Peer-based Promotion and Nurse-led Distribution of HIV Self-Testing Among Networks of Men in Dar es Salaam, Tanzania: Development and Feasibility Results of the STEP Intervention

Background: According to the 2016–2017 Tanzania HIV Impact Survey, only 45% of men living with HIV (MLWH) were aware of their HIV status. In an effort to increase HIV testing in Tanzania, including among men, the Government of Tanzania passed a law in December 2019 to allowing HIV self-testing (HIVST) to be included in the national testing strategies. The objective of this paper is to describe the development and pilot feasibility assessment of the Self-Testing Education and Promotion (STEP) intervention, which was one of the projects conducted in Tanzania focusing on men to inform policy change. Methods: The development and piloting processes were guided by the ADAPT-ITT model and informed by a national PEPFAR/USAID-funded HIV implementation science project called Sauti. The adapted STEP intervention included the following two components: 1) peer-based HIVST promotion; and 2) nurse-led HIVST distribution. For the feasibility assessment, 25 men were selected and trained to promote HIVST among their peers before helping to recruit 253 men to receive instructions and collect an HIVST kit from a nurse at a community-based study tent site. Results: Of the 236 participants who completed the 1-month follow-up survey, 98.3% reported using the kit. The majority (92.4%) of participants reported a negative HIVST result while 4.2% (n=10) received a positive result. Most (70%, n=7) of the participants with a positive result sought follow-up services at a healthcare facility while 40.3% (n=95) of the participants with a negative self-test result visited the community-based project site. Most of the men (53%, n =129) did not visit a healthcare facility or the study site. The majority of participants reported having a mobile phone and forty-seven of them called someone to share their results while twenty-seven sent a text message about their results. Conclusion: The findings demonstrate that the combined peer-based promotion and nurse-led distribution of HIVST intervention in the community for men was acceptable and feasible. However, the high proportion of men who visited the tent site in the community after self-testing indicated that future research should evaluate the potential for nurses to provide community-based linkage to HIV care and prevention services for self-testers.


Introduction
The 2016-2017 Tanzania HIV Impact Survey found that only 52.2% of people living with HIV (PLWH) ages 15 to 64 years knew their status (1).Men were less likely to know their HIV status compared to women (46% versus 57%) and less likely, upon knowing their status, to initiate antiretroviral therapy (ART) (86% versus 92%) (1).Consequently, there was a need for new strategies designed to improve casending, especially among men, and move towards epidemic control.To address this need, the Government of Tanzania (GoT) and Tanzania Commission of AIDS (TACAIDS) collaborated with Family Health International (FHI) 360 to develop, implement, and scale up Furaha Yangu! (My Happiness!), a national campaign to promote HIV Test and Treat services with a focus on reaching men (2,3).
Additionally, the GoT supported the development of the 2020 Male Catch-Up Plan, which provided national strategies to reach heterosexual men with HIV services (4).
Although these efforts have been successful in increasing HIV testing services in Tanzania among men, HIV self-testing (HIVST) was not included due to a lack of policy in the country for its rollout, and a dearth of evidence supporting the feasibility and acceptability within the population (5).Global evidence had shown that HIVST, which allows individuals to test for HIV in privacy, is acceptable, feasible, and effective in increasing HIV testing (6-8).However, the lack of country-speci c evidence for HIVST contributed to a delay in introducing and integrating HIVST into the national policy in Tanzania.Prior to approval of HIVST in Tanzania, the 2008 National HIV Act required that HIV testing be conducted by a healthcare professional.In order to generate country-speci c data on different factors relating to HIVST implementation, Jhpiego Tanzania collaborated closely with the National AIDS Control Program (NACP) to conduct a national HIVST demonstration project as a part of Sauti (meaning "voice of the people").
