An investigation of interventions to increase uptake of HIV self-testing and linkage to post-test services among higher education students in Zimbabwe

Adolescents and young people in Africa have the worst health outcomes of adolescents and young people globally, in large part because of the high rate of new HIV infections, particularly among young women. Despite this, young people are less likely to know their HIV status than older adults and as such are less likely to benefit from prevention and treatment options. The population of young Africans is set to double in the next 30 years meaning that if nothing is done to improve young people's access to HIV prevention and care, the number of new infections in young people will also double. This project targets young students attending higher education institutions with a novel intervention, HIV self-testing, aimed at improving their uptake of HIV testing and supporting them to take up prevention and care services. HIV self-testing, where people test themselves for HIV infection, has been shown to be safe and accurate and of importance here, highly acceptable to young people who desire privacy and autonomy when testing. I propose to compare the effectiveness and cost and cost effectiveness of two models of distributing HIV self-testing among students, in a trial where higher education institutions are allocated by chance to one of two distribution models. Outcomes include: i) uptake of self-testing, ii) linkage to HIV prevention and care services depending on their HIV result and, iii) cost per person tested, diagnosed positive and started on treatment or preventive service. The two HIV self-test distribution models to be compared are a peer-led plus mass-media supported model with a mass media only model. I will also develop an internet based tool to measure distribution of self-test kits and support and measure subsequent engagement with services. I will then explore how to adapt these self-testing models for young people to other settings (eg schools or workplaces) and to support prevention and care for other chronic diseases in young people (eg hypertension or poor mental health).

Adolescents and young people in Africa have the worst health outcomes of adolescents and young people globally, in large part because of the high incidence of HIV, particularly among young women. Despite this high incidence, young people are less likely to know their HIV status than older adults and as such are less likely to benefit from prevention and treatment options. Africa's impending demographic transition means that if nothing is done to improve young people's access to HIV prevention and care, the number of new infections in young people will double in the next 30 years. This implementation science proposal targets young people attending higher education institutions with a novel intervention, HIV self- testing, aimed at improving their uptake of HIV testing and subsequent engagement with prevention and care services. HIV self-testing, where people test themselves for HIV infection, has been shown to be safe and accurate and of importance here, highly acceptable to young people who desire privacy and autonomy when testing. I propose to compare the effectiveness and cost effectiveness of two distribution models of HIV self-testing among students in higher education, in a cluster randomised trial.

Higher education institutions will be the units of randomisation. Outcomes include: i) uptake of self-testing, ii) linkage to the appropriate post-test services and, iii) cost per person tested, diagnosed positive and started on treatment or preventive service. The two HIV self test distribution models to be compared are a peer-led plus mass-media supported model which will be compared with a mass media only model. I will also develop an mHealth tool to facilitate measurement of self-test kit uptake and support measurement of subsequent engagement to prevention and care. I will then explore how to adapt these self-testing models for young people into other settings and to support prevention and care for other chronic diseases in young people.

The proportion of people who are under 25 is large in Africa and is growing. Young Africans particularly young women are at high risk of HIV. They are least likely to know their status and as such cannot benefit from prevention and treatment options. Without improving access to prevention and care the number of new infections in young Africans is set to double in next 20 years. This proposal aims to test delivery of a novel technology (self-testing) to increase awareness of HIV status among students and promote linkage to HIV prevention and care in higher education institutions. It also will compare the cost effectiveness of two methods of delivering self-test kits and supporting linkage to treatment and prevention services. These models will be important in their own right - some students in higher education institutions are at particularly high risk but are also least likely to test. But if cost effective these models have the potential for adaptation to other settings including workplaces, schools, and community settings to increase status awareness in this important population. In addition, they have the potential to be adapted as tools to support prevention and care for other chronic diseases in young people.

The mHealth tool that will be developed in the study will benefit Ministry of Health and its implementing partners, who will have a tool for facilitating accurate measurement of uptake of services, with collection of accurate telephone contact details to enable measurement of linkage to post-test services. This tool has potential to be used for various health interventions in developing country settings.