HIV Infections
Conditions
Keywords
self-test, testing, cost-effectiveness
Brief summary
This study comprises two trials to evaluate the feasibility and cost-effectiveness of HIV self-testing strategies compared to standard of care among clients in outpatient departments (OPD; Aim 1) and the sexual partners of HIV-positive clients (index testing; Aim 2). Aim 1 will be a cluster-randomized trial in 15 clusters (high-burden health facilities) in Malawi. We will enroll 6,000 adult OPD clients (15 years or older) to test the feasibility and cost-effectiveness of facility-based HIV self-testing (HIVST) for OPD clients. Aim 2 will be an individually-randomized trial in 3 high-burden health facilities in Malawi. We will enroll 500 adult HIV-positive clients (15 years or older) to test the feasibility and cost-effectiveness of index HIVST among partners of HIV-positive clients.
Detailed description
The study includes two unblinded trials to evaluate the feasibility and cost-effectiveness of HIVST strategies among adults in Malawi. Aim 1 will test the feasibility and cost-effectiveness of facility-based HIVST in OPD sites in Malawi. It will be an unblinded cluster-randomized trial and include three arms: 1) standard of care for provider-initiated testing and counseling (PITC); (2) optimized standard of care for PITC; and (3) facility-based HIVST while clients wait for routine OPD services. The standard of care arm will receive no intervention. The optimized standard of care arm will receive training and support for implementing the Malawi guidelines for PITC and morning testing. OPD clients in the facility HIVST arm will receive a HIVST demonstration and distribution, followed by uses of HIVST and private spaces for kit interpretation before receiving routine OPD services. Participants may present their self-test results to their provider, who will refer them for confirmatory HIV testing and routine ART initiation (if positive). That same day, participants from all arms will complete a brief survey upon exiting the clinic. Survey and medical record data will be compared across arms to determine whether facility HIVST is superior in regard to number of individuals tested for HIV, cost-effectiveness, number of HIV-positive individuals identified, and linkage rates for those who identify as HIV-positive. Aim 2 will test the feasibility and cost-effectiveness of index HIVST for the sexual partners of HIV-positive clients. It will be an unblinded individually-randomized trial and include two arms: 1) standard of care partner referral slips for testing; and 2) HIVST. The standard of care arm will receive no intervention for partner notification and referral. HIV-positive clients in the HIVST arm will receive a HIVST demonstration and distribution, with instructions to give the HIVST kit to their sexual partner. Participants will be given one HIVST for each of their sexual partners who has an unknown HIV status or who tested HIV-negative more than six months prior (up to 3 HIVST kits distributed). Participants (index clients) will be given instructions on how their partner can complete the self-test and how to refer their partner(s) to care if they receive a positive result from the self-test. All participants (standard of care and HIVST arms) will complete a brief survey at the beginning of the intervention and a 4-week follow-up survey to assess primary and secondary outcomes. Medical chart reviews will be conducted for all partners reported to test HIV-positive in order to assess ART initiation rates. Survey and medical record data will be compared across arms to determine whether index HIVST is superior in regard to number of partners tested for HIV, cost-effectiveness, number of HIV-positive individuals identified, and linkage rates for those who identify as HIV-positive.
Interventions
BEHAVIORALOptimized PITC
Providers will receive training on the importance of HIV testing and their role in testing as part of OPD care and morning HIV testing will be offered. Providers will receive job aids on the importance of referring patients for HIV testing, and the study team will conduct regular monitoring and evaluation on PITC implementation.
DIAGNOSTIC_TESTFacility HIVST
HIVST will be carried out in a group setting among patients in the waiting area of OPD clinics. Eligible clients will receive education about HIV testing and a demonstration of how to use and interpret results of a self-test kit will occur in the group setting. Participants will use the HIVST kit in a group setting and will be given private settings (private room or booth) to interpret their results. Participants will disclose their results to their OPD provider if they choose. Routine linkage to confirmatory testing and ART initiation will be conducted.