The Sauti Project was launched in 2014 with funding from the President's Emergency Plan for AIDS Relief and U.S. Agency for International Development (PEPFAR/USAID) (9).Sauti was a community-based HIV combination prevention project, which offered clinical and structural support services to key and vulnerable populations (KVPs) in 14 regions (9).The Sauti Project was also involved in implementing the PEPFAR's Dreams Initiative (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe), which focused on adolescent girl and young women (AGYW) and offered comprehensive, evidence-based HIV prevention and treatment packages (10) Services included HIV prevention, testing, care, and treatment, and were offered to Sauti bene ciaries through mobile outreach units working in hot spots such as truck stops, brothels, bars, mining centres, nightclubs, guest houses, and truck drivers' parking places (9).The services were designed to be stigma-free by utilizing health care providers trained to work with populations that experience barriers to accessing reproductive health services (9).To ensure improved linkage to care, Sauti Project also offered transportation support or accompaniment by peer educators and home-based care providers (HBCs) for all female sex workers (FSWs) newly diagnosed with HIV infection to nearby health facilities for follow-up care.
Building on these services and evidence from other countries, Sauti Project advocated in 2017 for the inclusion of HIV self-testing (HIVST) in the HIV prevention portfolio in order to expand access to HIV testing services (HTS) among KVPs who may experience barriers to accessing health facilities or community-based health services.In March 2018, the Sauti Project team introduced HIVST in Dar es Salaam, Iringa, Morogoro, Njombe, and Tabora where the project was also offering comprehensive combination prevention services.Lessons learned from the initial national demonstration of HIVST allowed expansion to eight other regions.Distribution models were primarily community-based with trained nurses and community-based HIV service providers (CBHSPs formerly referred to as peer educators) delivering HIVST kits in the community and through HIV prevention peer education sessions.Clinical HIV testing providers working in the community also integrated HIVST with conventional HTS by offering HIVST kits to newly diagnosed individuals for secondary distribution to their peers or partners.A total of 35,137 clients received HIVST kits across 13 regions.However, given the focus of the Sauti Project to provide services for FSWs, MSM, and AGYW, heterosexual men were not included as a priority population for the national HIVST demonstration project.Therefore, there was a lack of country-speci c evidence for how best to reach heterosexual men for primary distribution of HIVST kits.
In order to address the lack of data on the feasibility of distributing HIVST among heterosexual men, this study, informed by the ADAPT-ITT model, aimed to develop and pilot a community-based HIVST intervention for heterosexual men.The ADAPT-ITT model utilizes an eight-phase process that can be used in whole or parts to adapt evidence-based interventions for a population and context of interest (11).The 8 phases include the following: 1) Assessment; 2) Decision; 3) Adaptation; 4) Production; 5) Topical experts; 6) Integration; 7) Training; and 8) Testing (11).The intervention is called Self-Testing Education and Promotion (STEP), locally referred to as Mate Yako Afya Yako (5).The objective of this paper is to describe the use of the ADAPT-ITT model to guide the development and pilot testing of the intervention for feasibility among social networks of men in Dar es Salaam, Tanzania.

Setting
The setting for this study was the Kinondoni Municipality of Dar es Salaam, Tanzania.Participants were recruited from "camps" located in this area.Camps are social groups consisting primarily of young men who often meet daily and are governed by leaders elected from within the camp (12).The research team chose to engage camps for the recruitment and training of CBHSPs and intervention participants due to the input of team members who had familiarity with these social networks, as well as research indicating that camps can serve as strategic venues for promoting HIV testing and education (13).The camps included in this study were identi ed through cluster randomized cluster trial (cRCT) assessing the e cacy of a combined micro nance and HIV prevention intervention (14).The contact information collected through the cRCT was used for recruitment in the STEP intervention.Participants from the camps were rst recruited into the formative study (Assessment Phase) (5), and later into the intervention following the recruitment and training of CBHSPs.

