SoC (effect size: 0.92 [0.45-1.86]; I2: 51%; p: 0.04). In the population subgroup analysis, female sex workers (FSWs) in the HIVST arm were significantly linked to care compared to the SoC arm (effect size: 0.53 [0.30-0.94]; I2: 0%; p: 0.41). HIVST interventions did not significantly improve ART initiation in the HIVST arm compared to the SoC arm (effect size: 0.90 [0.45-1.79]; I2: 74%; p: < 0.001). We found that more male partners of women living with HIV in the SoC arm initiated PrEP compared to partners in the HIVST arm. The meta-analysis showed no difference between the HIVST and SoC arm regarding the number of clients (effect size: - 0.66 [1.35-0.02]; I2: 64%; p: 0.09) and non-clients FSWs see per night (effect size: - 1.45 [- 1.45 to 1.38]; I2: 93%; p: < 0.001). HIVST did not reduce the use of condoms during insertive or receptive condomless anal intercourse among MSM. HIVST does not improve linkage to care in the general population but does among FSWs. HIVST intervention does not improve linkage to ART nor significantly stimulate healthy sexual behaviors among priority groups. The only RCT that linked HIVST to PrEP found that PrEP uptake was higher among partners of women living with HIV in the SoC arm than in the HIVST arm. More RCTs among priority groups are needed, and the influence of HIVST on PrEP uptake should be further investigated.

Investigating the emigration intention of health care workers: A cross-sectional study.

AIMS: To (1) explore the intramigration experience of HCWs within Nigeria, (2) explore the migration intention of health care workers (HCWs) in Nigeria and (3) identify the predictors of migration intention among HCWs in Nigeria. DESIGN: Cross-sectional study. METHODS: The online survey was used to collect data from 513 HCWs in Nigeria between May and June 2023. Crude and adjusted logistic regression were used to identify factors associated with emigration intention. Analyses were performed on SPSS version 26 at a 95% confidence interval. RESULTS: The study found that 34.4% had intramigration experience, and the rate of intention to emigrate to work in another country was 80.1%. The United Kingdom was the most preferred destination (109 HCWs), followed by Canada (92 HCWs) and the United States (82 HCWs). At the multivariate level, emigration intention was associated with the experience of burnout and duration of practice as a HCW. Nurses had higher emigration intentions than medical doctors. CONCLUSIONS: Many HCWs in Nigeria appear to have emigration intent, and nurses are more likely to be willing to migrate than doctors. The Nigerian government may want to explore strategies to reverse the emigration intent of the HCWs in Nigeria.

Does adherence to antiretroviral therapy differ by place of residence in Nigeria? A systematic review and meta-analysis protocol.

INTRODUCTION: Retention in care is still a significant challenge in the HIV treatment cascade and varies extensively across regions, leading to poor adherence to antiretroviral therapy (ART). Several factors across different socioecological levels, such as health and community-level factors, inhibit ART adherence among people living with HIV (PLWH) in Nigeria. This review seeks to ask whether adherence to ART differs by place of residence in Nigeria. METHOD AND ANALYSIS: This systematic review and meta-analysis will follow the updated Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. We will search PubMed, SCOPUS, CINAHL, Web of Science, MEDLINE (Ovid) and Google Scholar from onset to 30 April 2023. We will include only quantitative observational studies or mixed-method studies that measured the association between place of residence (urban and rural) and adherence to ART among PLWH aged ≥15 years. Title and abstract screening, full-text screening, data extraction and quality assessment will be done by two reviewers independently. A third reviewer will resolve disagreements. We will extract the author's name and year of publication, study aim(s), participant's characteristics, sample size, sampling method, region and state, adherence definition and adherence level in urban and rural areas. Data will be analysed with Review Manager V.5.4. The Q statistical test will be used to assess between-study heterogeneity, while Higgins and Thompson's I2 will be used to quantify the heterogeneity level. Several subgroups and sensitivity analyses will be conducted. ETHICS AND DISSEMINATION: Ethical approval is not warranted for this study since primary published data will be utilised. The findings of this review will be published in a high-impact peer-reviewed journal and presented at a conference. PROSPERO REGISTRATION NUMBER: CRD42022371965.

