There has been a substantial scale-up of HIV testing, yet 15% of people with HIV are still unaware of their status. Recent reports suggest many of those unreached are men, particularly those over 30 years of age, in sub-Saharan Africa. HIV self-testing (HIVST) has been proposed as one approach for reaching men who are hesitant or unable to access existing services. Despite this potential, concerns about lay people’s ability to self-test and link to care, as well as possible social harm, remain. This PhD investigates preferences for, and linkage following, HIVST, among men, as well as harms and benefits that emerge, to inform policy and implementation. This PhD is made up of the following pieces of work. First, a systematic review was conducted on the effectiveness of HIVST compared to standard HIV testing. Five randomised controlled trials (RCTs) were identified out of 638 citations; all were among men. The review found that compared to standard HIV testing, HIVST: doubled testing uptake (RR = 2.12; 95% CI: 1.51, 2.98), nearly doubled testing frequency (Rate ratio = 1.88; 95% CI: 1.17; 3.01) and doubled the likelihood of an HIV-positive diagnosis (RR = 2.02; 95% CI: 0.37, 10.76, 5.32). Linkage appeared suboptimal in one RCT, but data was limited and of very low-quality. There was no indication of harm attributable to HIVST. This paper was published in the Journal of the International AIDS Society in 2017. I used these results to inform development of guidelines from the World Health Organization. Second, cross-sectional analysis of data was conducted using 31 385 survey respondents from two of the first Demographic and Health Surveys to include HIVST questions (Malawi and Zimbabwe 2015-16). This work highlighted that nearly one-third of men had never tested and that HIVST awareness and experience was low, 12.6% and 1.2% respectively. Analysis of willingness to self-test was limited by data availability to Zimbabwean men but showed highest willingness to self-test among men at high HIV-related sexual risk (aOR = 3.74; 95%CI: 1.39–10.03). Effect modification was observed between HIV-related sexual risk and socioeconomic variables with multivariable analysis showing that high-risk men were more likely than low-risk men to be willingness to self-test if they were wealthier, unemployed, rural and tested before. These data can be used to investigate future impact of HIVST as programmes scale up. This paper was published in the BMC Public Health in 2020. Third, a formative qualitative study explored the potential for HIVST to be part of a broader strategy for engaging midlife-older Malawians in HIV testing, prevention and care. The study applied a life-course theoretical framework to understand how age is enacted socially and its implications on HIV testing and sexual risk behaviours in men and women. Adults over 30 years of age were considered “respectable”, beyond sexual risk taking and infidelity; and therefore, perceived as invulnerable to HIV. Thus, HIV testing was stigmatized as a threat to social status. Given this, self-testing was preferred to conventional alternatives, with older men wanting to access HIVST through fixed community collection points, workplaces or bus depots. Partner-delivered HIVST was also desired. This paper was published in the BMC Public Health in 2021. Fourth, a discrete choice experiment (DCE) was nested within a six-armed adaptive cluster- randomised trial using secondary HIVST distribution to male partners of pregnant women in Blantyre, Malawi, to provide proxy preferences on the feasibility of financial incentives. Overall, 602 pregnant women were surveyed about their partner’s preference for linkage interventions for anti-retroviral therapy (ART) or voluntary male medical circumcision (VMMC) following HIVST or standard HIV testing. Analysis using a multinomial logit model indicated that, according to women, men would prefer US$3, not US$10, for linking to ART (US$3: β= 0.087,p<0.10 vs US$10: -0.228, p<0.01). The latent class analysis revealed that for linkage to ART, women were split between those with significant preferences for standard testing (37.1%), those preferring HIVST plus US$3 (28.4%), those preferring a lottery (26.2%), and those feeling partners would never link (8.2%). For VMMC, the latent class analysis, found women to be either optimistic (77.0%) or those pessimistic (23.0%) their partners would link regardless of intervention. In qualitative interviews with 75 women, most were too unsure to guess their partner’s views, others considered their partner either very unlikely, or very likely, to link regardless of incentive. Concern with what men would do with the cash incentive was expressed. Findings contrasted with the parent study which showed a strong effect of incentives on men’s linkage, with US$10 outperforming US$3 financial incentives and lottery prizes ineffective. The paper is currently in preparation for submission to BMC Infectious Diseases. This PhD project supports HIVST as an important tool for reaching African men who may not otherwise test. HIVST implementation and linkage interventions, particularly for midlife-older men, need to factor in social and cultural norms, including attitudes among their female partners. The approach followed here, combining a systematic review, population survey, qualitative study, and DCE, provides insight into how valuable HIVST is for reaching men, and the importance of strategies that will reach midlife-older men and are accepted by female partners. As the largest gap in absolute diagnoses in sub-Saharan Africa continues to be among 35–49-year-old men, these findings are of critical importance and have been used to inform policy development globally and nationally, as countries scale-up HIVST and work toward achieving the “first 95” – diagnosis of 95% of all people with HIV by 2025.
