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  • Comparison of community-led distribution of HIV self-tests kits with distribution by paid distributors: a cluster randomised trial in rural Zimbabwean communities

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Original research
Comparison of community-led distribution of HIV self-tests kits with distribution by paid distributors: a cluster randomised trial in rural Zimbabwean communities
  1. Euphemia Lindelwe Sibanda1,2,
  2. Collin Mangenah1,
  3. Melissa Neuman3,
  4. Mary Tumushime1,
  5. Constancia Watadzaushe1,
  6. Miriam N Mutseta4,
  7. Galven Maringwa1,
  8. Jeffrey Dirawo1,
  9. Katherine L Fielding3,5,
  10. Cheryl Johnson6,
  11. Getrude Ncube7,
  12. Miriam Taegtmeyer2,
  13. Karin Hatzold8,
  14. Elizabeth Lucy Corbett9,10,
  15. Fern Terris-Prestholt11,12,
  16. Frances M Cowan1,2
  1. 1CeSHHAR Zimbabwe, Harare, Zimbabwe
  2. 2Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
  3. 3Department of Infectious Disease Epidemiology and MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
  4. 4Department of Sexual Reproductive Health Rights and Innovations, Population Services International Zimbabwe, Harare, Zimbabwe
  5. 5Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
  6. 6HIV, Hepatitis and STI Department, World Health Organisation, Geneva, Switzerland
  7. 7AIDS and TB Unit, Ministry of Health and Child Care, Harare, Zimbabwe
  8. 8Population Services International, Washington, District of Columbia, USA
  9. 9Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
  10. 10TB-HIV Group, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
  11. 11Department of Global Health & Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
  12. 12Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland
  1. Correspondence to Dr Euphemia Lindelwe Sibanda; euphemia{at}ceshhar.co.zw

Abstract

Background We compared community-led versus an established community-based HIV self-testing (HIVST) model in rural Zimbabwe using a cluster-randomised trial.

Methods Forty village groups were randomised 1:1 using restricted randomisation to community-led HIVST, where communities planned and implemented HIVST distribution for 4 weeks, or paid distribution (PD), where distributors were paid US$50 to distribute kits door-to-door over 4 weeks. Individual level primary outcomes compared household survey responses by arm 4 months post-intervention for: (1) newly diagnosed HIV during/within 4 months following HIVST distribution, (2) linkage to confirmatory testing, pre-exposure prophylaxis or voluntary medical male circumcision during/within 4 months following HIVST distribution. Participants were not masked to allocation; analysis used masked data. Trial analysis used random-effects logistic regression.

Distribution costs compared: (1) community-led HIVST, (2) PD HIVST and (3) PD costs when first implemented in 2016/2017.

Results From October 2018 to August 2019, 27 812 and 36 699 HIVST kits were distributed in community-led and PD communities, respectively. We surveyed 11 150 participants and 5683 were in community-led arm. New HIV diagnosis was reported by 211 (3.7%) community-led versus 197 (3.6%) PD arm participants, adjusted OR (aOR) 1.1 (95% CI 0.72 to 1.56); 318 (25.9%) community-led arm participants linked to post-test services versus 361 (23.9%) in PD arm, aOR 1.1 (95% CI 0.75 to 1.49.

Cost per HIVST kit distributed was US$6.29 and US$10.25 for PD and community-led HIVST, both lower than 2016/2017 costs for newly implemented PD (US$14.52). No social harms were reported.

Conclusions Community-led HIVST can perform as well as paid distribution, with lower costs in the first year. These costs may reduce with programme maturity/learning.

Trial registration number PACTR201811849455568.

  • community-based survey
  • health economics

Data availability statement

Data are available upon request. De-identified data are available. For access please contact the principal investigator, euphemia@ceshhar.co.zw. Protocol and statistical analysis plan are available.

https://creativecommons.org/licenses/by-nc/3.0/igo/

This is an open access article distributed under the terms of the Creative Commons Attribution IGO License (CC BY NC 3.0 IGO), which permits use, distribution,and reproduction in any medium, provided the original work is properly cited. In any reproduction of this article there should not be any suggestion that WHO or this article endorse any specific organization or products. The use of the WHO logo is not permitted. This notice should be preserved along with the article’s original URL.Disclaimer: The author is a staff member of the World Health Organization. The author alone is responsible for the views expressed in this publication and they do not necessarily represent the views, decisions or policies of the World Health Organization.

https://doi.org/10.1136/bmjgh-2021-005000

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    Data availability statement

    Data are available upon request. De-identified data are available. For access please contact the principal investigator, euphemia@ceshhar.co.zw. Protocol and statistical analysis plan are available.

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    Footnotes

    • Handling editor Seye Abimbola

    • Twitter @Euphemia4, @cmangenah01, @MTumushime, @ccasejohn, @MiriamTaegtmeye

    • Contributors Formulated the research study and design: FMC, ELC, MTa, KH, CJ, ELS, GN, KLF, MN and FT-P. Informed development of data collection methods and collected data: FMC, ELC, MTu, MTa, MN, JD, MM, ELS, GN, CW, CM and GM. Analysed the data or contributed to the analysis: MN, ELS, KLF, CM, FT-P and GM. Substantially provided intellectual input to the manuscript: FMC, ELC, KH, FT-P, KLF, MTu, MTa, CJ, MN, MM, CM and CW.

    • Funding This study was funded by Unitaid (STAR Initiative), subagreement number 4214-CeSHHAR. ELC is funded by Wellcome Trust (WT200901/Z/16/Z).

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.