There is an urgent need for a global rural health research agenda.

People living in rural areas generally experience adverse health outcomes compared to their urban counterparts. They experience a greater burden of non-communicable diseases including: diabetes, hypertension, stroke, kidney disease, and chronic obstructive pulmonary disease (COPD), have limited access to healthcare services, and experience scarcity in specialized healthcare services. The disproportionately high all-cause mortality experienced by rural residents has been termed "the rural mortality penalty". With over 90% of the world's rural population living in Africa and Asia, we argue that the lack of an authoritative and respected global rural health research agenda contributes to increasing health inequalities, given that many of these people are receiving substandard care. There are differences in how rural and urban resident's experience healthcare. Living in rural settings might not be systematically connected to adverse health outcomes. It is important to clearly articulate the positive health outcomes associated with living in rural settings (e.g., the positive relationship between mental health and strong social ties/green spaces). Indeed, health policies stand the chance of unconsciously excluding the positive outcomes associated with rurality, as well as the rural experiences of health. Defining rural health remains an issue of controversy with a persistent reality regarding the lack of consensus as to what it means for a region or area to be considered as "rural". We outline the most common definitions of "rural areas" in the literature, as well as the shortcomings of these definitions. By unpacking the meaning of "rural health", we aim to foster communication among rural health professionals and researchers locally and internationally, as well as highlight the key research and policy implications that could emanate from a "good" definition of rural health. We agree that context remains key when it comes conceptualizing complex subjects like rurality. However, developing minimum criteria to foster communication among rural health researchers is needed. Systematically providing operational definitions of what authors describe as "rural" in the rural health research and policy literature is of utmost relevance.

Process evaluation of peer-to-peer delivery of HIV self-testing and sexual health information to support HIV prevention among youth in rural KwaZulu-Natal, South Africa: qualitative analysis.

OBJECTIVE: Peer-to-peer (PTP) HIV self-testing (HIVST) distribution models can increase uptake of HIV testing and potentially create demand for HIV treatment and pre-exposure prophylaxis (PrEP). We describe the acceptability and experiences of young women and men participating in a cluster randomised trial of PTP HIVST distribution and antiretroviral/PrEP promotion in rural KwaZulu-Natal. METHODS: Between March and September 2019, 24 pairs of trained peer navigators were randomised to two approaches to distribute HIVST packs (kits+HIV prevention information): incentivised-peer-networks where peer-age friends distributed packs within their social network for a small incentive, or direct distribution where peer navigators distributed HIVST packs directly. Standard-of-care peer navigators distributed information without HIVST kits. For the process evaluation, we conducted semi-structured interviews with purposively sampled young women (n=30) and men (n=15) aged 18-29 years from all arms. Qualitative data were transcribed, translated, coded manually and thematically analysed using an interpretivist approach. RESULTS: Overall, PTP approaches were acceptable and valued by young people. Participants were comfortable sharing sexual health issues they would not share with adults. Coupled with HIVST, peer (friends) support facilitated HIV testing and solidarity for HIV status disclosure and treatment. However, some young people showed limited interest in other sexual health information provided. Some young people were wary of receiving health information from friends perceived as non-professionals while others avoided sharing personal issues with peer navigators from their community. Referral slips and youth-friendly clinics were facilitators to PrEP uptake. Family disapproval, limited information, daily pills and perceived risks were major barriers to PrEP uptake. CONCLUSION: Both professional (peer navigators) and social network (friends) approaches were acceptable methods to receive HIVST and sexual health information. Doubts about the professionalism of friends and overly exclusive focus on HIVST information materials may in part explain why HIVST kits, without peer navigators support, did not create demand for PrEP.

Low coverage of HIV testing among adolescents and young adults in Nigeria: Implication for achieving the UNAIDS first 95.

