Zambian Peer-Educators for HIV Self-Testing Study

Study Overview
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Brief Summary
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ZEST is a cluster-randomized trial designed to determine whether HIV self-tests are acceptable and improve HIV testing rates and HIV status knowledge among female sex workers in Zambian transit towns. This study will determine whether directly giving participants an HIV self-test or giving them a coupon to collect a test at a drug store or clinic improves outcomes compared to standard of care.

Detailed Description
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Although Zambia has a generalized HIV epidemic, with approximately 13.3% of adults aged 15 to 49 living with HIV, the epidemic remains even more highly concentrated in key populations, including female sex workers (FSW). A particular concern for FSW is access to healthcare services, including HIV testing services. FSW face significant barriers to accessing healthcare. In other settings, evidence has suggested that stigma is a significant barrier to FSW seeking HIV testing. It is likely that similar mechanisms exist in Zambia. Evidence from Zambia has indicated that complex multilevel factors, such as stigmatization and harassment, contribute to vulnerability among FSW. User-controlled HIV prevention interventions that lead to empowerment of FSW may therefore be a powerful way to address the HIV epidemic in this key population. Oral HIV self-testing consists of an oral swab kit that allows individuals to test for HIV in the privacy of their own homes whenever they want. The ease of use of HIV self-testing, that it can be done at any time, and that is completely private may make it an attractive alternative to currently-available HIV testing mechanisms for FSW in Zambia. HIV self-testing has generally been shown to be acceptable in a variety of populations, however evidence related to its uptake and acceptability remain sparse, especially among key populations and in Sub-Saharan Africa. This research will provide rigorous evidence of the uptake and efficacy of HIV self-testing for this population. ZEST was designed to determine whether either direct distribution of HIV self-test kits via peer educators or distribution of HIV self-tests via coupons that participants can use to collect kits at collection points such as drug stores or health posts leads to better coverage of HIV testing and better awareness of HIV status. ZEST is a cluster-randomized trial in which peer educators recruit a small group of FSW participants, and the peer educator group is randomized to one of three study arms: 1) direct distribution of test kits, 2) fixed distribution of test kits, or 3) referral to standard of care HIV testing. The primary outcome is HIV testing in the past month measured at one and four months after the first peer educator visit (when the test kits or coupons are distributed in the intervention arms).

Official Title
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A Peer Educator-delivered HIV Self-testing Intervention for Female Sex Workers in Zambian Border Towns

Conditions
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HIV Infection

Intervention / Treatment
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* Other: Oral HIV Self-Testing


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: 18 years of age or older Female sex Reports exchanging sex (including vaginal, anal, and/or oral) for money or goods at least once in the past month Self-reported HIV negative with last HIV test at least 3 months OR HIV status unknown Permanent residence in the study town of enrollment (Kapiri, Livingstone, or Chirundu) Willing to be visited by and meet with assigned peer educator on a monthly basis over the 4-month study period Exclusion Criteria: Less than 18 years of age on the enrollment date Has not exchanged any form of sex in the past one month Self-reported to be living with HIV Self-reported HIV negative status and tested within the past 3 months Living in PopART catchment area (Livingstone only) Concurrently participating in another HIV prevention study Meets criteria but does not wish to participate Other

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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Female

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Diagnostic
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Direct Distribution<br>The direct distribution arm consists of peer educators directly distributing HIV self-test kits to participants. Peer educators will briefly describe HIV self-testing to participants but will not provide extensive training on the use of the test kit. Peer educators also provide referral to existing services for HIV testing. | Other: Oral HIV Self-Testing<br>* The Oral HIV Self-Test is an in-home test that uses an oral swab to collect samples of oral mucosa that is used to detect the presence of HIV antibodies. The test is read after 20 minutes by the user. The test can be done by an individual at any time and place of the user's choosing. The test is read visually.<br>* Other names: OraQuick HIV Self-Test;|
| Experimental: Fixed Distribution<br>The fixed distribution arm consists of peer educators distributing coupons to participants. The participants can then use the coupon to collect an HIV self-test kit at a participating distribution point, including drug stores, pharmacies, and health posts. Peer educators will briefly describe HIV self-testing to participants but will not provide extensive training on the use of the test kit. Peer educators also provide referral to existing services for HIV testing. | Other: Oral HIV Self-Testing<br>* The Oral HIV Self-Test is an in-home test that uses an oral swab to collect samples of oral mucosa that is used to detect the presence of HIV antibodies. The test is read after 20 minutes by the user. The test can be done by an individual at any time and place of the user's choosing. The test is read visually.<br>* Other names: OraQuick HIV Self-Test;|
| No Intervention: Referral to Existing Services<br>Peer educators will not provide HIV self-tests to participants. Peer educators will only provide referral to existing services for HIV testing. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| HIV testing in the previous month |  | One month from first intervention visit | 
| HIV testing in the previous month |  | Four months from first intervention visit | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Correct knowledge of HIV status |  | Four months from first intervention visit | 
| HIV self-test kit use in the two intervention arms |  | One month from first intervention visit | 
| HIV self-test kit use in the two intervention arms | In the intervention arms | Four months from first intervention visit | 
| Linkage to HIV care and confirmatory testing |  | One month from first intervention visit | 
| Linkage to HIV care and confirmatory testing |  | Four months from first intervention visit | 
| HIV risk perception and beliefs about acquiring HIV |  | One month from first intervention visit | 
| HIV risk perception and beliefs about acquiring HIV |  | Four months from first intervention visit | 
| HIV disclosure with sexual partners |  | One month from first intervention visit | 
| HIV disclosure with sexual partners |  | Four months from first intervention visit | 
| Condom use with commercial sexual partners since last visit |  | One month from first intervention visit | 
| Condom use with commercial sexual partners since last visit |  | Four months from first intervention visit | 
| Condom use with non-commercial sexual partners since last visit |  | One month from first intervention visit | 
| Condom use with non-commercial sexual partners since last visit |  | Four months from first intervention visit | 
| Average number of commercial sexual partners |  | One month from first intervention visit | 
| Average number of commercial sexual partners |  | Four months from first intervention visit | 
| Average number of non-commercial sexual partners |  | One month from first intervention visit | 
| Average number of non-commercial sexual partners |  | Four months from first intervention visit | 
| Intimate partner violence, including sexual, physical, or verbal |  | One month from first intervention visit | 
| Intimate partner violence, including sexual, physical, or verbal |  | Four months from first intervention visit | 
| HIV fatalism |  | One month from first intervention visit | 
| HIV fatalism |  | Four months from first intervention visit | 
| Self-reported self-efficacy as measured by the General Self Efficacy Scale |  | One month from first intervention visit | 
| Self-reported self-efficacy as measured by the General Self Efficacy Scale |  | Four months from first intervention visit | 
| Female sex worker empowerment as measured by Beattie et al 2014 |  | One month from first intervention visit | 
| Female sex worker empowerment as measured by Beattie et al 2014 |  | Four months from first intervention visit | 
| Pre-exposure prophylaxis preferences |  | One month from first intervention visit | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Female sex workers, HIV testing, HIV self-test