The electronic search strategy identified 22 446 references (Figure 1). Title screening resulted in the exclusion of 19 274 articles. Fourteen duplicates were removed, leaving 3 158 articles which then underwent abstract screening, resulting in the further exclusion of 3 087 articles. We assessed the full text of 71 articles and excluded 56 of them for the following reasons: six were opinion/commentary papers, five were study protocols, and 45 did not present evidence on HIVST and linkage to HIV care among men in sub-Saharan Africa. Therefore, 15 articles met our inclusion criteria and were included in this review.
The characteristics of included studies
The included studies were conducted in the following countries: Zambia (43), Malawi (26, 44, 45), Tanzania (46), Uganda (47-50), South Africa (51-54), and Kenya (55, 56). There were seven quantitative studies, seven qualitative studies, and one mixed methods study. This review included studies published from January 2005 to January 2022. Our search excluded studies conducted prior to 2005 because they were unlikely to reflect key aspects and information pertaining to the use of the HIVST model in SSA. All of the included studies were published after 2015. Details of the included studies are presented in Table 2, with the quality assessment presented in Appendix Table 1.
Table 2: Characteristics of included studies
Author & year
|
Country
|
Study aim
|
Sample
/population
|
Number of participants
|
Age group
|
Research Method
|
Key finding(s)
|
Qualitative studies
|
|
|
|
|
|
|
|
Muwanguzi et al, 2021
|
Uganda
|
To explore employed professional men’s preferences for uptake of HIV self-testing, and linkage to HIV care, or prevention services.
|
Males
|
33
|
18-55 years
|
Qualitative (interviews)
|
Incentives could be used to improve the rates at which men are linked to HIV care following a reactive HIVST result
|
Rujumba et al, 2021
|
Uganda
|
To explore perceptions of pregnant and lactating women, their male partners and health care providers regarding both initial and repeat HIV self-testing for women and their male partners during pregnancy and lactation in Kampala and generated suggestions for potential integration and scale-up of HIV self-testing in PMTCT programs.
|
Males &
females
|
22 females
12 males
23 health care providers
|
24-40 years
|
Qualitative
(interviews & focus group discussions)
|
Concern that, in addition to confidentiality concerns and stigma, the lack of active linkage to care systems could be another barrier to timely linkage
|
Matovu et al, 2020
|
Uganda
|
To generate data necessary to inform the design of a peer-led HIV self-testing (HIVST) intervention intended to improve HIV testing uptake and
linkage to HIV care in Kasensero fishing community in rural Uganda.
|
Males &
females
|
16 females
31 males
|
15 years & older
|
Qualitative
(focus group discussions)
|
Men preferred a home visit from a health care provider as a follow up strategy to encourage them to confirm reactive HIVST results and link to HIV care
|
Conserve et al, 2018
|
Tanzania
|
To assess men's attitudes and personal agency towards HIV self-testing (HIVST) and confirmatory HIV testing in order to inform the development of the Tanzania STEP (Self-Testing Education and Promotion) Project, a peer-based HIV self-testing intervention for young men in Tanzania
|
Males
|
23
|
Mean age: 27.3 years
|
Qualitative (interviews)
|
Men preferred phone call reminders over SMS reminders after HIVST
|
Choko et al, 2017
|
Malawi
|
To describe the views of pregnant women and their male partners on HIV self-test kits that are woman-delivered, alone or with an additional intervention.
|
Males & females
|
31 females
31 males
|
Median age for men: 28.5 years; women: 23.5 years
|
Qualitative (focus group discussions & in-depth interviews)
|
Men felt that providing a fixed financial incentive of approximately USD$2 would increase linkage to HIV care following a reactive HIVST result
|
Martinez Perez et al, 2016
|
South Africa
|
To examine the feasibility and acceptability of unsupervised oral self-testing for home use in an informal settlement of South Africa.
|
Males
|
11 - females;
9 - males
|
18 years & older
|
Qualitative (couple interviews, in-depth interviews, focus group discussions)
|
Healthcare providers’ home visits may deter future utilization of HIVST. Concern that home visits could potentially stigmatize HIVST clients who are labelled as HIV infected
|
Makusha et al, 2015
|
South Africa
|
To explore: interest in HIV self-testing; potential distribution channels for HIV self-tests to target groups; perception of requirements for diagnostic technologies that would be most amenable to HIV self-testing and opinions on barriers and opportunities for HIV-linkage to care after receiving positive test results
|
Males & females
|
2: Government Officials; 4: NGOs; 2: Donors; 3 Academic Researchers; 1 Int. stakeholder
|
18 years & older
|
Qualitative (in-depth interviews)
|
Some of the barriers to linkage to HIV care after a reactive HIVST result pertain to the lack of a personal referral system
|
Quantitative studies
|
|
|
|
|
|
|
|
Sithole et al, 2021
|
South Africa
|
To investigate whether HIVST distribution was a feasible approach to reach men and assessed the proportion of participants who reported their HIVST results, tested positive and linked to care
|
Males
|
2 634 - males
|
Median age: 27 years (IQR 22 to 33).