BACKGROUND: Most studies on HIV testing among young people in Nigeria are not nationally representative. As such, recent nationally representative data, such as the Multiple Indicator Cluster Survey (MICS), could help assess the current level of HIV testing among young people, a key target population for HIV prevention in the country. In this study, we examined the coverage and factors associated with HIV testing among adolescents and young adults (AYA). METHODS: We used the data for 14,312 AYA that examined recent and lifetime HIV testing from the 2017 MCIS. Our outcomes of interest were ever tested for HIV and recently tested for HIV. We examined the association between socio-demographic factors (e.g., age, marital status, education attainment, wealth status), stigma belief, exposure to media and HIV knowledge, and uptake of HIV testing using adjusted and unadjusted logistic regression models. RESULTS: Less than a quarter of the AYA (23.7%) had ever tested for HIV, and an even lower proportion (12.4%) tested in the year preceding the survey. More females (25.4%) compared to males (20.8%) had ever tested for HIV. Young people who were aged 20-24 years (AOR 1.52, 95% CI 1.34-1.72), married (AOR 2.42, 95% CI 1.98-2.97), had higher educational attainment (AOR 5.85, 95% CI 4.39-7.81), and belonged to the wealthiest quintile (AOR 1.99, 95% CI 1.53-2.60), had higher odds of having ever tested for HIV compared to those aged 15-19 years, never married, had no formal education and belonged to the poorest wealth quintile. Also, those who had positive stigma belief towards people living with HIV (AOR 2.93, 95% CI 2.47-3.49), had higher HIV knowledge (AOR 1.62, 95% CI 1.24-2.11), and higher media exposure (AOR 1.64, 95% CI 1.36-1.97), had higher odds of having ever tested compared to those who had more negative stigma belief, had low knowledge of HIV and low media exposure. CONCLUSION: The HIV testing coverage among AYA in Nigeria is well below the national target of 95% indicated in the national HIV/AIDS strategic framework (2017-2021). Also, the low rate of HIV testing found in this study means realising the UNAIDS first 95 will require interventions targeting AYA. These interventions should focus on improving young people's knowledge of HIV, reducing negative stigma belief through media campaigns and increasing access to HIV testing through home-based testing and "opt-out" strategy at the point of care.

Cluster randomised controlled trial to determine the effect of peer delivery HIV self-testing to support linkage to HIV prevention among young women in rural KwaZulu-Natal, South Africa: a study protocol.

INTRODUCTION: A cluster randomised controlled trial (cRCT) to determine whether HIV self-testing (HIVST) delivered by peers either directly or through incentivised peer-networks, could increase the uptake of antiretroviral therapy and pre-exposure prophylaxis (PrEP) among young women (18 to 24 years) is being undertaken in an HIV hyperendemic area in KwaZulu-Natal, South Africa. METHODS AND ANALYSIS: A three-arm cRCT started mid-March 2019, in 24 areas in rural KwaZulu-Natal. Twenty-four pairs of peer navigators working with ~12 000 young people aged 18 to 30 years over a period of 6 months were randomised to: (1) incentivised-peer-networks: peer-navigators recruited participants 'seeds' to distribute up to five HIVST packs and HIV prevention information to peers within their social networks. Seeds receive an incentive (20 Rand = US$1.5) for each respondent who contacts a peer-navigator for additional HIVST packs to distribute; (2) peer-navigator-distribution: peer-navigators distribute HIVST packs and information directly to young people; (3) standard of care: peer-navigators distribute referral slips and information. All arms promote sexual health information and provide barcoded clinic referral slips to facilitate linkage to HIV testing, prevention and care services. The primary outcome is the difference in linkage rate between arms, defined as the number of women (18 to 24 years) per peer-navigators month of outreach work (/pnm) who linked to clinic-based PrEP eligibility screening or started antiretroviral, based on HIV-status, within 90 days of receiving the clinic referral slip. ETHICS AND DISSEMINATION: This study was approved by the Institutional Review Boards at the WHO, Switzerland (Protocol ID: STAR CRT, South Africa), London School of Hygiene and Tropical Medicine, UK (Reference: 15 990-1), University of KwaZulu-Natal (BFC311/18) and the KwaZulu-Natal Department of Health (Reference: KZ_201901_012), South Africa. The findings of this trial will be disseminated at local, regional and international meetings and through peer-reviewed publications. TRIAL REGISTRATION NUMBER: NCT03751826; Pre-results.