Study overview
Findings from a recent study published in the journal, Archives of Public Health, by a team of investigators led by Dr Joseph KB Matovu, an Associate Professor at Busitema University Faculty of Health Sciences, Mbale, Uganda, shows that it is safer and easier to reach men with HIV self-testing services if delivered to them by fellow men in their respective communities. Implemented under the code-name, “PEST4MEN” (which stands for “peer-led HIV self-testing intervention for men”), the study identified and trained laymen in the fishing communities who were given HIV self-test kits to pass on to fellow men in their respective groups.
This concept emerged from our prior research that involved consultations with men in one of the fishing communities regarding how best to reach men with HIV testing services in their communities. During the consultations, men suggested that we could identify men in the communities who could be trained to deliver HIV self-test kits to fellow men, with most of the men attending the consultations indicating that they were willing to serve in that role. One of them men had this to say: “I would like to be part of the program [of distributing HIV self-test kits to fellow men], however, I am a fisher man and sometimes I fish from far distance from here, where by I spend more than two days in the lake yet you might need someone who is always on the mainland. … [but] yes, I would like to be part of the team distributing [kits] because I have all the qualities, I am approachable, social and trustworthy”.
We identified men from existing social networks and trained them in how to distribute HIV self-test kits as well as in how to conduct the test and interpret the results.
Dr .Matovu
“A total of 22 men were trained in HIV self-testing processes. These men (also referred to as “peer-leaders”) were asked to refer at least 20 men from their social networks. All the men referred to the study team by the peer leaders were screened for study eligibility, and those who were found to be eligible were administered a baseline questionnaire. Men who were interviewed were asked to go to their peer-leaders to pick up kits”, Dr Matovu emphasized.
The PEST4MEN intervention: implementation and uptake of HIV self-testing
The PEST4MEN intervention was built on the principle of social networking. It was based on the belief that men who live or work together are more likely to see each other and can thus deliver HIV self-test kits to fellow men than outsiders. They were also considered to be aware of their own community dynamics and could advise the study team regarding when, whom, and where to implement the study. “We found a high level of interaction between men enrolled in the study and their peer-leaders, with 82% of the men reporting that they met with their peer-leaders every day, while 17% met them between 1-3 times a week. This suggests that nearly all (99%) of the people we enrolled into the study could meet at least weekly, which made it easy for them to distribute kits to their respective social network members”, Matovu added.
For each of the 400 men who were enrolled in the study, two kits were given to their peer-leaders for a total of 800 kits distributed in the two study districts. Peer leaders distributed 782 kits (98%) to their social network members, suggesting that this is a highly feasible intervention within a fishing community setting. At the next follow-up visit, two months after the men were enrolled in the study, 361 men were located and interviewed (up to 48% of those who were not located had moved outside the fishing community at the time of the visit). Of these, 355 reported that they actually received HIV self-test kits from their peer leaders, and 352 (99%) of them indicated that they used the kits to self-test for HIV. This suggests a high level of acceptability of this peer-led HIV self-testing intervention.
Each social network member was asked to return their used kits for re-reading by a member of the study team. We found a high correlation between the respondents’ own reading of the results on the used kits and the results read by a member of the study team. Dr Matovu concluded.
When asked how soon they received kits from their peer-leaders, 62% reported that they received their kits within one week, pointing to the advantage of meeting on a weekly basis. Definitely, we would have expected that since 99% could meet at least once again, this percentage should have been much higher. However, we also noted that 50% of the men reported that they usually traveled outside of their communities, and this could explain why the peer-leaders could not see all the men in the same week. Luckily, up to 92% of the men reported that they had already received their kits by the third week since distribution started. When asked how comfortable they were to receive HIV self-test kits from fellow men, 88% reported that they were either comfortable or very comfortable to receive the kits from fellow men, with only 12% indicating that they were uncomfortable to do so. Most of those who indicated that they were uncomfortable to receive the kits from their peer-leaders were men aged 18-34 years, with only 5% of men aged 35 years or older indicating that they were uncomfortable. The level of discomfort was also high among men with no education, decreasing with each increasing levels of education. These observations suggest a need to revisit this approach for young and less-educated men who may find challenges accessing HIV self-test kits from fellow men.
