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Meta-Analysis
. 2021 Jul;6(Suppl 4):e004986.
doi: 10.1136/bmjgh-2021-004986.

ART initiations following community-based distribution of HIV self-tests: meta-analysis and meta-regression of STAR Initiative data

Melissa Neuman  1 , Katherine L Fielding  2   3 , Helen Ayles  4   5 , Frances M Cowan  6   7 , Bernadette Hensen  8 , Pitchaya P Indravudh  9   10 , Cheryl Johnson  11 , Euphemia Lindelwe Sibanda  6   7 , Karin Hatzold  12 , Elizabeth Lucy Corbett  5   10
Affiliations
Meta-Analysis

ART initiations following community-based distribution of HIV self-tests: meta-analysis and meta-regression of STAR Initiative data

Melissa Neuman et al. BMJ Glob Health. 2021 Jul.

Abstract

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.

Keywords: HIV.

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Conflict of interest statement

Competing interests: None declared.

Figures

Figure 1
Figure 1
Monthly ART initiations in HIVST distribution and non-HIVST distribution areas. ART, antiretroviral therapy; CBDA, community-based distribution agents; HIVST, HIV self-testing; mos, months; SOC, standard of care (no HIVST); w, weeks.
Figure 2
Figure 2
Meta-analyses of the association between community HIVST distribution and clinic ART initiation using primary findings (A) and exploratory analysis findings (B). ART, antiretroviral therapy; HIVST, HIV self-testing.
See this image and copyright information in PMC

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