Online HIV self-testing kit dissemination through a peer-led, community-based HIV organization

Queensland, Australia
2021

Queensland Positive People (QPP), a peer-led, community-based HIV organization, hosted a website where people could order free HIV self-testing (HIVST) kits online and have them mailed to them. The program targeted men who have sex with men (MSM) over the age of 18 years but was open to all adults in Queensland. Nine hundred and twenty-seven HIVST kits were ordered by 794 people. The majority of first orders were from MSM (62%) and people having condomless sex (50%). The top reasons that people chose an HIV self-test were because it was convenient (79%) and they did not want to wait for test results (44%). Forty-five percent of people who ordered a HIVST kit were first-time testers.

Program description

QPP hosted an HIVST registration page on their website (along with other HIV-related resources) where people could order HIVST kits. The webpage also included links to information on HIV testing and treatment, as well as links to referral and support services for people newly diagnosed.

Methods used to advertise the HIVST kits included:

  • targeted advertising on gay-identifying apps (e.g., Grindr, Squirt) and Facebook
  • advertising in gay press and by HIV and peer organization websites
  • promotion on non-gay-identifying classified websites (e.g., Craigslist)
  • website promotion
  • word of mouth

The program used peer test facilitators (PTFs) to coordinate the receipt and postage of HIVST kit orders, which were mailed-out in a nondescript package. People were allowed to make repeat orders. In addition to the OraQuick ADVANCE HIV-1/2 Test, the HIVST kit included:

  • instructions (text and images) on how to perform the test and read the results
  • information on pre- and post-exposure prophylaxis and the benefits of regular testing
  • information to assist with linkage to care in the event of a reactive result (e.g., contact details for support organizations)

In addition to the pre-test information provided in the HIVST kit, people were offered the option of direct contact with a PTF for oral pre-test information and guidance on how to use the HIV self-test. Three pre-test information options were provided:

  • HIVST kits mailed with no oral pre-test information
  • HIVST kits mailed after a PTF contacted the participant
  • HIVST kits mailed after the participant contacted a PTF

PTFs received training on a variety of medical and social topics related to HIV (e.g., HIV transmission, HIV stigma), as well as on how to use the HIVST kit, provide pre- and post-test information and follow up with people who received a reactive test result.

Two weeks after the test was mailed out, a PTF contacted people who had ordered a test to determine if they had received it, if they had used it, if they had had any issues performing the test, and what the results were, and they also gave people an opportunity to ask any questions. If people reported a reactive test result, they were supported in accessing HIV confirmatory testing, as well as HIV care. They could also be connected to the peer navigation program at QPP, which provides support to people diagnosed with HIV, or they could be linked to a same-day consultation with a specialist medical provider.

Results

From December 2016 to April 2018, 794 individuals ordered 927 HIVST kits, with 14% of people ordering two or more. The majority of individuals placing first-time orders were recruited through Internet searches (29%), Facebook (29%) and word of mouth (24%). Most people who ordered HIVST kits were MSM; 62% of first orders and 79% of repeat orders were made by MSM. Identifying as MSM was significantly associated with ordering more than one HIVST kit.

Of the 794 individuals who made first orders:

  • 95% were not interested in pre-test contact (i.e., oral pre-test information and guidance on how to use the kit) with a PTF
  • 45% were first-time testers and a further 30% reported their last HIV test was more than a year ago
  • 85% were cis males
  • 50% reported condomless sex
  • 38% lived outside a major city

Reasons for choosing an HIVST included:

  • convenience (79%)
  • not wanting to wait for results (44%)
  • not wanting to talk about sex (33%)
  • not having time to test elsewhere (29%)
  • fear of stigma (22%)
  • lack of local testing options (7%)

Half (50%) of all participants who placed first orders indicated condomless sex as a motivation for HIV testing. Forty percent of people indicated that never having tested for HIV was their reason for testing and 35% of people indicated testing was part of their regular screening practices. Fifty-one percent of people who placed first orders said they were unwilling to pay for an HIVST kit.

Two-week follow-up attempts were completed for all 794 people who requested an HIVST kit and 52% (428) of those who ordered a test were successfully contacted by a PTF. In total, one person had a reactive test result (0.1%), 48% of people had non-reactive test results, 6% had not used the test and 46% of people could not be reached and therefore had an unknown test result. Of the 190 people who placed first orders and responded to the post-test survey, 21% reported that they would have not tested elsewhere if the HIV self-test had not been available. The one person with a known reactive test result was able to self-navigate to a confirmatory HIV test on the basis of the information in the HIVST kit and link themselves to care.

What does this mean for service providers?

This study demonstrated that offering HIVST kits online through a community-based organization’s website was able to increase access to HIV testing, especially for those who may not test otherwise, as the majority of testers were first-time testers or had not tested in the previous year. Dissemination of HIVST through similar mechanisms in Canada may help to reduce the number of people with an undiagnosed HIV infection. However, the study also demonstrated that people may be unwilling to pay for these kits and mechanisms to fund distribution are necessary.

The study also demonstrated that HIVST is a feasible and acceptable way to reach a target population of MSM, including those at risk for HIV infection. This may be due to the fact that it overcomes some of the typical barriers to testing, such as inconvenience and experiences of stigma and discrimination. The study also showed that it increased access to testing for those in non-urban areas, which may be due to the lack of local testing options for people in rural communities.

Finally, this study demonstrated that mechanisms can be put in place to overcome some of the concerns around HIVST such as pre-test counselling, post-test support and linkage to confirmatory testing. This study implemented formalized operating procedures for PTFs to provide people with the support they needed both before and after taking the test. These mechanisms can help to ensure that people receive confirmatory HIV testing and linkage to care and support when needed.

Related resources

HIV self-testing - fact sheet

HIV self-testing: Putting it into practice - webinar

HIV self-testing: Learning from international program models to increase testing

Reference

Bell SFE, Lemoire J, Debattista J et al. Online HIV self-testing (HIVST) dissemination by an Australian community peer HIV organisation: a scalable way to increase access to testing, particularly for suboptimal testers. International Journal of Environmental Research and Public Health. 2021;18:11252.