In test-and-treat HIV prevention, HIV testing and linkage-to-care (LTC) are pivotal steps. However in low- income Sub-Saharan African countries, there are many underserved areas with low access to HIV testing and LTC. Tanzania is among those countries with high HIV prevalence, a generalized epidemic, low access to care, and large population segments who are impoverished and have limited education. Adolescent Tanzanian youth are faced with limited clinic based testing opportunities and an inadequate LTC system. Oral self- implemented HIV testing (oral-SIT), if appropriately translated, may offer a viable alternative for increasing the reach of HIV testing services to low-income youth and support LTC. Oral-SIT kits have not been translated to low-income, low literacy, low technology populations. Moreover, both literate and low literacy persons have challenges with performing oral-SIT procedures correctly (high fidelity). In general, low-income, low literacy, low technology countries are faced with significant challenges to implementing new public health technology. Using a translation framework, the proposed research builds on previous pilot research conducted in Tanzania to examine low technology, low literacy methods of training youth to self-implement oral-SITs with high fidelity and extend prior work on linkage-to-care among urban Tanzanian youth. We compare two methods of training youth (15-19 yrs.; N = 286) to use oral-SITs and increase their understanding of the importance of receiving treatment: (a) one that uses a low cost, low literacy, low technology pictorial instruction book (PIB), and (b) one that employs a brief video to enhance youths' comprehension of the PIB. Oral-SIT performance, and intentions to seek confirmatory testing and treatment will be examined. An important step in implementation failure or success is in understanding how participants comprehend implementation instructions. Consequently, we also assess participants' comprehension of instruction materials. Although the addition of video delivery, as proposed, is societally more expensive, this approach is sustainable if video training occurs primarily at the organizational level. That is, once the consumer has been trained via video in the use of the PIB, we expect that the PIB alone will be sufficient to sustain high fidelity in future use of oral-SIT. The propoed study lays the groundwork for randomized field trials to further evaluate the ability of oral-SITs, when used correctly, to increase identification of HIV cases beyond levels currently obtained with clinic based testing. The study provides considerable control that would not be achievable through in vivo studies, and the procedures allow for direct observation of self-implementation. The proposed R01 will add to the science of translation by expanding our knowledge of the antecedents of self-implementation fidelity. The overarching goal of this study is to solve self-implementation fidelity problems with oral HIV testing and cost-efficiently increase HIV testing and LTC aimed at reducing HIV transmission, morbidity, and mortality.
The proposed research compares strategies designed to solve the challenges faced by low-income, low literacy, low technology Tanzanian youth (15-19 years of age) in using self-implemented oral HIV testing and in understanding the importance of treatment as prevention. The overarching goal of this study is to solve self- implementation fidelity problems with oral HIV testing, and provide a path for subsequent field studies designed to cost-efficiently increase HIV testing and linkage-to-care aimed at reducing HIV transmission, morbidity, and mortality.