Phases of ADAPT-ITT model for STEP Intervention
Completion of the eight phases of the ADAPT-ITT model for the STEP intervention occurred over 4 years (2015)(2016)(2017)(2018)(2019).Phase I (Assessment) involved conducting a cross-sectional survey and in-depth interviews with men in between 2015 and 2017 to assess their perceptions of HIVST, willingness to self-test (15), and their recommendations for the intervention (5).Phase II (Decision) involved meeting with key stakeholders, including from the National AIDS Control Program (NACP), in 2018 to decide on the key components for the intervention.Phase III (Adaptation) included the adaptation of Sauti's communitybased HIV prevention intervention for the STEP intervention.The community engagement strategies for the Sauti Project were informed by the Engaging Men at the Community Level training manual created by EngenderHealth and Promundo (16).In addition, the Sauti Project was using the "National Training for HIV Prevention using HIV Self Testing" manual developed by the National AIDS Control Program (NACP) as part of the national HIVST demonstration project.
We reviewed the Engaging Men at the Community Level and National Training for HIV Prevention using HIV Self Testing manuals and made the necessary adaptations for the STEP intervention training modules.Table 1 describes the old modules and the adaptations made for the STEP intervention modules.As shown in Table 1, two new modules, Module V and Module VI, were added as part of the adaptation to teach participants effective communication and counseling skills and provide information to male CBHSPs on the de nition of HIVST, the bene ts, and the different types of self-testing methods, along with an HIVST demonstration using the OraQuick Rapid HIV-1/2 Antibody Test, OraSure Technologies.This demonstration includes using the test and interpreting the results.Next, participants receive information about the bene ts of engaging in HIV care and initiating treatment.In addition, the team decided to include a nurse-based HIVST distribution component of the STEP intervention to align with the national HIVST demonstration project being implemented as part of Sauti project.
Table 1 Description of the Adapted Training Modules for Component I of the STEP Intervention Module I: Introductory Activities.(a) Explores attitudes about gender differences, roles, and inequalities; (b) Understand the difference between "sex" and "gender;" (c) Understand the terms "gender equity" and gender "equality;" (d) Identify the different gender roles and expectations; (e) Understand how gender roles affect the lives of women and men; (f) Understand social norms on masculinity and the social pressures of being a man; (g) Increase awareness about the existence of power in relationships and its impact on individuals and relationships; (h) Identify different types of violence that may occur in intimate relationships and communities; (i) Explore issues and challenges faced by men who are victims of violence; (j) Discuss the relationship between the violence that men suffer and the violence they use against others; and (k) Describe Tanzanian laws and policies related to gender-based violence.Module 1 begins with an activity for participants to see how others view gender differences, roles, and inequalities.Then, they learn about gender, sex, gender equality, gender equity, and gender norms through a ipchart and group discussions.Participants will use role-play activities, case studies, discussions, presentations, and ipchart activities to explore power and violence in relationships and their impact.
Adaptation to Model 1: (a) de ne HIV and AIDS; (b) understand the modes of HIV transmission; (c) describe how HIV is diagnosed; (d) identify HIV prevention methods; (e) describe types of HIV prevention methods; (f) describe the need for HIVST; (g) identify concerns regarding the implementation of HIVST; and (h) describe ethical considerations to enable effective implementation (see Table 1).Module 1 begins with participants learning the correct de nitions for HIV and AIDS, the modes of transportation, how it is diagnosed, and some types of tests.Participants will then review HIV prevention methods, learn why HIVST is needed, the ethical considerations, and the risks and bene ts of HIVST.
