HIV Self-testing Skyrockets Among Transgender Individuals in New Study

Compared with being offered standard testing services, offers of initial and repeat self-testing led to a 3.5-fold greater uptake of testing for HIV among transgender individuals in a new study out of England and Wales published in EClinicalMedicine. The London School of Hygiene & Tropical Medicine, University College London, and the Medical Research Council Clinical Trials Unit collaborated on the study.

Overall, from this subanalysis of 94 transgender men and 24 transgender women from the SELPHI randomized controlled trial (N = 10,135 cisgender men, transgender men, and transgender women), 93% in the self-testing group compared with 26% in the standard care/no self-testing group got tested for HIV. The median (interquartile range) baseline age was 29 (22-37) years, most (79%) were White or born in the United Kingdom (79%), and one-third (31%) had never been tested for HIV.

“Trans people are at increased risk of HIV and poor sexual health compared to other groups. They tend to test less often and have worse clinical outcomes when they are diagnosed with HIV,” the authors said in a statement. “Rolling out self-testing more widely and making sure it is accessible to trans people will increase HIV testing rates.”

Despite being legalized in the United Kingdom in 2014, the rollout of HIV self-testing has been sporadic, they added.

There were 2 rounds of randomization in the trial:

• 60/40 to free baseline HIV self-testing vs standard care/no self-testing (n = 118)
• 50/50 after 3 months (n = 20; 16 transgender men, 4 transgender women) to self-testing every 3 months or no repeat self-testing, with a 2-year follow-up

Following the 60/40 randomization, 95% (n = 36) of the transgender men in the baseline self-testing group who completed a 3-month survey had been self-tested for HIV compared with 29% (n = 6) in the baseline non–self-testing group (risk ratio [RR], 3.32; 95% CI, 1.68-6.55; P < .001). And during the subsequent 2-year follow-up for those randomized 50/50, there was a more than 3 times greater difference in testing uptake between the repeat-testing and non–repeat-testing groups (incidence rate ratio [IRR], 3.66; 95% CI, 1.86-8.01; P < .0001).

Analysis of a possible correlation between testing uptake for HIV and sexually transmitted infections (STIs) resulted in neutral findings. STI testing did not concurrently worsen, but it also did not improve across any of the study arms; instead, it remained low in the repeat-testing (0.03) and non–repeat-testing (0.01) groups (IRR, 1.86; 95% CI, 0.77-5.15; P = .15).

Additionally, most participants in the baseline self-testing group thought the instructions were easy to understand (97%) and the test was easy to use (97%), while all reported “a good overall experience.”

There were no HIV diagnoses in the 2-year follow-up, no false-positive results were reported, and none of the participants reported feeling pressured or persuaded to take a test.

“In interviews, reported HIV self-testing benefits included increased autonomy, privacy, convenience, and avoidance of health care providers perceived to be discriminatory and services that increased dysphoria,” the authors said.

“It should be noted that services designed specifically for trans people were very highly valued,” they added.

Research on self-testing from the United States and Latin America espouses its benefits, showing that transgender women are accepting of HIV self-testing and that providing this option in a private, convenient setting could increase its uptake. However, there are also global data showing that transgender individuals encounter care barriers many other patient groups do not, such as culturally insensitive services, health care provider hostility, and risk of arrest and imprisonment. Making self-testing more accessible to transgender individuals is of paramount importance.

“Future research and implementation activities should be attentive to developing innovative ways to engage trans people with HIV self-testing interventions that are specifically tailored to their needs,” the authors concluded. “Peer-led approaches are critical to achieving this.”

To help advance these goals, there should be investments in staff training, monitoring of current programs that provide HIV self-testing, and additional studies that investigate outcomes from tailoring self-testing initiatives to transgender individuals.

Reference

Witzel TC, Wright T, McCabe L, et al. Impact and acceptability of HIV self-testing for trans men and trans women: a mixed-methods subgroup analysis of the SELPHI randomized controlled trial and process evaluation in England and Wales. EClinicalMedicine. Published online February 11, 2021. doi:10.1016/j.eclinm.2020.100700