The Zambian Peer Educators for HIV Self-Testing (ZEST) Study: A randomized controlled trial of HIV self-test provision for female sex workers in Zambia

Background: HIV testing is the critical first step for realization of the 90-90-90 targets, which aim to have 90% of people living with HIV aware of their status, 90% of those linked to care, and 90% of those virally suppressed. However, HIV testing among female sex workers (FSWs) in sub-Saharan Africa remains below the 90% target. The objective of this study was thus to evaluate 1) the effectiveness of HIV self-test provision compared to standard of care HIV testing for increasing HIV testing coverage among FSW and 2) the effectiveness of two delivery models for HIV self-test provision. Methods: This study was a cluster randomized trial conducted in three transit towns in Zambia: Livingstone, Chirundu, and Kapiri Mposhi. FSWs were recruited by a peer educator. FSW-peer educator groups were randomized in a 1:1:1 ratio to one of three groups: 1) standard-of-care, which consisted of referral to existing HIV testing facilities 2) direct delivery of an HIV self-test kit from the peer educator to the participant or 3) distribution of a coupon from the peer educator, which could be used to collect an HIV self-test kit at a participating distribution point. Results: At one month, 94.9% and 84.4% of participants in the delivery and coupon arms reported testing for the past month, compared to 88.5% in the standard-of-care arm. Participants in the delivery arm were significantly more likely to report testing for HIV in the past month compared to the coupon arm but not compared with standard of care (Direct vs SOC: RR 1.07, P=0.29, Coupon vs SOC: RR 1.05 P=0.10, Direct vs Coupon RR 1.13, P=0.005). At four months, 84.1%, 79.8%, and 75.1% of participants reported testing for HIV in the past month in the delivery, coupon, and standard-of-care arms. There were no statistically significant differences in HIV testing at four months. Conclusion: Although HIV self-testing did not increase HIV testing, high reported use of HIV self-tests indicate that it is acceptable to FSWs in Zambia. Although directly providing the HIV self-test may increase use in the short-term, delivery models utilizing distribution via existing distribution points (e.g., clinics or pharmacies) will likely be successful in distributing kits.