Background: HIV self-testing (HIVST) is a promising new testing strategy for female sex workers (FSW) because it has the potential to reduce testing barriers for this population, i.e. provider stigma and discrimination. We explored the impact of HIVST via different delivery platforms on recent testing, status knowledge, and linkage to care among FSW in Kampala, Uganda.
Methods: FSW peer educators each recruited and enrolled 8 eligible participants. Peer educator-participant groups were randomized to one of three study arms: (1) distribution of a HIVST, (2) distribution of a HIVST coupon (exchangeable at specified clinics), or (3) referral to standard testing services, all by the peer educator. Participants in the intervention arms received two HIVSTs or coupons, one after enrollment and one three months later. Participants completed baseline, one-month, and four-month assessments. HIV status knowledge was assessed at four months with a perceived conditional cash transfer; participants received ~1 USD if their reported HIV status matched the results of a rapid test.
Results: 960 participants were enrolled from October to November 2017; median age was 28 years (IQR: 24-32). Relative to the standard arm, recent HIV testing was more common in the HIVST arm at one-month (95.2% HIVST vs. 71.5% standard, P=< 0.001) and both intervention arms at four-months (45.9% standard; 59.5% HIVST, P=0.04; 62.3% coupon, P=0.008). There were no significant differences in correct HIV status knowledge across study arms at four-months (88.0% standard; 88.1% HIVST, P=0.96; 86.9% coupon, P=0.73). Among those testing positive, there was no difference in linkage to care between HIVST and standard arms. Linkage was lower in the coupon arm compared to the standard arm at both follow-up assessments (one-month: 24.1% coupon vs. 64.1% standard, P=0.001; four-months: 49.2% coupon vs. 75.0% standard, P=0.02).
Conclusions: HIVST is acceptable among FSW in Kampala, Uganda. Compared to standard testing, HIVST increased rates of recent testing, but did not change correct HIV status knowledge and resulted in decreased linkage to care among HIV-positive participants who received HIVST coupons. In order for HIVST to reduce gaps in the HIV treatment cascade, additional efforts are need to ensure individuals correctly interpret the HIVST results and link to care.

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