DIAGNOSTIC_TESTIndex HIVST
HIVST demonstration and distribution will be provided to HIV-positive clients in participating facilities to distribute to their partners. Partners who have a reactive HIVST test result, or are unable or unwilling to use HIVST, will be asked to present at the health facility for routine HIV testing. Routine linkage to confirmatory testing and ART initiation will be conducted.
Sponsors
Partners in Hope, Inc.
United States Agency for International Development (USAID)
Right to Care
Ministry of Health, Malawi
University of California, Los Angeles
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
DIAGNOSTIC
Masking
NONE
Intervention model description
The study will include two arms and methodology: (Aim 1) A cluster-randomized trial comparing HIV testing strategies for OPD clients, clustered by health facility; and (Aim 2) A individual-randomized trial comparing HIV testing strategies for partners of HIV-positive clients.
Eligibility
Sex/Gender
ALL
Age
15 Years to No maximum
Healthy volunteers
Yes
Inclusion criteria
* 15 years or older * Willing and able to provide informed consent * Being seen for OPD services at the time of the study (Aim 1) * HIV-positive (Aim 2) * Have at least one sex partner in the catchment area with an unknown HIV status at the time of study enrollment (Aim 2)
Exclusion criteria
* Currently enrolled in the INTERVAL study * Guardians attending clinics with OPD clients (Aim 1) * History of intimate partner violence in the past 12 months (Aim 2) * Fear of intimate partner violence as a consequence of participating in the study (Aim 2)
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Aim 1: Proportion of Adult OPD Clients Tested for HIV | 1 day | Same day HIV testing among OPD clients, measured by self-reports from OPD clients |
| Aim 2: Proportion of Sexual Partners Tested for HIV | 4-weeks | HIV testing among sexual partners of HIV-positive clients within 4-weeks of study enrollment, measured by secondary reports from HIV-positive clients |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Aim 1: Presence of Non-serious Adverse Events | as enrollment (measuring adverse events that occurred at the OPD clinic that 1 day) | Presence of adverse events due to the HIV testing intervention, including coercion to test, share test results, and unwanted status disclosure, measured by self-report on the day the intervention was delivered. |
| Aim 1: Cost Per Person Initiated ART | 3 months | Total cost per arm (including human resources, testing, training, equipment, facility over head, staff, and testing supplies) / total number of individual initiated ART by each arm, respectively. All costs in 2017 US$. Cost calculations do not include cost of ART. Cost data in each study group were derived from a health care perspective using micro-costing methods using the HIV Counselling and Testing costing tool developed by the Health Economics and Epidemiology Research Office in South Africa. All costs are reported in 2017 US$. We use mean cost per ART initiate. Standard deviation is not included due to the nature of calculating a 'production cost'- or the total cost incurred per the respective number of outcomes. |
| Aim 2: HIV-positivity Rates Among Sexual Partners Tested for HIV | 4-weeks | HIV-positivity rate measured by secondary report by the HIV-positive client |
| Aim 1: HIV-positivity Rate | Same 1 day as enrollment (measuring HIV testing before clients leave the OPD clinic that day) | HIV-positivity rate among OPD clients, measured by self-report |
| Aim 2: Presence of Non-serious Adverse Events | 4-weeks | Presence of adverse events due to the HIV testing intervention, including coercion to test, share test results, unwanted status disclosure, and interpersonal violence measured by self-report by the HIV-positive client |
| Aim 2: Cost Per Person Tested HIV-Positive | 1 month | Total cost per arm (including human resources, testing, training, equipment, facility over head, staff, and testing supplies) / total number of individual tested HIV-positive by each arm, respectively. All costs in 2017 US$. Cost calculations include all costs associated with HIV testing. Cost data in each study group were derived from a health care perspective using micro-costing methods using the HIV Counselling and Testing costing tool developed by the Health Economics and Epidemiology Research Office in South Africa. All costs are reported in 2017 US$. We use mean cost per HIV-positive individual identified. Standard deviation is not included due to the nature of calculating a 'production cost'- or the total cost incurred per the respective number of outcomes. |
