One in four Zambian men test positive for HIV in targeted testing initiative

An innovative initiative that combined community-based HIV testing with 'index testing' – where people who test positive are supported to inform their sexual partners so that they can also test – has reached large numbers of men who didn't know they were living with HIV.

HIV testing is lower among men than women in Zambia, with 25% of men living with HIV unaware of their status in 2018, compared to 15% of women. The problem is more acute among younger men, with over two-thirds of men living with HIV aged 25 to 29 undiagnosed.

To address this, the Community Impact to Reach Key and Underserved Individuals for Treatment and Support (CIRKUITS) project trained community health workers in rural and urban parts of Eastern, Western and Lusaka provinces to provide index testing and targeted community-based HIV testing, and link people to antiretroviral treatment (ART) and prevention services.

Testing was conducted in workplaces that mainly employ men, such as construction sites, police departments and utility companies. Testing was also provided in 'male‐dense' spaces, such as markets, taxi ranks, car washes, bus stations, sporting events, and insakas (village meetings). Churches, community centres, schools and pop-up testing sites also participated.

In the project's first year (2018 – 2019), 38,255 people tested for HIV with a roughly equal split between men and women. Just under a third of people (29%) tested HIV positive. Around half of those diagnosed with HIV were identified through index testing and half through community-based testing.

One in four men who took an HIV test had a positive result of whom 93% were linked to treatment, the same linkage level as women.

Most of the men diagnosed with HIV were aged 25 to 39 (60%), followed by those aged 40 to 49 (21%), those aged 15 to 24 (13%) and those aged 50 or older (6%).

More than 93% of people diagnosed with HIV provided information about their sexual partners to enable contact tracing. More than three‐quarters of those traced were unaware of their HIV status.

Index testing resulted in a 'higher positivity yield', which means it reached a higher proportion of people living with HIV than community-based testing, with 40% of men testing through this method receiving a positive result. This is the highest yield reported by any study to date and is much higher than the 18% yield achieved through CIRKUITS' community-based testing.

In terms of absolute numbers, index testing resulted in fewer men living with HIV being identified (2,186) than community‐based approaches (2,272).

It was also less successful at linking men to treatment as it resulted in 88% of men diagnosed with HIV accessing ART, compared to 98% of men diagnosed through community-based testing. This may be because community-based testing being offered immediate, on-site treatment initiation, whereas those diagnosed through index testing then had to go to a clinic. It may also reflect different levels of engagement as people reached through community-based testing more actively chose to test.

The research team behind the initiative said: "In CIRKUITS, we achieved high testing positivity among men primarily by engaging them where they were found, rather than expecting them to come to the facility. As we move towards achieving epidemic control, there is ever‐greater need to…reach men and other hidden populations."