HIV self-tests, available over-the-counter at pharmacies in the United States since 2012,1 offer a convenient and private way to test for HIV and have been shown to increase the frequency of HIV testing among men who have sex with men (MSM) in clinical trials.2–4 However, cost and access may limit use outside research settings.5–8 To address these barriers, the New York City (NYC) Health Department conducts the online Home Test Giveaway, in which HIV self-test are purchased in bulk at a reduced cost by the NYC Health Department and are mailed at no cost to cisgender MSM and transgender and gender-nonconforming (TGNC) individuals who have sex with men. In NYC, where there are approximately 2000 new HIV diagnoses annually, these groups are among those with the highest HIV burden, especially those who are black or Latino/a.9 We describe the Home Test Giveaway 2015–2018, including the intervention's process and outcome measures.
MATERIALS AND METHODS
The Home Test Giveaway intervention and its recruitment were informed by focus groups with community stakeholders. Recruitment of MSM and TGNC individuals occurred through paid digital advertisements displayed on social media and mobile dating applications, and websites across 5 “waves” (Appendix Fig. 1). Each wave consisted of limited-time advertising campaigns (wave 1 [“pilot”]: November 2015–December 2015; wave 2: June 2016–August 2016; wave 3: November 2016–January 2017; wave 4: May 2017–July 2017; wave 5: December 2017–February 2018). Advertisements hyperlinked to an eligibility questionnaire.
After wave 1 (the pilot), subsequent waves incorporated innovations in response to findings and discussions with stakeholders. This included broadened marketing across web platforms (waves 2–5), images of TGNC individuals in advertisements (waves 4–5), and Spanish-language materials (waves 3–5). Recruitment was expanded in collaboration with New York State (NYS) Department of Health to NYC-adjacent counties (wave 3) and statewide (waves 4–5; data not shown here).10
Eligibility was limited to MSM or TGNC living in NYC who reported sex with men in the past 12 months, were 18 years or older, and had no prior HIV diagnosis. The eligibility questionnaire also captured information on race/ethnicity and HIV testing history (ever/never tested, time since last test). Eligible respondents were e-mailed a “discount code” to be redeemed on the manufacturer's website for a free HIV self-test (Orasure Technologies, Bethlehem, PA). Efforts were made to provide only one discount code per person per wave (e.g., through deduplication by e-mail address), with no such restriction across waves. Eligible respondents could redeem their discount code for up to 2 weeks after the close of advertising.
Receipt of HIV Self-Test
HIV self-tests were mailed in nondescript packaging directly from the manufacturer, accompanied by informational inserts developed by NYC Health Department on HIV testing and preexposure and postexposure prophylaxis (Appendix Fig. 2); specifically, these inserts addressed the window period of the test, symptoms of acute HIV and how to pursue testing in that context, basic information about preexposure and postexposure prophylaxis, and how to access them.
Approximately 2 months after each wave of HIV self-test distribution concluded, eligible respondents were e-mailed a link to an online follow-up survey and asked to complete it within 4 weeks. Survey completion was incentivized with a $25 gift card, and reminder e-mails were sent with the survey link. The follow-up survey included questions about sociodemographics (education, annual income, health insurance); information on the Home Test Giveaway study flow (received self-test, used self-test), HIV self-test result, and, if appropriate, confirmatory testing and HIV care; and to self-test users, feedback on the Home Test Giveaway experience (how soon used self-test, tested sooner because of Giveaway, likelihood of recommending Giveaway to friends) and feedback on self-test use (what respondent liked about it, how much they are willing to pay for HIV self-test).
Analyses presented here include measures of process (study flow and respondents' characteristics) and outcomes (respondents' HIV self-test results and experience with the Home Test Giveaway). For most key measures, we present simple means across the 5 waves of Home Test Giveaway (“mean”) of frequencies (∑(N)/5) and percents (∑[(n/N) × 100)]/5), as well as ranges across the 5 waves (“range”). For the outcomes measure of self-test results, data are presented as the proportion of total tests reported through the follow-up surveys. Data analyses were conducted using SAS Analytics Software 9.4.
The Home Test Giveaway project was reviewed and approved by the NYC Health Department Institutional Review Board.