| Aim 2: Cost Per Person Initiated ART | 3 month | Total cost per arm (including human resources, testing, training, equipment, facility over head, staff, and testing supplies) / total number of individual initiated ART by each arm, respectively. All costs in 2017 US$. Cost calculations do not include cost of ART. Cost data in each study group were derived from a health care perspective using micro-costing methods using the HIV Counselling and Testing costing tool developed by the Health Economics and Epidemiology Research Office in South Africa. All costs are reported in 2017 US$. We use mean cost per ART initiate. Standard deviation is not included due to the nature of calculating a 'production cost'- or the total cost incurred per the respective number of outcomes. |
| Aim 2: ART Initiation Among Sexual Partners Tested HIV-positive | 3 months | ART initiation within 3-months after being identified as HIV-positive within the study, measured by medical chart reviews of all Partners in Hope supported health facilities in participating districts |
| Aim 1: ART Initiation Among OPD Clients Tested HIV-positive | 3 months | ART initiation within 3-months after being identified as HIV-positive within the study, measured by medical chart reviews of all Partners in Hope supported health facilities in participating districts |
Countries
Malawi
Participant flow
Recruitment details
Participants were recruited during routine health services at participating facilities. For Aim 1, participants were recruited from September 18, 2017 - February 19, 2018. For Aim 2, participants were recruited from March 21, 2018 - June 13, 2018.
Participants by arm
| Arm | Count |
|---|---|
| AIm 1: Standard of Care Facilities assigned to the standard of care arm will receive no intervention and will continue with Ministry of Health National HIV Guidelines for provider-initiated testing and counseling (PITC) for outpatients in Aim 1. PITC guidelines recommend providers inform their OPD clients about HIV testing and refer them to HIV testing services at the facility. | 1,951 |
| Aim 1: Optimized Standard of Care Facilities assigned to the optimized standard of care arm will receive additional guidance and support from the study team to adopt the Ministry of Health National HIV Guidelines for provider-initiated testing and counseling (PITC) for Aim 1.
Optimized PITC: Providers will receive training on the importance of HIV testing and their role in testing as part of OPD care and morning HIV testing will be offered. Providers will receive job aids on the importance of referring patients for HIV testing, and the study team will conduct regular monitoring and evaluation on PITC implementation. | 1,837 |
| Aim 1: Facility HIVST Facilities assigned to the HIVST arm will implement HIVST procedures in lieu of recommendations provided by the Ministry of Health National HIV Guidelines (PITC).
Facility HIVST: HIVST will be carried out in a group setting among patients in the waiting area of OPD clinics. Eligible clients will receive education about HIV testing and a demonstration of how to use and interpret results of a self-test kit will occur in the group setting. Participants will use the HIVST kit in a group setting and will be given private settings (private room or booth) to interpret their results. Participants will disclose their results to their OPD provider if they choose. Routine linkage to confirmatory testing and ART initiation will be conducted. | 2,097 |
| Aim 2: Standard of Care Facilities assigned to the standard of care arm will receive no intervention and will continue with Ministry of Health National HIV Guidelines for index HIV testing for sexual partners of HIV-positive clients. Partner referral slips will be given to HIV-positive clients to encourage partner testing. | 135 |
| Aim 2: Index HIVST Facilities assigned to the HIVST arm will implement HIVST procedures in lieu of recommendations provided by the Ministry of Health National HIV Guidelines (partner referral slips).
