HIV Self Testing in the Emergency Medicine Department at the University Hospital of the West Indies: Protocol of an Implementation Science Demonstration Project (Preprint)
Authors: Barrow Geoffrey , Woodward Eva N , Dasgupta Shuvra , Short Duncan , Anzinger Joshua J , Graham Leohrandra , French Simone , Williams Eric Wilson 
Published: December 2021

BACKGROUND

Background
The World Health Organization (WHO) defines HIV self-testing (HIVST) as “a process in which a person collects his or her own specimen (oral fluid or blood) and then performs an HIV test and interprets the result”.1 Previous studies on the use of HIVST have shown this is a viable and influential new technology to increase HIV screening and diagnosis by double in several populations.2-5 The WHO/ Pan American Health Organization (PAHO) 1, International Association of Providers of AIDS Care (IAPAC) 6, the Global Fund to Fight AIDS, Tuberculosis and Malaria (GF)7 and PEPFAR8 all recommend implementation of HIVST.

Both assisted and unassisted HIVST methodologies have been proven to be effective techniques of capturing HIV diagnoses. 9 In this meta-analysis, assisted and unassisted HIV screening technologies have been equally effective in detecting HIV diagnoses (Cohen’s κ: directly assisted 0·98, 95% CI 0·96–0·99 and unassisted 0·97, 0·96–0·98; I²=34·5%, 0–97·8).

The specific HIVST kit to be used in this study is the OraQuick® kit. OraQuick® is the only HIVST kit recommended by the WHO 10 OraQuick® has been previously used in Jamaica for community-based assisted HIV self-testing. The documented Sensitivity and Specificity of OraQuick® reported by the US Food and Drug Administration (FDA) is 91.7% and 98.7% respectively.6 This modality involves a screening test and all positive screens must be confirmed by laboratory based diagnosis.

HIV self-testing kits have primarily been used during targeted interventions in high risk groups in Jamaica using assisted self-testing 11. The HIVSTI/Tb Unit of the Jamaica Ministry of Health wishes to develop a comprehensive programme to ensure the maximum possible benefits of HIVST on the HIV epidemic.

The HIV treatment cascade for Jamaica in 2020 shows many gaps affecting population viral suppression. Firstly, there is an approximate 14% decline between those estimated to be infected and those diagnosed with HIV and secondly, a further 45% reduction in those retained in care12. In 2013, the National HIV/STI/Tb Unit (HSTU) of the Ministry of Health and Wellness (MOHW), introduced a policy supporting universal routine HIV screening for attendees of healthcare facilities in Jamaica. However, the coverage and constancy of this intervention has remained low13. Consultations at public healthcare facilities in Jamaica revealed competing priorities, limited structural capacity and insufficient human resources as key barriers to increasing coverage, particularly in hospital settings.

Prior Work
At the University Hospital of the West Indies (UHWI), preliminary research conducted within the Department of Medicine outpatient clinics, on routine HIV screening showed high acceptability: 80% uptake for HIV rapid tests, along with high capture of positive HIV diagnoses, prevalence 1.8 (above the National HIV prevalence), and significant improvements for linkage to care were achieved at this location14. Increasing the capture and linkage of People Living with HIV (PLHIV) to this site can therefore have significant effects on HIV epidemic control and provide a high-quality service to improve the lives of patients.

In the Emergency Medicine Division (EMD) at the University Hospital of the West Indies, the triage system used to see patients is the Emergency Severity Index (ESI)15. It is a five-tier emergency department triage system where patients are stratified to an ESI level from 1 through 5, on the basis of acuity and resource need, where 1 is the most urgent and 5 the least urgent.

The EMD is physically sectioned into three areas, Fast-track where the ESI level 4 and 5 patients are seen, Intermediate for ESI Level 3, and the ‘Main’ section where ESI level 1 and 2 patients are seen. HIV testing has been previously used in two ways in the EMD. Laboratory based screening has always been available for patients irrespective of acuity, but over the last decade, targeted testing of symptomatic patients with rapid test kits has also been available. These clients are often sicker with Emergency Severity Index scores of less than 4, suggesting greater morbidity/severity of illness. Patients ESI 4 and 5 are not routinely offered HIV screening. Generally, HIV testing algorithms have employed both screening with the HIV Determine® rapid test kit followed by laboratory confirmation using the Trinity Biotech Uni-Gold HIV test and and SD BIOLINE HIV-1/2 3.0 test, run sequentially. Any discrepancies are resolved using the Abbott Architect HIV-1/2 Ag/Ab Combo test.
HIVST is being explored for expanded implementation in Jamaica by the Ministry of Health and Wellness as exemplified by its inclusion in the HIV epidemic control strategies listed in the Jamaica National HIV Strategic Plan 2020-2025.16 Prior to HIVST being made available, HIV screening in the EMD has been limited by physical space, confidential areas to perform point-of-care rapid testing, human resource capacity, the staff to perform testing and counselling, and the time to perform rapid testing.

