In West Africa, only 68% of people living with HIV were aware of their HIV status in 2019 [1], which is far from the 95% UNAIDS 2030 target. Knowing one’s HIV status is essential to engagement in the HIV status neutral prevention continuum. It is also a first and necessary step to enter the HIV treatment and care cascade. By receiving treatment and achieving viral load suppression, people living with HIV (PLHIV) considerably reduce their risk of morbidity and mortality and their risk of onward transmission of the virus [2].
In its efforts to help countries increase HIV testing uptake, the World Health Organization (WHO) developed global guidelines on HIV self-testing (HIVST) in 2016, recommending that this strategy to be offered as an additional approach to traditional HIV testing services [3]. The recommendation was further reinforced in the WHO’s 2019 consolidated guidelines [4]. After the successful implementation of HIVST in Eastern and Southern Africa through the HIV Self-Testing Africa Initiative – Research (STAR) project [5], Unitaid funded the ATLAS project (AutoTest VIH, Libre d’Accéder à la connaissance de son Statut) to promote self-testing and distributed approximately 400,000 HIVST kits from 2019 to 2021 in three countries in West Africa (Côte d’Ivoire, Mali, and Senegal) [6].
This region of Africa has a unique epidemiologic context, characterized by a comparatively low but still generalized prevalence of HIV in the general adult population (between 0.4% and 3%) and a high prevalence among key populations (female sex workers, men having sex with men, and people who use drugs, among others). The stigmatization experienced by these groups limits their access to traditional facility-based testing strategies [7]. Community-based outreach testing activities have been successfully implemented in West Africa but still face difficulties in reaching all members of these key populations. Considering this specific context, the ATLAS project designed a strategy that combines both primary and secondary distribution of HIVST kits. Primary distribution is a strategy whereby HIVST kits are given directly to final users for their own use, while secondary distribution refers to HIVST kits being provided to primary contacts who redistribute them to their sexual partners, peers, or clients.
ATLAS is implemented in partnership with the ministries of health of the three countries and national implementers already involved in HIV testing activities. Eight delivery channels have been identified to prioritize different populations (female sex workers—FSWs, men having sex with men—MSM, people who use drugs—PWUD, people living with HIV, and patients consulting for a sexually transmitted infection) and their networks, and they include both facility-based and outreach strategies [6]. In all three countries, dedicated information leaflets have been developed using cognitive interviews [8]. These leaflets (Fig. 1) are systematically distributed with all HIVST kits. They provide visual information adapted to the local context, including a link to a demonstration video, and promote the national toll-free HIV hotline (with the phone number 106 in Côte d’Ivoire), where users can obtain information and support to learn about HIVST. At the bottom left of the fourth page of the leaflet, there are coloured, numbered circular stickers to identify the distribution channel and the implementing partner for monitoring purposes.
Although it is crucial from a monitoring and evaluation point of view to document the socio-behavioural profiles and experiences of HIVST users, the private nature of HIVST makes such documentation challenging [3]. To ensure privacy and confidentiality for final users, ATLAS does not systematically track the use of HIVST kits. Dispensing agents can, and are invited to, provide their contact information to those wanting additional support to perform HIVST or interpret their HIVST results. A free national hotline is also available in all ATLAS countries. However, HIVST users have no obligation to report whether they actually used the HIVST kit or to report their test results.
To circumvent such issues, we designed an anonymous phone-based survey (named the Coupons Survey) that relied on ‘passive’ participant recruitment—with HIVST users invited to voluntarily call a survey toll free telephone number. The survey was designed to not interfere with HIVST kit distribution and to smoothly operate within the ATLAS project while maintaining voluntary participation, anonymity, privacy, and autonomy.
Due to the many challenges of implementing such a survey, we started with a pilot phase in Côte d’Ivoire. This paper aims to report on the lessons learned from this pilot and on the recommendations for the full implementation phase.