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Zambia's targeted testing initiative finds one in four men testing positive

An innovative initiative that combined community-based HIV testing with 'index testing' – where people who test positive are supported to inform their sexual partners so that they can also test – has reached large numbers of men who didn't know they were living with HIV.

HIV testing is lower among men than women in Zambia, with 25% of men living with HIV unaware of their status in 2018, compared to 15% of women. The problem is more acute among younger men, with over two-thirds of men living with HIV aged 25 to 29 undiagnosed.

To address this, the Community Impact to Reach Key and Underserved Individuals for Treatment and Support (CIRKUITS) project trained community health workers in rural and urban parts of Eastern, Western and Lusaka provinces to provide index testing and targeted community-based HIV testing, and link people to antiretroviral treatment (ART) and prevention services.

Testing was conducted in workplaces that mainly employ men, such as construction sites, police departments and utility companies. Testing was also provided in 'male‐dense' spaces, such as markets, taxi ranks, car washes, bus stations, sporting events, and insakas (village meetings). Churches, community centres, schools and pop-up testing sites also participated.

In the project's first year (2018 – 2019), 38,255 people tested for HIV with a roughly equal split between men and women. Just under a third of people (29%) tested HIV positive. Around half of those diagnosed with HIV were identified through index testing and half through community-based testing.

One in four men who took an HIV test had a positive result of whom 93% were linked to treatment, the same linkage level as women.

Most of the men diagnosed with HIV were aged 25 to 39 (60%), followed by those aged 40 to 49 (21%), those aged 15 to 24 (13%) and those aged 50 or older (6%).
More than 93% of people diagnosed with HIV provided information about their sexual partners to enable contact tracing. More than three‐quarters of those traced were unaware of their HIV status.

Index testing resulted in a 'higher positivity yield', which means it reached a higher proportion of people living with HIV than community-based testing, with 40% of men testing through this method receiving a positive result. This is the highest yield reported by any study to date and is much higher than the 18% yield achieved through CIRKUITS' community-based testing.

In terms of absolute numbers, index testing resulted in fewer men living with HIV being identified (2,186) than community‐based approaches (2,272).

It was also less successful at linking men to treatment as it resulted in 88% of men diagnosed with HIV accessing ART, compared to 98% of men diagnosed through community-based testing. This may be because community-based testing being offered immediate, on-site treatment initiation, whereas those diagnosed through index testing then had to go to a clinic. It may also reflect different levels of engagement as people reached through community-based testing more actively chose to test.

The research team led by Cassidy W Claasen at the Maryland Global Initiatives Corporation Zambia and the University of Maryland School of Medicine, Baltimore, behind the initiative said: "In CIRKUITS, we achieved high testing positivity among men primarily by engaging them where they were found, rather than expecting them to come to the facility. As we move towards achieving epidemic control, there is ever‐greater need to…reach men and other hidden populations."

Introduction: Current healthcare systems fail to provide adequate HIV services to men. In Zambia, 25% of adult men living with HIV were unaware of their HIV status in 2018, and 12% of those who were unaware of their HIV statu were not receiving antiretroviral therapy (ART) due to pervasive barriers to HIV testing services (HTS) and linkage to ART. To identify men and key and priority populations living with HIV in Zambia, and link them to care and treatment, we implemented the Community Impact to Reach Key and Underserved Individuals for Treatment and Support (CIRKUITS) project. We present HTS and ART linkage results from the first year of CIRKUITS.
Methods: CIRKUITS aimed to reach beneficiaries by training, mentoring, and deploying community health workers to provide index testing services and targeted community HTS. Community leaders and workplace supervisors were engaged to enable workplace HTS for men. To evaluate the effects of these interventions, we collected age‐ and sex‐disaggregated routinely collected programme data for the first 12 months of the project (October 2018 to September 2019) across 37 CIRKUITS‐supported facilities in three provinces. We performed descriptive statistics and estimated index cascades for indicators of interest, and used Chi square tests to compare indicators by age, sex, and district strata.
Results: Over 12 months, CIRKUITS tested 38,255 persons for HIV, identifying 10,974 (29%) new people living with HIV, of whom 10,239 (93%) were linked to ART. Among men, CIRKUITS tested 18,336 clients and identified 4458 (24%) as HIV positive, linked 4132 (93%) to ART. Men who tested HIV negative were referred to preventative services. Of the men found HIV positive, and 13.0% were aged 15 to 24 years, 60.3% were aged 25 to 39, 20.9% were aged 40 to 49 and 5.8% were ≥50 years old. Index testing services identified 2186 (49%) of HIV‐positive men, with a positivity yield of 40% and linkage of 88%. Targeted community testing modalities accounted for 2272 (51%) of HIV‐positive men identified, with positivity yield of 17% and linkage of 97%.
Conclusions: Index testing and targeted community‐based HTS are effective strategies to identify men living with HIV in Zambia. Index testing results in higher yield, but lower linkage and fewer absolute men identified compared to targeted community‐based HTS.

Linah K Mwango, Kristen A Stafford, Natalia C Blanco, Marie‐Claude Lavoie, Morley Mujansi, Nasho Nyirongo, Kalima Tembo, Henry Sakala, Julian Chipukuma, Beauty Phiri, Carol Nzangwa, Susan Mwandila, Kennedy C Nkwemu, Ahmed Saadani, Annie Mwila, Michael E Herce, Cassidy W Claassen


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