Home-Based HIV Testing Strategies for Older Adults in Rural South Africa: A Randomized Controlled Trial

Background: Many older adults in rural South Africa still lack knowledge of their HIV status despite a high burden of HIV in this population. HIV self-testing may offer a powerful approach to increase HIV testing in older populations. This study sought to evaluate the comparative effectiveness of three different home-based HIV testing strategies for older adults in rural South Africa.<br><br>Methods: We studied 2,963 individuals of the ‘Health and Ageing in Africa: a Longitudinal Study of an INDEPTH Community in South Africa (HAALSI)’ cohort study, who were randomized 1:1:1 to one of three types of home-based and home-delivered HIV testing modalities: (1) rapid testing with counseling; (2) self-testing, and (3) both rapid testing with counselling and self-testing. In modified Poisson and OLS regression analyses we estimated the treatment effects on HIV testing, HIV testing frequency, and potential adverse effects on dimensions of mental health, linkage to care, and risky sexual behavior.<br><br>Findings: There were no significant differences in HIV testing uptake or testing frequency across groups. However, respondents in the self-testing treatment arms were more likely to shift from testing at home and a facility (ST: RR 0.86, 95% CI 0.76 – 0.97; ST+RT+C: RR 0.85, 95% CI 0.75 – 0.95) to testing only at home (ST: RR 1.67, 95% CI 1.17 – 2.39; ST+RT+C: RR 1.62, 95% CI 1.13 – 2.32) in comparison to the treatment arm of rapid testing with counselling – suggesting a revealed preference for self-testing in this population. We also found no adverse effects from this testing strategy: treatment effects on linkage to care for HIV and comorbidities, recent sexual partners, or condom use were insignificant. Finally, being in the self-testing only arm significantly decreased depression scores by 0.58 points (95% CI: -1.16 – -0.01) on the CESD20 scale.<br><br>Interpretation: Our results indicate that HIV self-testing is a safe and seemingly preferred home-based testing option for older adults in rural South Africa, offering a promising policy tool in the effort to achieve the UNAIDS 95-95-95 target.<br><br>Trial Registration: The trial registration number is: ClinicalTrials.gov ID: NCT04131465<br><br>Funding: This work was supported by the National Institute on Aging at the National Institutes of Health (P01 AG041710), and is nested within the MRC/Wits Rural Public Health &amp; Health Transitions Research Unit (Agincourt) which is supported by the Wellcome Trust (058893/Z/99/A; 069683/Z/02/Z; 085477/Z/08/Z; 085477/B/08/Z), the University of the Witwatersrand, the South African Medical Research Council and the South African Department of Science and Technology (via the South African Population Research Infrastructure Network). <br><br>Declaration of Interest: None to declare. <br><br>Ethical Approval: Ethical approval was obtained from Harvard University's Institutional Review Board (protocol #IRB18-1214), the Human Research Ethics Committee at the University of the Witwatersrand (protocol #M180477), and Mpumalanga Province Research Ethics Committee (protocol #MP_201902_001).