Promoting HIV self-testing among female sex workers in Zambia
Despite significant progress in increasing HIV treatment and reducing deaths since 2010, progress in reducing new infections has been slower. Reducing new infections requires reaching groups who may be left out by existing HIV prevention efforts. Female sex workers (FSW) represent one group that is disproportionately affected by the HIV epidemic. The rates at which they are tested for the virus are limited by factors like healthcare provider stigma, restricted access to tests and lack of legal protection.
HIV testing is a critical step to achieving the UNAIDS target that 90 percent of all HIV-positive persons know their status. The World Health Organization recommends focused and strategic use of innovative approaches like peer-delivered HIV self-tests to increase uptake of HIV testing among key populations such as FSWs.
To better understand the efficacy of peer-delivered HIV testing services, a 3ie-supported randomized control trial evaluated the effectiveness of two delivery models: HIV self-test provision and standard facility-based HIV testing to increase HIV testing coverage among urban FSW in Zambia. The study hypothesized that peer-based HIV test kit delivery would lead to improved testing rates and better knowledge of HIV status as compared to standard practices. Peer educators were current or former sex workers recruited by partner organizations operating in the study communities.
The evaluation compared standard facility-based testing, which consisted of peer educators referring FSWs to existing HIV testing facilities, with the distribution of HIV self-testing kits for FSWs. The evaluation was conducted in three of the country’s transit border towns: Livingstone, Chirundu and Kapiri Mposhi. HIV self-tests were distributed through two mechanisms: 1) direct distribution from peer educators and 2) referral via coupon to HIVST distribution points in the town, such as drugstores and health centres. As a part of these trials,160 peer educators and 965 participants were enrolled.
The findings indicated that HIV self-testing was accessible and acceptable to the FSWs. There were no significant differences in rates of testing or in access to care among the different treatment arms four months after the intervention.
Multilevel stigma was a barrier to HIV self-testing within the FSW community. The study indicated that access to peer educators provided participants agency to seek HIV testing.
While HIV self-testing did not appear to increase intimate partner violence on average, findings show that implementation programs need to recognize the possibility of intimate partner violence following self-testing.
Type of impact: Inform global guidelines and policy discussions
When findings from an evaluation or review can be traced to discussions or actions. Examples include governments or multilateral or bilateral donors’ mentioning the findings to inform policy or programming. To date, we have only one case of an individual impact evaluation informing global health guidelines. WHO guidelines require that the guidance is based on randomised evaluation evidence.
This is one of 3ie’s seven types of evidence use. Impact types are based on what we find in the monitoring data for an evaluation or review. Due to the nature of evidence-informed decision-making and action, 3ie looks for verifiable contributions that our evidence makes, not attribution.
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The World Health Organization (WHO) recommends improving access to HIV self-testing among key populations, men and young people as a means to increase testing, especially in eastern and southern Africa. The recommendation, in the organization’s HIV self-testing strategic framework of 2018, offers countries and implementers guidance in planning, starting and scaling up HIV self-testing implementation, citing the 3ie-supported evaluation among others. The findings of the evaluation inform the WHO’s recommendations on leveraging health facilities and community outreach for more effective distribution and uptake of HIV self-testing in key populations.
The evaluation is also one of the 32 randomized control trials reviewed by the WHO to inform its consolidated guidelines on HIV testing services (2019). The updated guidance strongly recommends HIV self-testing as an approach to HIV testing services. The guidelines emphasize community-based HIV testing models and tools. They recognize the effectiveness of HIV self-testing kit distribution by peer educators in encouraging HIV testing among hard-to-reach key populations, as was studied in this evaluation. The guidelines also cite seven other 3ie evaluations; more details are here.
International Initiative for Impact Evaluation (3ie), 2021. Promoting uptake of HIV self-testing among female sex workers in Zambia (online summary), Evidence Impact Summaries. New Delhi: 3ie.
Evidence impact summaries aim to demonstrate and encourage the use of evidence to inform programming and policymaking. These reflect the information available to 3ie at the time of posting. Since several factors influence policymaking, the summaries highlight contributions of evidence rather than endorsing a policy or decision or claiming that it can be attributed solely to evidence. If you have any suggestions or updates to improve this summary, please write to firstname.lastname@example.org