The Research to Practice Gap
A literature search of the implementation of home-based HIV self-test distribution in an emergency medicine department setting identified limited studies or information on factors influencing successful implementation. The studies generally identified positive attributes of self-testing to fill gaps in current HIV testing models17. Common influencing factors included cost 18, 19, usability 20 and supportive policy environments 1, 21

A systematic review of HIV screening in emergency departments 22 highlighted the central role of emergency department testing in epidemic control in the United States, and the paucity of such applications found in the literature for low and middle income countries. The review outlined a high prevalence of HIV among those attending the emergency departments including high proportions of previously undiagnosed persons. The review concluded that HIV testing in these locations offer a “unique testing venue” with a high probability of successful capture of PLHIV.
One randomized controlled trial indicated the gap in testing coverage in an EMD can be filled with HIVST. 23 However, a strategy of referral cards for increasing distribution among sexual networks was not successful as none of the cards were used to access HIVST kits. The strategy proposed by Patel et al. was to provide the study participant with referral cards that would be distributed throughout the participants’ network. The recipients would subsequently use the cards to access HIV self-test kits for themselves..

Rationale for Proposed Research
Introducing HIVST in the context of the EMD is well placed to be an effective intervention and acceptable to patients. This method of HIV screening can compensate for limited human resources and structural capacity that are generally required for other modalities of testing. We hypothesise the introduction of HIVST distribution in EMDs for unassisted testing will expand coverage of HIV testing and increase the capture and linkage of asymptomatic, undiagnosed HIV positive patients, a key intervention to achieve the UNAIDS 2025 AIDS targets.24

We will use an implementation science framework to assess determinants that hinder/enhance HIV screening implementation and guide the process of overcoming barriers to implementation—the Health Equity Implementation Framework.25 This framework also specifies a process or implementation strategy, known as facilitation, to overcome barriers related to equity in HIV care in this context to launch HIVST in this setting and sustain it long term. This framework also specifies domains to assess and consider when facilitating implementation of HIVST: the innovation itself (HIVST using oral fluid); factors of the people offering HIVST (staff, providers) and those who are targeted recipients of HIVST (patients), especially their cultural norms and beliefs; clinical encounter between EMD staff/providers and patients; local context of the emergency medicine clinical service, such as leadership support and culture regarding clinical changes; organizational context of the larger emergency medicine department; outer context of the University Hospital of the West Indies; and societal context, such as legal ramifications of being criminalized for same-sex behaviour in Jamaica (a key risk behaviour of HIV in the country) or economic concerns about limited healthcare coverage if a person was to test positive for HIV.
We chose to use the Health Equity Implementation Framework for the following reasons: 1) detailed focus on facilitation, our key implementation strategy; 2) focus on domains that we believe contribute to poor uptake of HIVST in Jamaica, such as cultural norms of patients (“recipients”) and physical structures in the EMD such as limited confidentiality for private matters such as HIV screening; and 3) use of many of its domains in a prior HIV screening implementation project that was successful.26

OBJECTIVE

Research Question, Aims and Objectives

Research Question
The following research questions will be addressed:
•	How can HIV Self-Testing using oral fluid to diagnose non-emergency patients in an urban hospital’s emergency department be implemented effectively?
•	What is the potential public health impact of implementing facility-based HIV Self Testing access at healthcare locations in Jamaica?

Aims
The aims of this study are:

1.	To assess the factors that influence the implementation of the HIV Self Testing intervention.
2.	To determine the effectiveness of the HIV Self Testing intervention to promote access to antiretroviral therapy.

