Web-Based Multifaceted Approach for Community-Based HIV Self-Testing Among Female Sex Workers in Indonesia: Protocol for a Randomized Community Trial
Authors: Yunus Jessie Olivia , Sawitri Anak Agung Sagung , Wirawan Dewa Nyoman , Mahendra I Gusti Agung Agus , Susanti Dewi , Utami Ds Ni Kadek Ayu Dwi , Asanab Dedison , Narayani Ida Ayu , Mukuan Oldri Sherli , Widihastuti Asti , Magnani Robert , Januraga Pande Putu 
Published: May 2021

Background
New HIV infections in Indonesia continue to be concentrated among key populations, including female sex workers (FSWs). However, increasing HIV testing among this subpopulation remains a challenge, necessitating exploration into alternative testing modalities.

Objective
This study aims to assess whether the addition of an oral fluid testing option in community settings would increase the rate of HIV case identification among FSWs. Because the study was implemented early in the outbreak of COVID-19 in Indonesia, a secondary objective is to assess approaches and tools for implementing both community outreach and community HIV screening for FSWs during pandemic conditions.

Methods
We undertook a community-based randomized trial in 23 national priority districts in which community outreach services were being provided. Community-based screening using an oral fluid-based rapid test was added to the community outreach standard of care in intervention districts with clients having the option of performing the test themselves or being assisted by outreach workers. A web-based system was created to screen for eligibility and collect participant data and test results, facilitating the process for both unassisted and assisted participants. Participants with reactive screening results were encouraged to undergo HIV testing at a health facility to confirm their diagnosis and initiate antiretroviral treatment as needed. Multiple means of recruitment were deployed including through outreach workers and social media campaigns.

Results
Of the 1907 FSWs who registered, met the eligibility criteria, and gave consent to participate, 1545 undertook community oral fluid test (OFT) screening. Most (1516/1545, 98.1%) opted for assisted screening. Recruitment via social media fell far short of expectations as many who registered independently for the OFT because of the social media campaign did not identify as FSWs. They were eventually not eligible to participate, but their interest points to the possibility of implementing HIV self-testing in the general population. The successful recruitment through outreach workers, facilitated by social media, indicates that their roles remain crucial in accessing FSW networks and improving HIV testing uptake.

Conclusions
The addition of HIV self-testing to the standard of care supported by a web-based data collection system was able to increase HIV case identification among FSWs in intervention districts. The high satisfaction of OFT users and the interest of the general population toward this alternative testing modality are promising for scaling up community HIV screening nationally.

Trial Registration
ClinicalTrials.gov NCT04578145; https://clinicaltrials.gov/ct2/show/NCT04578145

International Registered Report Identifier (IRRID)
RR1-10.2196/27168