Do community-level factors play a role in HIV self-testing uptake, linkage to services and HIV-related outcomes? A mixed methods study of community-led HIV self-testing in rural Zimbabwe.

Community-led interventions, where communities plan and lead implementation, are increasingly being adopted within public health programmes. We explore factors associated with successful community-led distribution of HIV self-test (HIVST) kits to guide future service delivery. Twenty rural communities were supported to distribute HIVST kits for 1-month between January and September 2019. Social science researchers observed communities during planning and HIVST distribution, documenting findings in a standard observation template. Three months post-intervention, a population-based survey measured self-reported new HIV diagnosis, HIVST uptake, linkage to post-test services; and collected blood samples for viral load testing. The survey also included questions related to community cohesion; respondents' communities were grouped into low/medium/high based on community cohesion scores. We used mixed effect logistic regression to assess how outcomes differed based on community cohesion scores. In total, 27,812 kits were distributed by 348 distributors. Two HIVST distribution models were implemented: door-to-door only or at community venues/events. Of 5,683 participants surveyed, 1,831 (32.2%) received kits and 1,229 (67.1%) reported self-testing; overall HIVST uptake was 1,229/5,683 (21.6%). New HIV diagnosis increased with community cohesion, from 32/1,770 (1.8%) in the low-cohesion group to 40/1,871 (2.1%) in the medium-cohesion group, adjusted odds ratio (aOR) 2.94 (1.41-6.12, p = 0.004) and 66/2,042 (3.2%) in the high-cohesion group, aOR 7.20 (2.31-22.50, p = 0.001). Other outcomes did not differ by extent of cohesion. Our findings demonstrate the more cohesive communities are, the more effective they may be at distributing HIVST kits and identifying people with undiagnosed HIV. Efforts to increase community cohesion should be considered as part of public health programmes and for planning and scaling-up HIVST implementation in communities.