Acceptability of Oral-fluid rapid HIV 1 and 2 antibody test among selected key populations in Sri Lanka

Introduction: Oral-fluid rapid HIV 1 and 2 antibody test is recommended by WHO to be used as a “test for triage” to support expanding community-based HIV testing services among Key populations (KPs) for HIV infection such as Men who have sex with men (MSM), Beach boys (BB), Female sex workers (FSW) and Drug users (DUs) Objective: The aim of this study was to ascertain the acceptability of oral fluid rapid HIV 1/2 antibody test (OraQuick®) among key populations receiving services under the Global Fund HIV prevention project during 2013-2015 in Sri Lanka. Methods: Out of the total registered members of KPs (21,014), a purposive sample of 614 (MSM185, BB-128, FSW-155, DU-146) was studied. Data collected by WHO certified community testers using three tools, i). interviewer administered questionnaire, ii) confidential oral fluid rapid HIV test and recording, iii), a self-administered feedback form. Results: Mean age of the sample was 34 years (Mdn=32.7 years). Males, females and transgender people were 68.9%, 30.6%, 0.5% respectively. Further, 40.7% were single, 36.5% married, 11.7% living together and 11% were separated. It seems that these groups prefer both community testing (49%) as well as outreach testing by STD staff (49%). However, going to an STD clinic was preferred only by 10%. Majority preferred oral-fluid testing (88%) and finger prick testing preferred by 10.2%. Majority expected test report just after the test (88.3%). The overall satisfaction of the oral-fluid rapid HIV test by KPs was MSM 97%, BB-99%, FSW-99%, DU-99%. Conclusions: Members of KP groups show high level of acceptability for the oral-fluid rapid HIV 1 and 2 antibody test. This type of “test for triage” approach can be used to improve the community based HIV testing in Sri Lanka.


Introduction
Sri Lanka is a country with low level of HIV epidemic. HIV prevalence has not consistently exceeded 5% in any of the key populations such as female sex workers (FSW), men who have sex with men (MSM), and drug users (DU). A cumulative total of 2308 HIV  Those who received all 1 to 5 services in the HPP are defined as "reached". Once the reached person is escorted to a STD clinic, they are defined as "escorted". This HPP was delivered to KPs through peer educators (PE) scattered in selected districts in the country. Each PE has regular contact with another 6-15 peers forming a peer group (PG). Total of 1,284 peer groups (PG) were operational at the end of 2015 (MSM 382, BB 116, FSW 374, DU 412). However, in this model, approximately 60% of key populations in the project do not take the escorting step for HIV testing. In this background, a national steering committee was formed to introduce an oral-fluid rapid HIV antibody test as a community based testing model to Sri Lanka. The committee decided to test its acceptability in a research model among those currently in the peer group intervention. In the recently released WHO consolidated Guidelines on HIV Testing Services introduces a strategy to support expanding communitybased HIV testing services (HTS), particularly to reach higher risk populations who may not otherwise test for HIV and link to prevention, treatment and care. (2) Test for triage is an approach to support community-based HTS provided by lay community providers. In this approach, trained and supported lay providers conduct an HIV rapid diagnostic test (RDT) and if reactive, the individual is promptly linked to a facility for further HIV testing where the validated national testing algorithm is performed. (2) Therefore, the objective of the study is to ascertain the acceptability of Oral-fluid rapid HIV 1/2 antibody test (OraQuick) among key populations receiving services under GFATM HIV prevention project in Sri Lanka Training of research assistants: A Mixed group of individuals representing community and non-community groups were trained in a three day residential programme. All were trained to become WHO certified community testers. The training programme was conducted by an international consultant with the help of local consultants.

Methods
Data collection process: First, the study information sheet was given to study participants to read and understand or was read to participants who were illiterate. Then, informed consent was taken for the questionnaire and the oral-fluid HIV test. Participants were interviewed in a private and a confidential setting to complete the questionnaire. Then oral-fluid rapid HIV test was performed by gently swiping the test swab along upper and lower gums. Then the swab was inserted to a test tube provided with the test pack and results were read in 20 minutes and recorded. Participants were given pre-and post HIV test counseling. After the HIV test, participants were given a self administered feedback form as the final step of the data collection process.

Results
All the potential participants completed the questionnaire and the oral-fluid rapid HIV test and no withdrawals reported during the phase of the completion of the study.
Sample characteristics: Table 2 indicates the sample characteristics by different type of peer groups of key populations studied.

Acceptability of oral-fluid rapid HIV test (OraQuick) among different KP groups
The following table describes the study participants' feedback on the level of satisfaction towards the oral fluid rapid HIV testing process. The feedback given to individual statements showed that participants were satisfied with the oral-fluid rapid test. However, some respondents had felt a pressure to get the test done (18%) and another 13% still complained that they had to wait too long even for the oral-fluid rapid test. Furthermore, about 6% did not like the test. About one fourth of MSM (28%) and BB (27%) believed that this type of HIV test is a barrier to receive other services from STD clinics. (Table 6)

Overall satisfaction of the oral fluid rapid HIV test
As the final evaluation on the level of satisfaction, respondents were asked to rate the overall satisfaction of the oral-fluid rapid HIV test. Following table shows the ratings given by peer type. Overall satisfaction about the oral-fluid rapid HIV test had been rated "Good", "Very good" or "Excellent" by over 97% of respondents.

Discussion
The national steering committee formed to introduce the oral-fluid rapid HIV antibody test wanted to look at the acceptability of the test among key populations before being introduced as a community based test (CBT). Test sensitivity and specificity was a major concern at the beginning. However, the Thailand version of this oral-fluid test (OraQuick) has 100% sensitivity and 99.87% specificity according to the manufacturers brochure enclosed with the product package. There were no results of any validation in the country. This study's main target was not to detect new cases but to comprehend the acceptability of the oral-fluid HIV test as a community based test among key populations, which can mainly be introduced at community settings such as drop-in centres and other forms of community locations in order to reduce the testing gap.
Different types of Oral-fluid rapid HIV tests are available and its technologies are evolving. Therefore, the steering committee mainly focused at assessing the acceptability of the test hoping to replace high quality oralfluid test in future in the country as a community based HIV test. The study showed high acceptability for an oral-fluid test of this nature and over 97% expressed satisfaction regarding the test and the testing procedure done by the trained community testers. Furthermore, participants expressed their willingness to undergo the test done by both community testers and out-reaching healthcare workers. In contrast, the access to a STD clinic is accepted only by 10%, which reflects the need for an alternative method of testing. In this high acceptable situation, the test can also be introduced as a self-test of HIV.

Conclusion
Majority of members of the key populations has accepted oral-fluid rapid HIV test. Rating of satisfaction as good, very good and excellent were taken as expression of satisfaction and 97% of MSMs and 99% of BB, 99% of FSW and 99% of DUs were overall satisfied with the test.
However, some respondents had felt a pressure to get the test done (18%) and another 13% still complained that they had to wait too long even for the oral-fluid rapid test. Furthermore, about 6% did not like the test. About one fourth of MSM (28%) and BB (27%) believed that this type of HIV test is a barrier to receive other services from STD clinics. The oral-fluid rapid HIV test can be introduced to key populations an community based HIV test based on the acceptability and satisfaction expressed.