Evaluation of community-led delivery of HIV self-testing in Malawi

Response to the HIV epidemic is a global health priority, with HIV a leading cause of morbidity and mortality in sub-Saharan Africa. The United Nations Fast-Track Strategy sets to accelerate reductions in incidence and AIDS-related deaths by 2030. Undiagnosed infection, especially among underserved population subgroups, continues to drive ongoing transmission and poorer outcomes from late diagnosis. This thesis evaluates the health, social, and economic impact of an alternative approach for providing HIV testing using community-led delivery of HIV self-testing. First, it includes a mixed methods systematic review and shows that community-led responses for communicable disease control can improve health behaviours, including for disease prevention, screening, and management. Second, a cluster-randomised trial was conducted to evaluate the effectiveness of community-led delivery of HIV self-testing in Malawi. The community-led HIV self-testing intervention was shown to increase HIV testing in adolescents, older adults, and men as well as population-level antiretroviral therapy initiation immediately following implementation. Additionally, the intervention was safe and associated with high uptake. Third, the economic costs and effects on HIV testing positivity were measured using a trial-based economic evaluation. The intervention was found to provide testing at a low additional cost but was unlikely to be cost effective in contexts with low prevalence of undiagnosed HIV. Lastly, pathways to impact were examined using causal mediation analysis. The intervention was reported to increase uptake of HIV testing directly through community contributions to service delivery rather than indirectly by modifying social and structural determinants. Collectively, this thesis shows that community-led delivery of HIV self-testing is an effective and cost-efficient strategy that enables communities to lead solutions for disease control. This thesis also provides insights on the value of community participation in public health and approaches to support their application in the delivery of novel self-care technologies.