Home Test Giveaway Study Flow
Across 5 waves, there were 466,954 click-throughs from online advertisements to the eligibility questionnaire (mean, 93,391; range, 39,605–115,337) resulting in 28,921 responses to the eligibility questionnaire (6% of clicks) and 17,383 eligible responses (60% of all responses; Fig. 1, Appendix Table 1). The most common reason for ineligibility was residency (outside NYC for waves 1–2, outside NYC and NYS for waves 3–5). Among eligible responses, there were 12,182 discount code redemptions for a free HIV self-test (70% of eligible responses) and 7935 responses to the follow-up survey (46% of eligible responses). Among follow-up survey responses, 7336 reported receiving a self-test (92% of follow-up survey responses), and among them, 5903 reported using the self-test to test themselves (80% of those who reported receiving a self-test). Among those who did not use the self-test, 5% reporting using the test for someone else and 14% reported not using the test. Among the latter, 90% reported that they planned to use it in the future.
Characteristics Throughout Home Test Giveaway Study Flow
Table 1 displays the distribution of demographic characteristics of respondents across the Home Test Giveaway study flow. Among eligible respondents, most were either 18 to 24 years old (mean, 23%) or 25 to 35 years old (mean, 49%) and cisgender-men (mean, 97%); approximately half were Latino/a (mean, 32%) or non-Latino/a black (mean, 17%). Mean report of never testing before the Home Test Giveaway was 16% (range, 14%–21%), and last test >1 year ago was 21% (range, 17%–28%). Among eligible respondents who also responded to the follow-up survey, a majority had college education or more (mean, 62%), approximately half had an annual income of <$40,000 (mean, 49%), and one quarter were uninsured (mean, 23%). Respondent demographic characteristics were relatively similar to the eligible respondents across the study flow (redeemed a code for an HIV self-test, responded to the follow-up survey, reported using the test).
HIV Self-Test Results and Care From Follow-Up Survey
Among all follow-up responses, 43 reported reactive results (0.73% of HIV self-tests used), of whom 32 reported no known previous HIV diagnosis (0.54%; approximately 1 in 185 self-tests; Appendix Table 2). Among those with no known previous diagnosis, 25 (78%) reported receiving confirmatory testing, of whom 84% reported receiving a confirmatory positive result, of whom 95% had their first HIV care appointment and, of whom, 85% had started treatment at the time of the follow-up survey.
Home Test Giveaway and HIV Self-Test Feedback From Follow-Up Survey
Most follow-up survey respondents who used the HIV self-test reported use within 1 week of receipt (mean, 71%; range, 68%–73%) and testing sooner or for the first time because of the Home Test Giveaway (mean, 70%; range, 64%–76%). Report of likelihood of recommending the Home Test Giveaway to friends was high (mean, 96%; range, 92%–98%). Respondents reported liking the privacy (mean, 71%; range, 62%–83%) and convenience (mean, 68%; range, 59%–91%) of home testing, although fewer would be willing to pay the estimated retail cost of $40 for an HIV self-test (mean, 30%; range, 22%–39%).
Between 2015 and 2018, we consistently recruited and distributed a large number of HIV self-tests to individuals in groups who are disproportionately affected by HIV in NYC9: MSM and TGNC who have sex with men. In addition, almost half of eligible respondents were either black or Latino, most were younger than 35 years, and more than a third of whom had not tested in the last year. Follow-up survey respondents reported self-test results and high levels of follow-up among those with reactive results. Positive feedback from respondents suggests that this is one acceptable way to reach MSM and TGNC persons for HIV testing.
This Home Test Giveaway intervention demonstrated consistent distribution of a large number of HIV self-tests over a relatively short period through online recruitment, with substantial follow-up participation. Other methods for free HIV self-test distribution to MSM in the literature include vouchers,11 vending machines,12 bathhouses,13 and social networks.14,15 All of these methods have the potential benefit of finely tuned recruitment to individuals who may be at increased risk of acquiring HIV, including those who may not be online. Our study and others have found that reaching MSM to distribute HIV self-tests through online advertisements16,17 or applications18 is feasible and can allow for a wider distribution of HIV self-tests rapidly. Although almost half of eligible respondents in the Home Test Giveaway were either black or Latino/a, a proportion similar to other HIV prevention programs in NYC,19,20 throughout the waves described here and ongoing, we have worked with stakeholders to improve participation level of these priority populations. In addition, although the Home Test Giveaway program was able to recruit TGNC respondents, other recruitment strategies may be needed to increase participation, which could include respondent-driven sampling21 and greater collaboration with organizations that support TGNC.
