%0 Journal Article %A Melissa Neuman %A Katherine L Fielding %A Helen Ayles %A Frances M Cowan %A Bernadette Hensen %A Pitchaya P Indravudh %A Cheryl Johnson %A Euphemia Lindelwe Sibanda %A Karin Hatzold %A Elizabeth Lucy Corbett %T ART initiations following community-based distribution of HIV self-tests: meta-analysis and meta-regression of STAR Initiative data %D 2021 %R 10.1136/bmjgh-2021-004986 %J BMJ Global Health %P e004986 %V 6 %N Suppl 4 %X Introduction Measuring linkage after community-based testing, particularly HIV self-testing (HIVST), is challenging. Here, we use data from studies of community-based HIVST distribution, conducted within the STAR Initiative, to assess initiation of antiretroviral therapy (ART) and factors driving differences in linkage rates.Methods Five STAR studies evaluated HIVST implementation in Malawi, Zambia and Zimbabwe. New ART initiations during the months of intervention at clinics in HIVST and comparison areas were presented graphically, and study effects combined using meta-analysis. Meta-regression was used to estimate associations between the impact of community-based HIVST distribution and indicators of implementation context, intensity and reach. Effect size estimates used (1) prespecified trial definitions of ART timing and comparator facilities and (2) exploratory definitions accounting for unexpected diffusion of HIVST into comparison areas and periods with less distribution of HIVST than was expected.Results Compared with arms with standard testing only, ART initiations were higher in clinics in HIVST distribution areas in 4/5 studies. The prespecified meta-analysis found positive but variable effects of HIVST on facility ART initiations (RR: 1.14, 95% CI 0.93 to 1.40; p=0.21). The exploratory meta-analysis found a stronger impact of HIVST distribution on ART initiations (RR: 1.29, 95% CI 1.08 to 1.55, p=0.02).ART initiations were higher in studies with greater self-reported population-level intensity of HIVST use (RR: 1.12; 95% CI 1.04 to 1.21; p=0.02.), but did not differ by national-level indicators of ART use among people living with HIV, number of HIVST kits distributed per 1000 population, or self-reported knowledge of how to link to care after a reactive HIVST.Conclusion Community-based HIVST distribution has variable effect on ART initiations compared with standard testing service alone. Optimising both support for and approach to measurement of effective and timely linkage or relinkage to HIV care and prevention following HIVST is needed to maximise impact and guide implementation strategies.Data are available upon request. All data used in meta-analyses comes from peer-reviewed published manuscripts or manuscripts in preparation. Survey data used to estimate proportion taking up an HIVST or knowing how to link to care are available from datacompass.lshtm.ac.uk. Data on ART use among PLHIV are based on public Spectrum estimates or personal communication. Programmatic data on number of HIVST distributed in each study and other extracted data are available upon request from the corresponding author. %U https://gh.bmj.com/content/bmjgh/6/Suppl_4/e004986.full.pdf