Objectives
The Implementation Objectives are as follows:
1.	To document the implementation strategies of the HIVST intervention.
2.	To evaluate the facilitators and barriers of HIVST implementation in the EMD.
3.	To determine the acceptability of the HIVST intervention by EMD patients
4.	To determine the reach of HIV screening for
i.	EMD patients
ii.	The secondary contacts of EMD patients
5.	To determine the costs associated with implementing this HIVST intervention from the payer’s perspective.
6.	To measure the fidelity to HIVST activities delineated in the study protocol at the participant level (Implementation Fidelity27, 28)
The Effectiveness Objectives are as follows:
1.	To evaluate the effectiveness of the HIVST intervention to detect undiagnosed HIV positive EMD clients.
2.	To determine the effectiveness of risk network referrals to detect HIV positive secondary contacts of EMD clients.
3.	To determine the effectiveness of the HIV Self Testing intervention to link positive HIV diagnoses to treatment and care.

METHODS

Methods (Description)
Study Design
This is an implementation study design, specifically a hybrid type III 29 which includes implementation and effectiveness outcome measures, with an emphasis on implementation since HIVST has well-established efficacy already.30 We will conduct a cross-sectional, pre-post comparison over a 3-month period. A retrospective review of EMD patients previously tested for HIV will form the basis of the interrupted time series analysis. An outline of the essential elements of the study flow is detailed in Figure 1.

The Standards for Reporting Implementation Studies (StaRI) 31 and the 10 key elements described by Proctor et al. 32will be used to guide the reporting of this study. The documentation of the intervention component of this report will follow the STROBE statement.33

Setting and participants (Context)
The Emergency Medicine Department at the University Hospital of the West Indies, located in Kingston Jamaica, will be the location for the implementation of this intervention. The UHWI is in the urban area of Kingston, Jamaica. It is a 579-bed type A regional referral hospital with all major medical and surgical subspecialties. A total of approximately 49,000 to 53,000 patients are seen per year with an annual hospital admission rate of 15%.34 The department provides services to between 3000 and 5000 patients per month. Based on the severity of illness, the department is divided into three clinical areas: Main area (ESI 1 and 2), Intermediate (ESI 3) and Fast-track (ESI 4 and 5). This study will be situated in the ambulatory area, where the ESI 4 and 5 patients are seen. These patients are non-urgent and can easily be approached by the implementation team, without any delay in the patient’s clinical management.

Three intervention recipient populations (participants) will be included:
1.	EMD patients: The population who will be included in this study are adult patients, over the age of 17, of the EMD, UHWI. Patients with the lowest ESI scores (scores of 4 and 5) will be invited to participate in the study. Those who have had a previous HIV positive diagnosis or who have been tested for HIV within the last 12 months will be excluded.
2.	EMD Staff: A range of staff categories including Emergency Medicine Consultants, program residents, non-program residents, senior house officers, emergency medicine trained nurses, emergency room technicians, patient care advocates, registration, and billing. The number and specification of individuals will be determined during the pre-implementation activities.
3.	Study Staff: The study team who will guide implementation are comprised of EMD staff, one EMD consultant physicians, acting as an internal facilitator, one Head of Department, and one external facilitator outside the healthcare system. Non-EMD study staff will be comprised of two to four research assistants.

The effectiveness evaluation component will include comparing EMD patients who were previously tested for HIV in the EMD to those tested after HIVST is implemented. The retrospective analysis will include 3 years of data commencing in January 2018.

Description of the Implementation Strategies
Facilitation is our primary implementation strategy to prepare for, launch, and maintain HIVST in the EMD.25 Facilitation is an umbrella implementation strategy, such that it involves key steps (e.g., working with stakeholders to develop and execute an implementation plan) that can involve other specific implementation strategies as needed.25 We anticipate using at least these specific implementation strategies drawn from the list of Expert Recommendations for Implementing Change( compilation 35-37, although others may be used:
1.	Develop patient educational materials
2.	Distribute patient educational materials
3.	Involve patients
4.	Assess for readiness and identify barriers and facilitators
5.	Develop staff/provider educational materials
6.	Distribute staff/provider educational materials
7.	Conduct staff/provider educational meetings
8.	Develop a formal implementation blueprint
9.	Access new funding
Facilitators will work to initiate and enact these strategies, which will be critical for successful initial implementation of HIV screening, and for its sustainability and scale-out in Jamaica. There are multiple barriers to implementation and the emergency department, where screening is to be implemented, is nested within and overlaps with other organizational contexts. Thus, the complexity of the healthcare contexts and need for scale-out in subsequent initiatives warrant facilitation. Additionally, facilitation allows for a focus on capacity building of UHWI staff in implementation science during and after the project.
Description of the Intervention
The HIVST intervention will be comprised of three activities:
1.	HIVST Package
i.	Three HIV OraQuick® test kits.
1.	One for the EMD patient
2.	One for the EMD patient to distribute to a secondary contact
ii.	Information leaflet
iii.	Follow-up contact information
iv.	Condoms
2.	Active follow-up by research team at three time points:
i.	Within two (2) days of receiving test kits (as determined by the participant)
ii.	1 week after receiving test kits.
iii.	1 month after receiving test kits.
3.	Access to 24-hour information hotline