The consistent proportion of respondents who reported never testing has been considered a key indicator of the Home Test Giveaway's success. At an average of 16%, the proportion of never-tested respondents exceeds estimates from the National HIV Behavioral Surveillance 2017 surveys conducted among MSM across 23 US cities (range, 0.08%–11.6%; 3.1% in NYC).22 The proportion of never-tested individuals in the Home Test Giveaway was also greater than what was reported by MSM and TGNC clients of NYC's municipally funded Sexual Health Clinics23 in 2017 (5.6%; K. Jamison, personal communication) and of NYC-funded clinical and nonclinical HIV prevention programs24 in 2018 (3.5%; A. Merges, personal communication). Although the Home Test Giveaway data were self-reported and therefore subject to recall error and social desirability bias, other programs that have distributed HIV self-tests online have also found relatively high proportions of never-tested individuals (9%16, 12.8%17).
HIV self-test users reported their test results in follow-up survey responses across 5 waves. Although the rate of first-time positive results may not seem to be high, it is within the range of new diagnosis rates reported by US health department–supported, Centers for Disease Control and Prevention–funded testing programs in 2017: those in non–health care settings had a new diagnosis rate of 0.6% overall and 2% among MSM; in health care settings, it was 0.3% (rate among MSM unknown).25 The Home Test Giveaway data on HIV self-test results were from follow-up survey responses only, and thus, we do not know the results of all self-tests distributed or if the follow-up survey respondents were representative of all self-test users in the Home Test Giveaway, although the distribution of demographic characteristics was similar to those who were sent a self-test. Of those who reported reactive test results, rates of linkage to confirmatory testing and care were relatively high.
MSM and TGNC were encouraged to test for HIV through the Home Test Giveaway, a modality meant to complement the existing HIV testing programs in NYC. This method of free HIV self-tests can be adapted to other settings, with similar methods currently implemented in NYS,10 Virginia,26 and other jurisdictions. Cost of the self-test has been shown consistently to be a barrier for use, and this intervention helps surmount this for participants and transfers the financial burden to the public health entity conducting the program. In the cases where additional modifications may be needed to minimize programmatic costs, this can include advertising through different means (e.g., through social media posts or community-based organizations), limiting self-test purchase by prioritizing those in greatest need, and reducing use of follow-up survey incentives (e.g., by holding a raffle). Modifications needed to reach different populations should be explored with input from community stakeholders. Interventions such as this one help address the HIV diagnosis pillar of the national Ending the HIV Epidemic plan27 and should be considered as additional funds become available for implementation of this plan.
1. Food and Drug Administration. July 3, 2012 Approval Letter, OraQuick In-Home HIV Test. 2012. Available at: https://www.fda.gov/vaccines-blood-biologics/approved-blood-products/july-3-2012-approval-letter-oraquick-home-hiv-test
. Accessed January 5, 2020, 2020.
2. Jamil MS, Prestage G, Fairley CK, et al. Effect of availability of HIV self-testing on HIV testing frequency in gay and bisexual men at high risk of infection (FORTH): A waiting-list randomised controlled trial. Lancet HIV 2017; 4:e241–e250.
3. Katz DA, Golden MR, Hughes JP, et al. HIV self-testing increases HIV testing frequency in high-risk men who have sex with men: A randomized controlled trial. J Acquir Immune Defic Syndr
. 2018; 78:505–512.
4. Johnson CC, Kennedy C, Fonner V, et al. Examining the effects of HIV self-testing compared to standard HIV testing services: A systematic review and meta-analysis. J Int AIDS Soc
. 2017; 20:21594.
5. Myers JE, Bodach S, Cutler BH, et al. Acceptability of home self-tests for HIV in New York City, 2006. Am J Public Health 2014; 104:e46–e48.
6. Myers JE, El-Sadr Davis OY, Weinstein ER, et al. Availability, accessibility, and price of rapid HIV self-tests, New York City pharmacies, summer 2013. AIDS Behav 2017; 21:515–524.
7. Nunn A, Brinkley-Rubinstein L, Rose J, et al. Latent class analysis of acceptability and willingness to pay for self-HIV testing in a United States urban neighbourhood with high rates of HIV infection. J Int AIDS Soc
. 2017; 20:21290.
