Report of exploring the uptake and acceptability of HIV self-testing for men to have sex with men, male sex workers, and transgender people in Nepal.

Research Report.

SUMMARY: Title: Exploring the uptake and acceptability of HIV self-testing for men who have sex with men, male sex workers, and transgender people in Nepal Study #: 1089845 (Protection of Human Subjects Committee [PHSC]), 474/2017 (Nepal Health Research Council [NHRC]) Design: This was a cross-sectional, descriptive, mixed-methods study. Quantitative data were collected using recording forms developed for the HIV self-testing (HIVST) pilot study and monitoring and evaluation (M&E) data; secondary data were collected from HIV testing registers from HIV testing facility run by Linkages across the Continuum of HIV Services for Key Populations Affected by HIV (LINKAGES) Nepal implementing partner agency. Qualitative data were collected through semistructured interviews (SSIs) with key population (KP) study participants, health care providers, management staff, and government officials, and through focus group discussions (FGDs) with community-based supporters (CBSs). Sample size and populations: 1. A total of 440 individuals including 213 men who have sex with men (MSM), 108 male sex workers (MSWs), and 119 trans women who were 18 years of age or older and reached through LINKAGES Nepal project's peer outreach workers/CBSs in outreach activities. 2. One FGD was conducted with four CBSs; SSIs were conducted with 46 study participants, three health care workers, three management staff involved in HIVST, and four government officials who oversee HIV testing and treatment activities. Study Duration: June-September 2018 Objectives: 1. To describe self-test use by participating MSM, MSWs, and trans women, including choices made between assisted (supervised) and unassisted (unsupervised) testing 2. To monitor rates of confirmatory testing among those known to have a reactive result to the self-test 3. To understand the acceptability of self-testing and preferences for self-testing implementation among MSM, MSWs, trans women, CBSs, health facility staff, and government officials Study Sites: Lalitpur district of Nepal where LINKAGES Nepal project works with MSM, MSWs, and trans people for HIV prevention, care, support, and treatment services. Study Management: The study was implemented by LINKAGES Nepal, STD/AIDS Counseling and Training Center (SACTS) and Parichaya Samaj in collaboration with the National Center for AIDS and STD Control (NCASC) and the National Public Health Laboratory (NPHL), Ministry of Health and Population (MOHP) with funding support from the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for Development (USAID). Results Quantitative results: 1. During the study, 482 people were offered HIVST, out of which 440 (91.3 percent) provided consent and accepted HIVST. Acceptance was similar for MSM, MSWs, and trans women. 2. Of the total, 277 (63 percent) were 20-24 years old, and the average age of participants was 24 (23.7 among MSM, 23.9 among MSWs, and 25.1 among transwomen). 3. Of the total, 99 percent chose assisted/supervised HIVST, and only five participants (four MSM and one MSW) (1 percent) chose the unassisted/unsupervised approach. 4. Participants and service providers preferred performing HIVST under supervision. 5. Out of 440 who participated in HIVST, 428 (97 percent) were HIVST non-reactive and 12 (3 percent) were HIVST reactive. All 12 individuals with HIVST reactive results had an HIV confirmatory test using the national standard HIV testing algorithm, and all were confirmed HIV positive. Of the 12 positive cases, 11 (92 percent) were identified through the assisted/supervised approach. Qualitative results: 1. All the MSM, MSWs, and trans women participants reported they decided to have HIVST because it can be done easily, without drawing blood, and the result can be obtained immediately in front of them. The majority of respondents (n=34) said they would use HIVST in the future and would also recommend HIVST to their partners or friends. 2. Almost all MSM, MSWs, and trans women participants (n=42) preferred receiving the HIVST kit from the community people/organization. They felt they could trust the community, and their information would be kept confidential. 3. Almost all MSM, MSWs, and trans women participants agreed they had been given full information regarding HIVST, and they were aware the result would be kept confidential, HIVST is not a confirmatory test, and they would be enrolled in ART if confirmed HIV positive. 4. According to MSM, MSWs, and trans women participants, the information provided by the CBSs was easy to understand and follow, and the pictures on the leaflet were clear and easy to understand. HIVST users did not have any difficulty opening the test kit package, performing the test, and interpreting the results. CBSs and health care staff also reported it was easy to provide information to study participants. 5. The instructions provided in the leaflet were adequate for performing the test. However, CBSs and health care staff suggested enlarging the size of the type font and the pictures in the instruction material, and using an instructional video, if needed. 6. According to CBSs, health care providers, and government officials, there were no difficulties implementing HIVST. They advised that people should have awareness about HIV and HIVST before introducing it to the market. Platforms such as social media, mass media, and community groups should be used to raise awareness about HIV and HIVST among the population. HIVST should also be introduced to other KPs besides MSM, MSWs, and trans women. The test kit should be made available in all parts of the country. MSM, MSWs, and trans women said they would use HIVST if the cost for the HIVST kit were between NRs.100 (about US$1) and NRs.500 (about US$5), or free. According to both groups of participants, stigma related to HIV, sexual orientation, and disclosure of HIV status are challenges for implementation. Other challenges include interpreting the result when a distinct line does not appear in test window of the kit, acceptance of HIV-positive status, anxiety related to HIV-positive status, and taking HIVST reactive clients to the facility for confirmatory tests. Recommendations 1. HIVST is acceptable among MSM, MSWs, and trans women in Nepal. Coordinate with NCASC and NPHL for rolling out HIVST as an additional method of HIV testing along with facility-based testing and community-based testing for triage across the country. 2. Use the assisted/supervised approach, mobilizing community/outreach workers as a preferred method of implementation of HIVST. Use the unassisted/unsupervised approach as an alternative when individuals prefer it and/or when there are issues related to disclosure of being a member of a KP, HIV status, and stigma. 3. Use HIVST as an additional method of HIV testing, especially when traditional approaches are not adequate to increase case finding. 4. Mobilize the KP community for a community-led approach for performing HIVST during rollout. 5. Use the individual or one-to-one educational approach for providing information. Prepare a standard operating procedure for implementation including the procedures followed during the pilot study. 6. Mobilize CBSs or similar level lay providers for introducing HIVST during roll-out. 7. Develop instruction materials using the information provided in the leaflet used for client instruction during the pilot study. Enlarge picture and type font size in instruction materials and develop audiovisual instructions. 8. Develop information, education, and communication (IEC) materials and social media campaign messages for HIVST. The messages should focus on how HIVST uses saliva, and HIV is not transmitted through saliva. 9. Explore the options for either social marketing of HIVST test kit or providing free of cost. 10. Focus on maintaining confidentiality of the HIVST result, as well as the sexual orientation and personal information of the individuals. Develop message for providing counseling for HIVST reactive results. Develop and implement approaches for accompanying clients with HIVST reactive results to HIV testing facilities for confirmatory tests.