Index HIVST: HIVST demonstration and distribution will be provided to HIV-positive clients in participating facilities to distribute to their partners. Partners who have a reactive HIVST test result, or are unable or unwilling to use HIVST, will be asked to present at the health facility for routine HIV testing. Routine linkage to confirmatory testing and ART initiation will be conducted. | 349 |
| Total | 6,369 |
Withdrawals & dropouts
| Period | Reason | FG000 | FG001 | FG002 | FG003 | FG004 |
|---|---|---|---|---|---|---|
| Overall Study | Lost to Follow-up | 0 | 0 | 0 | 28 | 91 |
Baseline characteristics
| Characteristic | AIm 1: Standard of Care | Aim 1: Optimized Standard of Care | Aim 1: Facility HIVST | Aim 2: Standard of Care | Aim 2: Index HIVST | Total |
|---|---|---|---|---|---|---|
| Age, Categorical <=18 years | 280 Participants | 223 Participants | 264 Participants | 5 Participants | 6 Participants | 778 Participants |
| Age, Categorical >=65 years | 77 Participants | 71 Participants | 33 Participants | 4 Participants | 6 Participants | 191 Participants |
| Age, Categorical Between 18 and 65 years | 1594 Participants | 1543 Participants | 1800 Participants | 126 Participants | 337 Participants | 5400 Participants |
| Age, Continuous | 27 years | 36 years | 35 years | 35 years | 36 years | 35 years |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants | 0 Participants | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Asian | 0 Participants | 0 Participants | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Black or African American | 1951 Participants | 1837 Participants | 2097 Participants | 135 Participants | 349 Participants | 6369 Participants |
| Race (NIH/OMB) More than one race | 0 Participants | 0 Participants | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants | 0 Participants | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 0 Participants | 0 Participants | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) White | 0 Participants | 0 Participants | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Region of Enrollment Malawi | 1951 Participants | 1837 Participants | 2097 Participants | 135 Participants | 349 Participants | 6369 Participants |
| Sex: Female, Male Female | 1327 Participants | 1002 Participants | 1304 Participants | 105 Participants | 266 Participants | 4004 Participants |
| Sex: Female, Male Male | 624 Participants | 835 Participants | 793 Participants | 30 Participants | 83 Participants | 2365 Participants |
| Tested for HIV ≥3months ago | 625 Participants | 508 Participants | 320 Participants | 0 Participants | 0 Participants | 1453 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk | EG002 affected / at risk | EG003 affected / at risk | EG004 affected / at risk |
|---|---|---|---|---|---|
| deaths Total, all-cause mortality | 0 / 1,951 | 0 / 1,837 | 0 / 2,097 | 0 / 107 | 0 / 258 |
| other Total, other adverse events | 0 / 1,951 | 0 / 1,837 | 0 / 2,097 | 0 / 107 | 0 / 258 |
| serious Total, serious adverse events | 0 / 1,951 | 0 / 1,837 | 0 / 2,097 | 0 / 107 | 0 / 258 |
Outcome results
Primary
Aim 1: Proportion of Adult OPD Clients Tested for HIV
Same day HIV testing among OPD clients, measured by self-reports from OPD clients
Time frame: 1 day
Population: Descriptive statistics (mean, standard deviation, median, inter-quartile range, and frequency distribution) were generated for the demographic and clinical information to characterize the study population.
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| AIm 1: Standard of Care | Aim 1: Proportion of Adult OPD Clients Tested for HIV | 1951 Participants |
| Aim 1: Optimized Standard of Care | Aim 1: Proportion of Adult OPD Clients Tested for HIV | 1837 Participants |
| Aim 1: Facility HIVST | Aim 1: Proportion of Adult OPD Clients Tested for HIV | 2097 Participants |
Primary
Aim 2: Proportion of Sexual Partners Tested for HIV
HIV testing among sexual partners of HIV-positive clients within 4-weeks of study enrollment, measured by secondary reports from HIV-positive clients
Time frame: 4-weeks
Population: Descriptive statistics (mean, standard deviation, median, inter-quartile range, and frequency distribution) were generated for the demographic and clinical information to characterize the study population.