|
Quantitative
|
65% (102/157) and 70% (110/157) of men were linked to ART after a reactive HIVST result. Men who received an HIVST kit at a place other than the workplace or mobile van [AOR 3.58 95%CI (1.30–14.84), p = 0.033] and those with a secondary level of education or above [AOR 1.34 95%CI (1.00–1.78), p = 0.046] were more likely to report their HIVST results
|
Shapiro et al, 2020
|
South Africa
|
To understand whether HIVST distribution is feasible to engage men in testing, to determine the yield of HIV detection and linkage to care for men by providing HIVST in South African communities and to determine predictors of retention along the HIV cascade for men who use HIVST, in order to better optimize engagement for men
|
Males & females
|
4307 – males
189 - females
|
18 years & older
|
Quantitative (implementation)
|
72% of men with a reactive HIVST result received a confirmatory test, with 95% of these linking to ART. Overall linkage was confirmed for 68% of HIV diagnosed men.
|
Korte et al, 2020
|
Uganda
|
To evaluate the impact of offering HIVST to
male partners of ANC clients, with immediate relevance for public health policymaking in Uganda
|
Male partners of pregnant women attending ANC
|
1 455
|
18 years & older (mean age (SD) was 32.2 (8.1) years)
|
Quantitative (Cluster-randomized controlled trial)
|
23% (n=6/26) of men in the intervention vs 66.7% (n=4/6) in the control arm were linked to HIV care following a reactive HIVST result.
|
Choko et al, 2019
|
Malawi
|
To investigate the impact of HIVST alone or with additional interventions on the uptake of testing and linkage to care or prevention among male partners of antenatal care clinic attendees in a novel adaptive trial
|
Male partners of pregnant women attending ANC
|
2 349 - males
|
Mean age: 30 years
|
Quantitative (Cluster-randomized controlled trial)
|
91.3% (42/46) of men were linked to ART following a reactive HIVST result.
|
Thirumurthy et al, 2016
|
Kenya
|
To assess an approach of providing multiple self-tests to women at high risk of HIV acquisition to promote partner HIV testing and to facilitate safer sexual decision making.
|
Male partners of sex workers and women receiving antenatal and post-partum care
|
280
|
18-39 years
|
Quantitative (Cohort)
|
56% (23/41) of men were linked to HIV care following a reactive HIVST result.
|
Masters et al, 2016
|
Kenya
|
To determine whether providing multiple HIV self-tests to pregnant and postpartum women for secondary distribution is more effective at promoting partner testing and couples testing than conventional strategies based on invitations to clinic-based testing
|
Male partners of pregnant women attending ANC
|
570
|
18 years & older
|
Quantitative (Randomized clinical trial)
|
25% (2/8) were linked to ART following a HIVST reactive result.
|
Choko et al, 2015
|
Malawi
|
To evaluate uptake, accuracy, linkage into care, and health outcomes when highly convenient and flexible but supported access to HIVST kits was provided to a well-defined and closely monitored population
|
Males & females
|
7 868 –females
6 124 – males
|
16 years & older
|
Quantitative (Prospective - within a cluster-randomised trial)
|
Linkage to HIV care after a reactive HIVST result was at 56.3% (524/930)
|
Mixed methods
|
|
|
|
|
|
|
|
Chipungu et al, 2017
|
Zambia
|
To examine the intention to link to care amongst potential HIVST users and the suitability of three linkage to care strategies in Lusaka Province, Zambia
|
Males & females
|
Quantitative: 1 617 (60% females, 40% males)
Qualitative: 64 participants
|
16-49 years
|
Mixed methods: Quantitative (cross sectional survey) & qualitative (focus group discussions)
|
82% (533/647) of men were willing to link to ART within the first week after a reactive HIVST result
|
Key themes
We identified three main themes: evidence on linkage to HIV care following a reactive HIVST result; barriers to linking to HIV care following a reactive HIVST result; and strategies to increase linkage to care following a reactive HIVST result.