HIV self-test results and linkage to HIV or PrEP
Our study found a high HIV prevalence in the fishing communities: overall, 14.5% (51) of the men who self-tested for HIV in the two study districts were HIV-positive; higher in Kalangala (19.5%) than in Buvuma (9.5%). The prevalence of HIV in these island districts is thus much higher than the average national adult (15-49 years) HIV prevalence of 5.5% based on recent data from the 2020 Uganda Population-based HIV Impact Assessment (UPHIA). Matovu attributed the high HIV prevalence in the fishing communities to engagement in risky sexual behavior. For instance, of the 400 men interviewed at baseline, 58% reportedly engaged in sex with more than two sexual partners in the past 3 months. When asked how often they used condoms with those partners to protect themselves against the risk of HIV infection, only 13.3% of 173 men reported using condoms consistently; 54.3% reported inconsistent condom use, while 32.3% reported that they had never used condoms. Of men who self-tested HIV-positive, 31% were newly diagnosed with HIV and 88% sought confirmatory HIV testing. Of those confirmed as HIV-positive, 71% were linked to HIV care. “These men would not have known that they had HIV if we had not delivered the intervention at the community level, suggesting that this intervention can successfully identify men with HIV who can be linked to HIV care”, Dr Matovu argued.
These men would not have known that they had HIV if we had not delivered the intervention at the community level, suggesting that this intervention can successfully identify men with HIV who can be linked to HIV care
Dr Matovu
As already noted, men in the fishing communities exhibit high-risk sexual behaviors. Thus, men who tested HIV-negative were asked if they were counseled about using pre-exposure prophylaxis (PrEP) to reduce their risk of HIV infection. Only 29% of HIV-negative men reported that they were counseled about PrEP. PrEP use was virtually non-existent in this population. However, when asked if they would be willing to take PrEP if offered free of charge, 57% of at-risk HIV-negative men reported that they would be willing to use PrEP. These findings suggest that while PrEP was not being used at the time of our study, men are willing to use it.
Initial fears about HIV self-testing: fear of suicide
There were initial fears that men who self-tested for HIV and found themselves to be HIV-positive might commit suicide. This was because, with HIV self-testing, there is no-one to offer post-test counseling to the person who is performing the test. Thus, men were concerned that the lack of a person to offer counseling could lead one to commit suicide. On this issue, one man, during the initial consultations, had this to say:
My concern is about a person ‘hurting’ himself if results of HIV self-test are positive. Because he will know his self-test results in a private place, there are higher chances of this person ‘hurting’ himself. So, if self-testing is done with someone around then such scenarios can be avoided.
During the implementation of the pilot HIV self-testing intervention, we emphasized the importance of one being prepared to self-test for HIV, the importance of reading the information in the HIV self-testing package to get more information on what testing alone implies; and to seek guidance from our team and a designated health worker at the nearby health facilities. We gave them our telephone contacts and also the contact of one of the health workers at each of the two participating health facilities, and we asked men to not self-test for HIV if they still had any fears or doubts until these have been resolved. Ever since we started implementing this program (peer-led HIV self-testing), we have no heard of any cases of people committing suicide after self-testing for HIV.
Summary and next steps
Going forward, our experience suggests that it is possible to reach highly mobile male fisherfolk in the fishing communities (or even in other highly mobile occupations for men) using trained fellow men to reach their colleagues in their social networks. Men in these occupations tend to be organized in social groups; these can be harnessed to identify a “central man” that everyone trusts, and this person can be trained to deliver HIV self-test kits to fellow men. Men who test HIV-negative can be linked to PrEP if they qualify (based on national PrEP guidelines) while those who test HIV-positive can be linked to HIV care at accredited health facilities. We believe that:
Peer-led HIV self-testing may be the game-changer needed to improve access to health services in general and HIV testing services in particular among men in remote settings that are far away from main health facilities.