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Aim 2: Standard of Care | Aim 2: Proportion of Sexual Partners Tested for HIV | 107 Participants |
| Aim 2: Index HIVST | Aim 2: Proportion of Sexual Partners Tested for HIV | 258 Participants |
Secondary
Aim 1: ART Initiation Among OPD Clients Tested HIV-positive
ART initiation within 3-months after being identified as HIV-positive within the study, measured by medical chart reviews of all Partners in Hope supported health facilities in participating districts
Time frame: 3 months
Population: Descriptive statistics (mean, standard deviation, median, inter-quartile range, and frequency distribution) were generated for the demographic and clinical information to characterize the study population.
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| AIm 1: Standard of Care | Aim 1: ART Initiation Among OPD Clients Tested HIV-positive | 1951 Participants |
| Aim 1: Optimized Standard of Care | Aim 1: ART Initiation Among OPD Clients Tested HIV-positive | 1837 Participants |
| Aim 1: Facility HIVST | Aim 1: ART Initiation Among OPD Clients Tested HIV-positive | 2097 Participants |
Secondary
Aim 1: Cost Per Person Initiated ART
Total cost per arm (including human resources, testing, training, equipment, facility over head, staff, and testing supplies) / total number of individual initiated ART by each arm, respectively. All costs in 2017 US$. Cost calculations do not include cost of ART. Cost data in each study group were derived from a health care perspective using micro-costing methods using the HIV Counselling and Testing costing tool developed by the Health Economics and Epidemiology Research Office in South Africa. All costs are reported in 2017 US$. We use mean cost per ART initiate. Standard deviation is not included due to the nature of calculating a 'production cost'- or the total cost incurred per the respective number of outcomes.
Time frame: 3 months
Population: Total testing-related costs per person initiated on ART were calculated by study group.
| Arm | Measure | Value (MEAN) |
|---|---|---|
| AIm 1: Standard of Care | Aim 1: Cost Per Person Initiated ART | 121.02 US dollar |
| Aim 1: Optimized Standard of Care | Aim 1: Cost Per Person Initiated ART | 156.27 US dollar |
| Aim 1: Facility HIVST | Aim 1: Cost Per Person Initiated ART | 279.18 US dollar |
Secondary
Aim 1: HIV-positivity Rate
HIV-positivity rate among OPD clients, measured by self-report
Time frame: Same 1 day as enrollment (measuring HIV testing before clients leave the OPD clinic that day)
Population: Descriptive statistics (mean, standard deviation, median, inter-quartile range, and frequency distribution) were generated for the demographic and clinical information to characterize the study population.
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| AIm 1: Standard of Care | Aim 1: HIV-positivity Rate | 1951 Participants |
| Aim 1: Optimized Standard of Care | Aim 1: HIV-positivity Rate | 1837 Participants |
| Aim 1: Facility HIVST | Aim 1: HIV-positivity Rate | 2097 Participants |
Secondary
Aim 1: Presence of Non-serious Adverse Events
Presence of adverse events due to the HIV testing intervention, including coercion to test, share test results, and unwanted status disclosure, measured by self-report on the day the intervention was delivered.
Time frame: as enrollment (measuring adverse events that occurred at the OPD clinic that 1 day)
Population: Descriptive statistics (mean, standard deviation, median, inter-quartile range, and frequency distribution) were generated for the demographic and clinical information to characterize the study population.
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| AIm 1: Standard of Care | Aim 1: Presence of Non-serious Adverse Events | 1951 Participants |
| Aim 1: Optimized Standard of Care | Aim 1: Presence of Non-serious Adverse Events | 1837 Participants |
| Aim 1: Facility HIVST | Aim 1: Presence of Non-serious Adverse Events | 2097 Participants |
Secondary
Aim 2: ART Initiation Among Sexual Partners Tested HIV-positive
ART initiation within 3-months after being identified as HIV-positive within the study, measured by medical chart reviews of all Partners in Hope supported health facilities in participating districts
Time frame: 3 months
Population: Descriptive statistics (mean, standard deviation, median, inter-quartile range, and frequency distribution) were generated for the demographic and clinical information to characterize the study population.
