What role do community-level factors play in HIV self-testing uptake, linkage to services and HIV-related outcomes? A mixed methods study of community-led HIV self-testing programmes in rural Zimbabwe

Community-led interventions, where communities plan and lead implementation, are increasingly adopted in public health. We explore what factors may be associated with successful community-led distribution of HIV self-test (HIVST) kits to guide future service delivery.

Twenty rural communities were supported to implement month-long HIVST kit distribution programmes from January-September/2019. Participant observation was conducted to document distribution models. Three months post-intervention, a population-based survey measured: self-reported new HIV diagnosis; self-reported HIVST uptake; self-reported linkage to post-test services; and viral load. The survey included questions for a composite measure of ‗community cohesion‘. Communities were grouped into low/medium/high based on community cohesion scores. We used mixed effect logistic regression to assess how outcomes differed by community cohesion. In total, 27,812 kits were distributed by 348 distributors. Two kit distribution models were implemented: door-to-door distribution only or distribution at venues/events within communities. Of 5,683 participants surveyed, 1,831 (32.2%) received kits and 1,229 (67.1%) reported using it; overall HIVST uptake was 1,229/5,683 (21.6%). Self-reported new HIV diagnosis increased with community cohesion, from 32/1,770 (1.8%) in the lowest cohesion group to 40/1,871 (2.1%) in the medium group, adjusted odds ratio (aOR) 2.94 (1.41-6.12, p=0.004) and 66/2,042 (3.2%) in the highest cohesion group, aOR 7.20 (2.31-22.50, p=0.001). Other outcomes did not differ by extent of cohesion.

HIVST kit distribution in high-cohesion communities was associated with seven times higher odds of identifying people with new HIV diagnoses, suggesting more cohesive communities may better identify those most at risk of undiagnosed HIV. Communities can learn from and adopt these participatory community-led approaches to intervention planning and implementation, which may foster cohesion and benefit public health programmes.