Unassisted and assisted HIV self-testing among female sex workers, men who have sex with men, and priority populations before and during COVID-19 and political conflict in Mali

BACKGROUND: The USAID-funded EpiC Mali project supports the provision of HIV prevention and treatment services to key populations (KPs) (female sex workers (FSW) and men who have sex with men (MSM) and priority populations (PPs) (non-KPs at high risk). In collaboration with the UNITAID-funded ATLAS project, KP peer navigators create demand at hot spots, offer HIV self-testing (HIVST) following risk assessment and as part of index testing, and navigate individuals to confirmatory testing and treatment sites. In March 2020, Mali government issued a one-month curfew followed by other restrictions to control COVID-19, and political unrest, until September 2020.
DESCRIPTION: In October 2019, EpiC Mali began distributing HIVST kits to hard-to-reach KPs and PPs for unassisted use to increase case detection. During COVID-19 restrictions and political conflict, HIVST was further expanded to continue reaching high-risk KPs and PPs, in compliance with COVID-19 prevention measures, through contactless distribution, but now with increased provider assistance, and phone-based results follow-up.
LESSONS LEARNED: From October 2019 to September 2020, 11,579 HIVST kits were distributed. HIVST returns increased from 15% before COVID-19/political conflict to 72% post COVID-19/political conflict, particularly among KPs, although baseline return rate for PPs was four times higher than for KPs. The overall reactivity rate remained constant over time (KPs: 6%; PPs: 5%), but it decreased among MSM and increased among PPs. The contribution of HIVST to total HIV case finding increased from 4% to 13% (p< .01; OR 3.24; CI 2.36'4.45) (Table 1).

Table 1. HIVST cascade, October 1, 2019'September 30, 2020

Population	October 2019'March 2020 (Pre-COVID-19/Political Conflict)									April'September 2020 (during COVID-19/Political Conflict)									October 2019'September 2020 (Complete Time Period)
	HIVST kits distributed	HIVST returned	HIVST returned (%)	HIVST reactive	HIVST reactive (%)	HIVST reactive and confirmed positive	Total HIV positive (including reactive HIVST confirmed positive)	Reactive HIVST confirmed positive contribution to total HIV positive	HIVST distributed		HIVST returned	HIVST returned (%)	HIVST reactive	HIVST reactive (%)	HIVST reactive and confirmed positive	Total HIV positive (including reactive HIVST confirmed positive)	Reactive HIVST confirmed positive contribution to total HIV positive (%)	HIVST distributed		HIVST returned	HIVST returned (%)	HIVST reactive	HIVST reactive (%)	HIVST reactive and confirmed positive	Total HIV positive (including reactive HIVST confirmed positive)	Reactive HIVST confirmed positive contribution to total HIV positive (%)
FSWs	5,034	687	14%	39	6%	39	673	6%	4,550		3,328	73%	154	5%	115	1,042	11%	9,584		4,015	42%	193	5%	154	1,715	9%
MSM	847	116	14%	10	9%	10	151	7%	939		627	67%	39	6%	37	202	18%	1,786		743	42%	49	6%	47	353	13%
PP	130	81	62%	2	2%	2	214	1%	79		57	72%	22	39%	22	303	7%	209		138	66%	24	17%	24	517	4.6%
Total	6,011	884	15%	51	6%	51	1,265	4%	5,568		4,012	72%	215	5%	174	1,693	13%	11,579		4,896	42%	266	5%	225	2,958	8%

CONCLUSIONS: COVID-19 and political conflict provided the impetus to shift HIVST from unassisted to assisted, resulting in a fivefold increase in return rates and a continued high reactivity rate. Decreased reactivity among MSM could be due to less targeted HIVST kit distribution, while high baseline return rate and high reactivity rate at follow-up among PPs requires further analysis. The increased contribution to overall case finding highlights potential of HIVST, particularly when emergencies arise.