8. Lippman SA, Moran L, Sevelius J, et al. Acceptability and feasibility of HIV self-testing among transgender women in San Francisco: A mixed methods pilot study. AIDS Behav 2016; 20:928–938.
9. HIV Epidemology and Field Services Program. HIV Surveillance Report. New York, NY: New York City Department of Health and Mental Hygiene, 2017. November 2018.
10. Johnson MC, Chung R, Leung SJ, et al. Combating stigma through HIV self-testing: New York State's HIV Home Test Giveaway Program for sexual minorities [published online ahead of print February 3, 2020]. J Public Health Manag Pract
11. Marlin RW, Young SD, Bristow CC, et al. Piloting an HIV self-test kit voucher program to raise serostatus awareness of high-risk African Americans, Los Angeles. BMC Public Health
. 2014; 14:1226.
12. Stafylis C, Natoli LJ, Murkey JA, et al. Vending machines in commercial sex venues to increase HIV self-testing among men who have sex with men. Mhealth 2018; 4:51.
13. Woods WJ, Lippman SA, Agnew E, et al. Bathhouse distribution of HIV self-testing kits reaches diverse, high-risk population. AIDS Care 2016; 28(Suppl 1):111–113.
14. Lightfoot MA, Campbell CK, Moss N, et al. Using a social network strategy to distribute HIV self-test kits to African American and Latino MSM. J Acquir Immune Defic Syndr
. 2018; 79:38–45.
15. Wesolowski L, Chavez P, Sullivan P, et al. Distribution of HIV self-tests by HIV-positive men who have sex with men to social and sexual contacts. AIDS Behav 2019; 23:893–899.
16. Rosengren AL, Huang E, Daniels J, et al. Feasibility of using GrindrTM to distribute HIV self-test kits to men who have sex with men in Los Angeles, California. Sex Health
. 2016; 13:389.
17. Grov C, Westmoreland DA, Carneiro PB, et al. Recruiting vulnerable populations to participate in HIV prevention research: Findings from the Together 5000 cohort study. Ann Epidemiol 2019; 35:4–11.
18. Sullivan PS, Driggers R, Stekler JD, et al. Usability and acceptability of a mobile comprehensive HIV prevention app for men who have sex with men: A pilot study. JMIR Mhealth Uhealth
. 2017; 5:e26.
19. Pathela P, Jamison K, Blank S, et al. The HIV pre-exposure prophylaxis (PrEP) cascade at NYC sexual health clinics: Navigation is the key to uptake [published online ahead of print January 3, 2020]. J Acquir Immune Defic Syndr
20. Myers J, Merges A, Saleh L, et al. Building a citywide network for prevention navigation: Year one of new york city's playsure network. National HIV Prevention Conference 2019; Atlanta, GA 2019.
21. Nakelsky S, Moore L. Strategies to engage Los Angeles County's trans-identified community in PrEP social marketing campaign evaluation. National HIV Prevention Conference 2019. 2019. Atlanta, GA.
22. Centers for Disease Control and Prevention (CDC). HIV infection risk, prevention, and testing behaviors among men who have sex with men—National HIV Behavioral Surveillance, 23 U.S. Cities, 2017. HIV Surveillance Special Report 22
. 2019. Available at: https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html
. Accessed September 9, 2019.
23. New York City Department of Health and Mental Hygiene. Sexual Health Clinics. 2016. Available at: https://www1.nyc.gov/site/doh/services/sexual-health-clinics.page
. Accessed October 1, 2019.
24. New York City Department of Health and Mental Hygiene. PlaySure Network for HIV Prevention. 2017. Available at: https://www1.nyc.gov/site/doh/providers/resources/playsure-network.page
. Accessed October 1, 2019.
25. Centers for Disease Control and Prevention (CDC). CDC-Funded HIV Testing: United States, Puerto Rico, and the U.S. Virgin Islands, 2017. 2018. Available at: https://www.cdc.gov/hiv/pdf/library/reports/cdc-hiv-funded-hiv-testing-report-2017.pdf
. Accessed September 20, 2019.
26. Collins B. “Discreet”: Characteristics of MSM in a Virginia home testing program and reasons for requesting a home test kit. National HIV Prevention Conference, 2019 2019. Atlanta, GA.
27. Health and Human Services. What is ‘Ending the HIV Epidemic: A Plan for America’? 2019. Available at: https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/overview
. Accessed January 13, 2020.