The HIVST Intervention Details
1.	The HIVST Package
i.	Jamaica MOHW national policy on HIV screening recommends the use of opt-out testing. However, due to the requirement of patient consent for participation, an opt-in approach will be adopted.
ii.	Consent will be garnered from the participants specifically for the following processes:
1.	Follow up calls by the research team.
2.	Ascertaining HIVST result status.
3.	Confidential reporting of potential positive status to the Jamaica National Public Health Reporting System (Class I Notification).
4.	Active follow up by the study team for participants with a positive HIVST to link them to confirmatory testing at the UHWI and further HIV treatment and care as required.
iii.	The consented participants will then be provided with the HIVST package as outlined above. Participants will be encouraged to perform their self-tests kits at a secure location, for example at home. However, access to a secure location will be provided for those who wish to perform unassisted facility-based testing.
iv.	Participants will also be encouraged to provide the third HIVST kit to a secondary contact, which may include a present or previous sexual partner, family member or friend. Educational materials and follow-up information will be provided along with the additional kit.
v.	EMD clients that are unable to perform HIVST (for example the elderly or infirmed), HIV screening, using the hospital laboratory-based HIV testing algorithm, will be recommended as an included component of their visit to their EMD care team.

2.	Active follow-up activities will be performed for participants.
a.	Follow-up of participants will be conducted by the designated research team members via telephone or face to face.
b.	Follow-up will be conducted at three time points:
1.	Within 2 days of participant receiving the test kits to be determined in conjunction with the participant. The following activities will be performed:
	Address technical difficulties.
	Document test result.
	Provide post-test information
	Assessment of any adverse event
	Schedule follow-up and linkage activities
2.	One week after enrolment. The following activities will be performed:
i.	Address technical difficulties (if not previously done)
ii.	Document test result (If not previously done)
iii.	Document post-test information (if not previously done)
	Exit survey
	Assessment of adverse events
	Schedule follow-up and linkage activities
iv.	One month after enrolment. The following activities will be performed:
v.	Address technical difficulties (if not previously done)
vi.	Document test result (If not previously done)
vii.	Document post-test information (if not previously done)
	Exit survey (if not previously performed)
	Assessment of adverse events
	Schedule follow-up and linkage activities
3.	For participants where follow-up has been unsuccessful, referral to an appropriate agency’s linkage team will be performed. The linkage processes will follow the national HSTU guidelines and include telephone contact, referral to a Contact Investigator and home visits as required.
c.	Upon linkage activities will be tailored based on the HIVST result
i.	Positive HIVST
1.	Confirmatory testing at the UHWI.
2.	Post-test counselling.
3.	Submitting Class I notification form to MOHW for confirmed positive tests.
4.	Enrolment to preferred provider for further HIV treatment and care.
ii.	Negative HIVST
1.	Post-test counselling
2.	Referral to preferred provider for combination HIV prevention

3.	Access to a 24-hour hotline
a.	A hotline, manned by the study team, will also be provided to participants and their secondary contacts to address any emergency occurrences related to the study activities.

Methods (Evaluation)
Documenting Implementation Strategies
In our process evaluation, we will document implementation strategies used before and during the demonstration project and track any adaptations to those strategies. To document strategies, we will use the Pragmatic Implementation Strategy Reporting Tool which allows researchers to track strategies used with specificity according to top recommendations.38 We will collect this information during weekly team meetings of the facilitation team. Each strategy will be detailed by the specific actions that required, the personnel that will be performing each action, and the period over which each strategy will be performed. Subsequently, the frequency and duration of each action will be determined along with the total time spent by the assigned personnel.