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Aim 2: Standard of Care | Aim 2: ART Initiation Among Sexual Partners Tested HIV-positive | 107 Participants |
| Aim 2: Index HIVST | Aim 2: ART Initiation Among Sexual Partners Tested HIV-positive | 258 Participants |
Secondary
Aim 2: Cost Per Person Initiated ART
Total cost per arm (including human resources, testing, training, equipment, facility over head, staff, and testing supplies) / total number of individual initiated ART by each arm, respectively. All costs in 2017 US$. Cost calculations do not include cost of ART. Cost data in each study group were derived from a health care perspective using micro-costing methods using the HIV Counselling and Testing costing tool developed by the Health Economics and Epidemiology Research Office in South Africa. All costs are reported in 2017 US$. We use mean cost per ART initiate. Standard deviation is not included due to the nature of calculating a 'production cost'- or the total cost incurred per the respective number of outcomes.
Time frame: 3 month
Population: Arms in Aim 1 not included in this outcome
| Arm | Measure | Value (MEAN) |
|---|---|---|
| AIm 1: Standard of Care | Aim 2: Cost Per Person Initiated ART | 16.11 US dollar |
| Aim 1: Optimized Standard of Care | Aim 2: Cost Per Person Initiated ART | 68.27 US dollar |
Secondary
Aim 2: Cost Per Person Tested HIV-Positive
Total cost per arm (including human resources, testing, training, equipment, facility over head, staff, and testing supplies) / total number of individual tested HIV-positive by each arm, respectively. All costs in 2017 US$. Cost calculations include all costs associated with HIV testing. Cost data in each study group were derived from a health care perspective using micro-costing methods using the HIV Counselling and Testing costing tool developed by the Health Economics and Epidemiology Research Office in South Africa. All costs are reported in 2017 US$. We use mean cost per HIV-positive individual identified. Standard deviation is not included due to the nature of calculating a 'production cost'- or the total cost incurred per the respective number of outcomes.
Time frame: 1 month
Population: Arms in Aim 1 not included in this outcome.
| Arm | Measure | Value (MEAN) |
|---|---|---|
| AIm 1: Standard of Care | Aim 2: Cost Per Person Tested HIV-Positive | 14.9 US dollar |
| Aim 1: Optimized Standard of Care | Aim 2: Cost Per Person Tested HIV-Positive | 16.11 US dollar |
Secondary
Aim 2: HIV-positivity Rates Among Sexual Partners Tested for HIV
HIV-positivity rate measured by secondary report by the HIV-positive client
Time frame: 4-weeks
Population: Descriptive statistics (mean, standard deviation, median, inter-quartile range, and frequency distribution) were generated for the demographic and clinical information to characterize the study population.
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Aim 2: Standard of Care | Aim 2: HIV-positivity Rates Among Sexual Partners Tested for HIV | 107 Participants |
| Aim 2: Index HIVST | Aim 2: HIV-positivity Rates Among Sexual Partners Tested for HIV | 258 Participants |
Secondary
Aim 2: Presence of Non-serious Adverse Events
Presence of adverse events due to the HIV testing intervention, including coercion to test, share test results, unwanted status disclosure, and interpersonal violence measured by self-report by the HIV-positive client
Time frame: 4-weeks
Population: Descriptive statistics (mean, standard deviation, median, inter-quartile range, and frequency distribution) were generated for the demographic and clinical information to characterize the study population.
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Aim 2: Standard of Care | Aim 2: Presence of Non-serious Adverse Events | 107 Participants |
| Aim 2: Index HIVST | Aim 2: Presence of Non-serious Adverse Events | 258 Participants |