Evidence on linkage to HIV care following a reactive HIVST result
Evidence on linkage to HIV care following a reactive HIVST result was presented in 12 studies (seven quantitative, four qualitative, and one mixed methods). In Zambia, 82% (n=533/647) of men reported willingness to link to care within the first week after a reactive HIVST result (43). A recent study of 3 486 men conducted in South Africa showed that as high as 72% of men with a reactive HIVST result received a confirmatory test, and nearly all (95%) who were confirmed to be HIV positive were subsequently linked to HIV care and initiated ART (53); overall, 68% of men with a reactive HIVST result were linked to confirmatory testing and initiated ART successfully. In a study conducted in KwaZulu-Natal, South Africa, linkage to HIV care was confirmed for 65% (n=102/157) within seven months of testing and 70% (n=110/157) within 15 months of testing, among men who reported their results (54).
In Malawi, studies of secondary distribution of HIVST kits to male partners by women attending antenatal care found evidence of favorable opinions toward linkage to HIV care after a reactive HIVST result (44), especially when conditional financial incentives were included (45). In another Malawi study, among 676 HIVST male partners of antenatal care clinic attendees who attended a male-friendly clinic (i.e., a clinic designed specifically for men and/or with male staff), 46 (6.8%) had a newly confirmed reactive HIVST result, all of whom were referred for ART; of these, 42 (91.3%) were linked to HIV treatment on the same day as their HIV diagnosis (45).
In the Zambia study, linkage to HIV care was lower among men receiving HIV testing for the first time compared with men who had prior HIV testing experience (adjusted odds ratio [AOR] = 0.54; 95% confidence interval [CI]: 0.32 to 0.91; p=0.02), and was also lower among men with high incomes compared with men who had lower incomes (AOR = 0.59; 95% CI: 0.40-0.88; p=0.009) (43). While linkage to HIV care after a reactive HIVST result has been high in some studies, in a study conducted in Malawi, the authors estimated a much lower rate of linkage to HIV care after a reactive HIVST result (56.3%, n=524/930) (26). In Kenya, 63% (n=26/41) of participants with a reactive HIVST result sought confirmatory testing, and 56% (n=23/41) of those were linked to HIV care within three months (56). Lower rates of linkage to HIV care after a reactive HIVST result were reported in Kenya, where only 25% (2/8) of men with a reactive HIVST result obtained confirmatory testing and subsequently linked to HIV care (55). Similarly, only 23% (n=6/26) of men who were HIVST reactive in Uganda were linked to HIV care in the intervention arm compared with 66.7% (n=4/6) in the control arm (47).
In Zambia, the participants demonstrated an understanding that getting a confirmatory HIV test, seeking advice and starting ART was indicated after a reactive HIVST result, especially because some people may require more support and counselling, as echoed by a Zambian man:
“If a person is positive they need to find people who can help [them], so that they can be comforted and not have the feeling of saying ‘why have I been found positive or what can I do” [(43), p. 7].
A study in Tanzania found that men’s positive attitudes towards seeking confirmatory HIV testing and linkage to HIV care were motivated by the availability of lifesaving treatment (46):
“Truly if I see two lines [reactive HIVST results] have appeared I will be ready to move from this place to the responsible place to verify my results”. [(46), p. 8].
In another study, conducted among male partners of antenatal care clinic attendees, men felt that providing a fixed financial incentive of approximately USD$2 would increase linkage to HIV care following a reactive HIVST result, (44), citing the possibility that such a strategy would be used for transport costs, removing a crucial economic barrier:
“When you come to the clinic, you spend the whole day with no food for today. Providing a high financial incentive would encourage other male partners, upon hearing that their friend just got food for the day by simply going to the clinic”. [(44), p. 6].
However, also important to note is that these men would still have to deal with issues preventing them from attending an HIV clinic, including stigma and confidentiality concerns, long waiting times, lack of paid leave to attend clinic, and limited clinic operating hours (46, 53).
Some of the barriers to linkage to HIV care after a reactive HIVST result pertain to the lack of a personal referral system for linking people to HIV care (51). Setting up an efficient monitoring and evaluation programme for HIVST is important, as well as the provision for adequate follow up after a reactive HIVST result (51, 52).