Implementation and Effectiveness Outcomes and Measures
We will use the RE-AIM39 framework to select outcomes to assess public health impact of implementing HIVST in one emergency medicine department in Jamaica. RE-AIM represents five constructs to evaluate: Reach, Effectiveness, Adoption, Implementation, and Maintenance. Assessing Reach involves evaluating whether HIVST is reaching the intended population by describing which patients are offered and accept HIVST. Assessing Effectiveness involves evaluating how well HIVST is detecting HIV and leads to linkage of people testing positive for HIV to treatment for the virus. Adoption typically refers to clinicians deciding to use the intervention, and we will not assess Adoption in this study because our study staff will be offering HIVST to patients. Assessing Implementation involves evaluating a range of factors affecting how HIVST is actually used in routine practice.40 In this study, we will assess Implementation as 1) fidelity to the HIVST intervention with each patient and 2) costs associated with implementing the package of HIVST and facilitation. Maintenance refers to how each of the aforementioned constructs are maintained or sustained at a later timepoint; because this is a 3-month demonstration project, we will not assess Maintenance.

The evaluation methods for the implementation outcomes reach, implementation fidelity and cost, and acceptability will follow a mixed-methods approach and are summarized below (Table 1). Implementation cost will be guided by the methodology of time-driven activity-based costing. 41 The main effectiveness outcome is HIV testing uptake of the primary recipient, the EMD patient, but also uptake in the secondary recipient (the risk network of EMD patients). More detail is in Table 1.

Acceptability to Patients
Patient perspectives on HIV testing modalities have previously shown to be a critical factor in successful implementation. We will gather critical information on patient experiences and recommendations will be incorporated for the scale-out of HIVST beyond the EMD context. We use the theoretical framework of acceptability as proposed by Sekhon et al. 42 They propose acceptability as a multi-component construct which can be assessed before, during or after the intervention. We utilize this framework to perform a qualitative patient-level retrospective assessment of this HIVST implementation programme focusing on eight components of the acceptability construct, concentrating on the lived experience of the participants and their intention for future HIVST.

Sample Size
Sample size was determined by accounting for internal and external context, resource capacity and outcome timelines. The contextual factors considered included patient visit load to the EMD, estimated acceptance to participate, national prevalence of HIV, estimated response rate of participants. The capacity of the research team to conduct follow-up activities and total costs of the demonstration project were also included in sample size considerations. Lastly was the need for rapid production of data to influence national decision making on HIVST implementation.

Based on the national HIV prevalence of 1.8 in the general population and the sensitivity of the OraQuick® HIV test of 91.7% 6, if no attrition is assumed, approximately 10 positive tests are estimated. Estimates of the total number of patients fulfilling the inclusion/exclusion criteria is not currently available for the EMD as numbers based on Emergency Severity Index scores are not tracked and reported routinely. However, this information will be captured during the study period to provide a denominator for the relevant indicators. A total of 600 participants will be enrolled in the study over a 3-month period.

Data Analysis
A mixed methods approach to data collection will be used. Quantitative data will be collected and managed using structured data capture forms using the REDCap 43, 44 electronic data capture tools hosted at The University of the West Indies, Mona Campus. Qualitative data will be collected using voice recorders and subsequently transcribed by the study team. Inaudible segments will be discussed within the study team and resolved by the Principal Investigator.
Most quantitative and qualitative data will be collected and analysed simultaneously (see Table 1) and a concurrent triangulation technique to be employed 45 for interpretation.

Implementation Reach and Fidelity Analysis
Implementation reach will be operationalized as the proportion of clients who satisfy the inclusion/exclusion criteria that have been approached and agree to participate in the study. We will also assess demographic characteristics of those participants (e.g., gender identity, income). We will use descriptive statistics to analyse these data.

Fidelity will be assessed from the participant perspective. It will be operationalized as the proportion of participants who perform the HIVST testing procedure as described in the educational materials provided.

Implementation Cost Analysis
Total costs of facilitation will be calculated by combining human resource costs and the additional fixed costs and their associated expenses required for each strategy, consistent with time-driven activity-based costing.41

Effectiveness Analysis
The main indicator of increased HIV testing uptake will be analysed using an interrupted time series analysis46. The hypothesized impact model is one with no lag and a level change. The proposed segmented regression model will take the general form:

Yt = β0 + β1T + β2 Xt + ε

Where β0 represents the baseline HIV testing level at time T=0, β1 is interpreted as the change in HIV testing associated with a time unit increase, β2 is the level change in HIV testing following the introduction of the HIVST intervention.

