Comparative evaluation of strategies to scale-up an evidenced based social network and HIV self-testing and linkage to prevention and care intervention for highly mobile men

About This Grant

PROJECT SUMMARY / ABSTRACT Despite gains in men’s engagement in HIV testing, prevention, and treatment in sub-Saharan Africa (SSA), men are still less likely than women to test for HIV, less likely to start antiretroviral treatment (ART) and pre-exposure prophylaxis (PrEP), and more likely to default from care and have virological failure. Highly mobile Lake Victoria fishermen in Kenya are at high risk of HIV acquisition due to their mobility and a transactional sex economy embedded within the fish trade. Fishermen have difficulty accessing services during typical clinic hours, and HIV-related stigma and gender norms that run counter to men’s healthcare- seeking also limit their uptake of HIV testing, prevention and treatment. Our recently completed social network-based, HIV status-neutral intervention (“Owete”) significantly increased HIV testing and linkage for ART or PrEP among Kenyan fishermen. HIV self-testing was higher in intervention network clusters (60% vs. 10%, p<0.001), as was linkage to health facilities among those who tested (67% vs. 16%, p<0.001). In Owete we identified close social networks of men and trained socially connected men in networks to act as “Promoters” of HIV testing, prevention and treatment. Promoters distributed HIV self-test kits and a small (KSh500, $4) transport voucher redeemable at linkage to health facilities to men in their networks. Promoters were trained to encourage peers to test and link to either PrEP or ART. We have engaged the Kenya Ministry of Health to now address how the Owete intervention can best be deployed at scale to proceed with wide-scale implementation of the intervention. Challenges to wider-scale implementation of Owete in Kenya are: costs and complexity of full social network surveys and promoter selection, and a limited evidence base for the amount and use of vouchers as an incentive to link to care. We will use the Multiphase Optimization Strategy (MOST) to identify an effective, scalable, and cost- effective version of Owete. In the MOST Preparation Phase, we will Identify scalable options for selection of network central Promoters and incentive levels (Aim 1). We will: use existing data from Owete and modeling to identify candidate components, set optimization criterion, and pilot-test candidate components in one beach. In the MOST Optimization Phase, we will comparatively test Promoter selection strategies, voucher effects, examine mechanisms of intervention action (Aim 2). In a 2x3 factorial trial, we will assess HIV self-testing and linkage outcomes at 3 and 6 months in 6 beaches, and use mixed methods to identify pathways of intervention action. We will estimate the incremental cost-effectiveness of candidate intervention combinations (Aim 3), employing time-driven activity-based costing and Markov modeling to assess cost-effectiveness; and use optimization criteria to identify the most effective, feasible, and cost- effective combination of Promoter selection strategy and incentive level for scale-up. Impact: This research will result in a scalable approach to engaging mobile men in HIV testing and care to reduce HIV in Africa.