Research in context
Evidence before this study
We searched PubMed for studies published until March 1, 2016, with the terms “HIV” AND (“self-test*” OR “home test”). Several studies have noted high acceptability, accuracy, and safety of HIV self-testing in sub-Saharan Africa among individuals who directly receive a self-test. Community-based studies in Malawi have shown high uptake of self-testing, as well as linkage to HIV care that is comparable to what is found in other testing strategies. However, little is known about optimal distribution strategies to facilitate self-test use by high-risk, hard-to-reach individuals and to identify HIV-positive individuals. As opposed to primary distribution strategies that directly reach these individuals, secondary distribution is a strategy in which easier-to-reach individuals are given multiple self-tests to distribute to harder-to-reach individuals such as sexual partners or others in their social network. One pilot study involving a sample of high-risk men who have sex with men in the USA explored the feasibility of secondary distribution of HIV self-tests. 27 participants documented high acceptability and showed potential for use of self-tests to screen sexual partners. No studies in sub-Saharan Africa have explored secondary distribution of self-tests by pregnant and post-partum women or other key populations such as female sex workers.
Added value of this study
To our knowledge, this is the first assessment of the potential for secondary distribution of HIV self-tests by multiple populations of women to promote HIV testing among male sexual partners and among couples. This is also the first study to show that secondary distribution of self-tests by female sex workers can result in HIV testing among their high-risk commercial sex clients and that this strategy can identify a high proportion of HIV-positive individuals. Another important contribution of this study is its identification of a major potential for a secondary distribution strategy to facilitate point-of-sex HIV testing and lead to safer, better informed sexual decision making. The study shows that secondary distribution of self-tests is a safe and efficient way to promote HIV testing among hard-to-reach individuals and also achieve other HIV prevention objectives.
Implications of all the available evidence
These findings suggest that secondary distribution of HIV self-tests is a promising strategy for increasing HIV testing among populations that are traditionally hard to reach, including male partners of pregnant and postpartum women and clients of female sex workers. It may also facilitate safer sexual decisions by removing some barriers to mutual disclosure of HIV status. Further implementation and evaluation of this strategy is warranted as countries are developing HIV self-testing policies and considering how these technologies can be used to prevent new HIV infections. Along with other community-based HIV testing strategies implemented recently, secondary distribution of self-tests can be part of a multipronged approach to achieving the first of the UNAIDS 90-90-90 targets.