Patient Acceptability Analysis
A thematic approach will be used to analyse qualitative data from patient interviews on acceptability of HIVST47. Themes will be chosen based on the pre-identified implementation outcomes (deductive approach) and additions will be made based on the analysis of the transcripts (inductive approach). The methodology of coding the data has been previously documented48. Identified themes will be triangulated with quantitative data collected under the implementation outcomes.

RESULTS

Discussion
Principal Results
The investigation into HIVST implementation attempts to produce data that can maximize the utility of HIVST in Jamaica. HIV screening at healthcare facilities has historically had higher yields as compared to national HIV prevalence. However, the coverage in these settings has been limited. The introduction of HIVST present an opportunity to increase the coverage of routine HIV screening in healthcare facilities. Also, the potential impact of a novel approach to risk network referrals for HIV self-testing can improve the utility of this technology. EMD patient participants will be provided with additional HIVST kits which are to be distributed to a secondary contact, who can be a friend, family member, or sexual contact. As opposed to traditional definitions of risk network referrals, where affected individuals are required to be aware of their symptoms, this method is aimed at diagnosing HIV prior to symptom presentation and thus have a greater impact on epidemic control. This approach represents an adaption of previously attempted interventions aimed at leveraging social networks and HIV testing access.

In patient acceptability interviews, participant responses to educational material will be used to assess the promotional material for uptake but also linkage to care. Linkage following HIVST has previously been an inhibiting factor for implementation 49. Here, we will be using resource intensive method of active follow up of EMD patient participants to gather critical information particularly around acceptability, but also a resource light approach with risk network referral of secondary contacts.

Limitations
The physical structural capacity restrictions in the EMD to provide confidential spaces where study activities can be performed introduce a manufactured limitation on the potential expansion of HIV testing. The baseline procedures, including in-depth interviews, result in a maximum of 8 participants able to be enrolled per day. This limits the interrupted time series analysis to only a level-change but not a gradient change. This can result in an underestimate of the potential impact of HIVST on HIV testing coverage expansion.

The accuracy of HIV positive case finding using HIVST is solely dependent on self-reported diagnosis of participants. This effect may be even larger for risk network referral participants for whom an active initiation of engagement in the study is required. This will also affect the evaluation of linkage to care.

In addition, the impact of the COVID-19 epidemic on how the population accesses services in the EMD at UHWI, their willingness to participate in research study activities and the work flows within the department will need to be considered when interpreting the data. This demonstration project has already been delayed for one year due to the pandemic.

CONCLUSIONS

Conclusions
This study will use implementation science frameworks and outcome measures to assess the potential of HIVST to expand access to HIV testing in an emergency medicine department in Jamaica. The ultimate goal of this research is to provide an adequate baseline understanding of HIVST implementation to inform decisions on expanding access to HIVST in other settings.

Ethics and Funding
This proposal has been granted ethical approval by the University of the West Indies, Mona Campus Research Ethics Committee (March 23, 2020; Reference number ECP108, 18/19).
The study is supported by ViiV Healthcare.

Acknowledgements

GB was responsible for the conception and initial design, all authors contributed to the ideas and development of this protocol. GB, EWW, ENW, SD and DS led the writing of this paper, and all authors approved the final version. ViiV Healthcare is funding this study, GB received compensation as the principal investigator of this study. ENW refined implementation evaluation procedures and served as external facilitator (receiving compensation for facilitation and capacity building activities through funding from ViiV healthcare).

ENW’s contribution to writing the manuscript was supported by Career Development Award Number IK2 HX003065 from the United States (U.S.) Department of Veterans Affairs Health Services Research and Development (HSRD) Service. ENW is a fellow with the Implementation Research Institute (IRI), at the George Warren Brown School of Social Work, Washington University in St. Louis; through an award from the National Institute of Mental Health (5R25MH08091607).

Disclaimer: The views expressed in this article are those of the author(s) and do not necessarily represent the views of the U.S. Department of Veterans Affairs.

Conflicts of Interest
Disclose any personal financial interests related to the subject matters discussed in the manuscript here. If none, indicate with “none declared”.
DS is an employee and shareholder of GSK/ViiV Healthcare.

Abbreviations
HIVST: HIV self-testing
EMD: Emergency Medicine Department
ESI: Emergency Severity Index
HSTU: HIV/STI/Tb Unit
MOHW: Ministry of Health and Wellness
RE-AIM: Reach Effectiveness Adoption Implementation Maintenance
UHWI: University Hospital of the West Indies

CLINICALTRIAL

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