Barriers to linkage to HIV care following a reactive HIVST result
Evidence on the barriers associated with linkage to HIV care following a reactive HIVST result was presented in six studies. These consisted of three quantitative studies, two qualitative studies and one mixed methods study. Studies conducted in Zambia, Uganda, Malawi and South Africa indicated that men of limited financial means may not obtain confirmatory HIV testing and/or initiate ART due to financial constraints or travelling costs (43, 45, 47). In a study conducted in Uganda, participants suggested that incentives could be used to improve the rates at which men are linked to HIV care following a reactive HIVST result:
“Why would I want to take an HIV test? There must be a reason why, especially if you want me to take it at the office. But if you put a test and said those who take the test and go for treatment will be given something, then I would be willing to participate.” [(50), p. 8].
“You could even motivate them that you will give them a reward when they bring back the results or when they go for other services. For example, circumcision or when they start on treatment if they test positive.” [(50), p. 9].
Choko et al. (26, 45) also indicated that, while there is high readiness to engage in HIVST, optimal systems for linking clients to HIV care are not well established in Africa.
Additional barriers to linkage to HIV care include the potentially long wait times at the clinics, stigma, discrimination, and privacy concerns (46, 47). In a study conducted in Kampala, Uganda, some men expressed concern that, in addition to confidentiality concerns and stigma, the lack of active linkage to care systems could be another barrier to timely linkage:
“In case he tested himself he will not encourage himself to go to the clinic and start taking ARVs. Some people will not even know which hospital to go to for treatment. Some fear going to hospitals near their homes because they do not want to be known” [(48), p. 11].
Strategies to increase linkage to care following a reactive HIVST result
Evidence about the most appropriate strategies for increasing follow up after HIVST was reported in eight studies (43-46, 49, 50, 52, 54). These consisted of five qualitative studies, two quantitative studies, and one mixed methods study. A study conducted in Zambia indicated that more than half (51%; n=328/647) of men preferred a home visit from a health care provider as a follow up strategy for confirming reactive HIVST results and linking to HIV care, citing the enhanced privacy, greater trust, and more effective communication they perceived with home visits compared with health facilities (43). This finding was consistent with the findings from a study conducted in Rakai, Uganda, although study participants also noted concerns over potential breaches of confidentiality that could result from home visits:
“In my opinion it’s a good [idea] because no transport cost is involved by self-tested individuals. However, if community members become aware that a medical worker always visits a certain person in the village, they become suspicious that the person is HIV positive which may make the one [who] obtains ARVs from his home uncomfortable” [(49), p. 11].
In another study conducted in Uganda during the COVID-19 pandemic, men indicated that follow up telephone calls from health care providers would be preferred, due to their busy schedules and fears of COVID-19:
“I think the phone can be used for follow-up and support after getting one’s test results. In this era of COVID and with our busy schedules it's very hard for me to keep going to the facility, but if I have somebody to continually offer guidance and information, I think it makes it easier.” [(50) ,p. 8].
In the Zambian study, 31% (n=203/647) of men preferred a phone call and 18% (n=116/647) preferred SMS reminders (43). One man reported:
“I think both modes (phone and home visit) of talking to your counsellor are important, but if you want an effective communication, its better people come to your home so that you build trust and strong relationship” [(43), p. 8].
In a study conducted in Malawi among men with partners attending antenatal care, follow up phone call reminders were preferred, and these increased linkage to HIV care among men who received HIVST kits from their partners (44, 45). Phone call reminders after HIVST were also preferred over SMS reminders in Tanzania (46). In a study conducted in South Africa, confirmatory testing and linkage to HIV care after a reactive HIVST result were low, despite telephone reminders and home visits, because some participants could not be reached at home or by telephone. Following up with SMS reminders after HIVST was not perceived as effective for improving linkage to HIV care, because some people simply ignored them due to an influx of spam messages (44). Attempts by healthcare providers to provide repeated follow ups may deter future utilization of HIVST if these attempts are thought to compromise the autonomy of HIVST clients (52). Some have also voiced concern that home visits could potentially stigmatize HIVST clients who are labelled as “HIV infected” (52).
A study conducted in KwaZulu-Natal, South Africa, indicated that men who received an HIVST kit at a place other than the workplace or mobile van [AOR 3.58 95%CI (1.30–14.84), p = 0.033] and those with a secondary level of education or above [AOR 1.34 95%CI (1.00–1.78), p = 0.046] were more likely to report their HIVST results (54). In Rakai, Uganda, men suggested that peers could be used to encourage men with a reactive HIVST result to seek confirmatory results and, if confirmed to be HIV positive, link to HIV care as soon as possible:
“A peer educator can intervene and take HIV treatment to the homes of the self-tested individuals… [The use of a peer-leader] could be effective because the peer leader can reach his colleague who self-tested HIV positive without informing others… it is better if they get linked through the peer leader who distributed the kits.” [(49), p.11].