Module II: Working with Men on HIV and AIDS.(a) develop a better understanding of the reasons for, and bene ts for, working with men on HIV and AIDS; (b) promote greater awareness of the links between how men are raised and the health risks they face; (c) discuss situations in the life of young men that put them at risk of STI's, HIV/AIDS, and/or unplanned pregnancy and to identify sources of support to reduce these risks; (d) discuss the sexual transmission of STI's and HIV/AIDS; (e) discuss the stigma that people living with HIV/AIDS face; and (f) understand the basic facts about HIV and AIDS.Module II begins with a small group discussion about why men are working with HIV and AIDS and other health risks that men may face.Participants will then complete group activities about situations in life when they put themselves at risk of STIs, HIV/AIDS, and/or unplanned pregnancy.Review of facts and case studies about the stigma faced by PLWHIV Module III: Making Change, Acting.(a) identify the reasons why men might be interested in changing gender norms; (b) identify key roles that men can play in promoting health; (c) identify ways in which men can hold each other accountable in being gender-equitable; (d) discuss key concepts related to community engagement; (e) identify different types of community engagement activities; (f) help community members or groups plan a theatrical performance about gender, HIV, and male engagement; (g) understand the principles of social marketing and practice the Training Steps for developing a Community-based or mass media campaign; (h) help community members or community groups plan a health fair on gender, HIV, and male engagement; (i) develop the skills necessary to conduct group discussions around gender and HIV; (j) identify methods of using sports to reach men and the community; (k) provide participants with the skills to make door-to-door visits in their communities; and (l) discuss strategies for reaching men through peer outreach.In module III, participants are educated on ways men are interested in changing gender norms and promoting health and gender equitability through activities with small groups and discussions.Participants are then educated on community engagement activities, including a theatrical performance about gender, HIV, and male engagement, a mass media campaign, a health fair on HIV and gender, group discussions on HIV and gender, outreach through sports, door-to-door visits, and one-on-one discussions.This is achieved through small group brainstorming, discussions, and demonstrations of each community engagement activity.
Module I: Introductory Activities.(a) Explores attitudes about gender differences, roles, and inequalities; (b) Understand the difference between "sex" and "gender;" (c) Understand the terms "gender equity" and gender "equality;" (d) Identify the different gender roles and expectations; (e) Understand how gender roles affect the lives of women and men; (f) Understand social norms on masculinity and the social pressures of being a man; (g) Increase awareness about the existence of power in relationships and its impact on individuals and relationships; (h) Identify different types of violence that may occur in intimate relationships and communities; (i) Explore issues and challenges faced by men who are victims of violence; (j) Discuss the relationship between the violence that men suffer and the violence they use against others; and (k) Describe Tanzanian laws and policies related to gender-based violence.Module 1 begins with an activity for participants to see how others view gender differences, roles, and inequalities.Then, they learn about gender, sex, gender equality, gender equity, and gender norms through a ipchart and group discussions.Participants will use role-play activities, case studies, discussions, presentations, and ipchart activities to explore power and violence in relationships and their impact.
Module IV: Men Under 35.Provide strategies for facilitators who want to host a meeting to initiate a MEN UNDER).Module IV begins with several questions re ected on, discussed in small groups, then discussed in the whole group.The groups will then create a shared vision and mission statement for the Men Under Added Module VI: HIV Self-Testing.(a) de ne the HIV Self-Testing concept; (b) discuss the bene ts of HIV Self-Testing; (c) explain the methods of HIV self-tests to be used in the pilot; (d) describe the type of self-tests available; (e) explain the bene ts of con rmatory HIV testing for self-testers and differentiate "triaging" from "con rmatory" tests; (f) explain the components of the oral HIV self-test kits; (g) demonstrate step by step how to perform HIV Self-Testing accurately using OraQuick; (h) be able to read and interpret HIV test results using OraQuick; (i) explain the bene ts of linking to HTs after self-testing for both negative and positive client; (j) outlines perceived barriers for linkages to care and strategies to overcome those barriers; (k) discuss how to detect the indicators of social harm; (l) de ne the roles and responsibilities of the CBHW/ peer educators for the community-based distribution model; (m) describe Standard Operating Procedures (SOPs) for HIVST.In this module, participants will be educated on the de nition of HIVST, the bene ts, and the different types of Self Testing methods.Then, there will be an HIVST demonstration using OraQuick.This demonstration will include conducting the test and interpreting the results.Participants will then learn about the bene ts of linking HIV care and treatment, social harm, and incident identi cation and reporting.• Mapping, identifying high-risk men, and mobilizing men for HTS -Hotspot analysis, contact mapping, network mapping, Gap analysis on the services available.
• Action plans • Weekly/monthly Performance tracking Tools • Linkage mechanism and tools • Follow up visit forms by community volunteers/men's champions • Directory of referral sites/hotlines/mapping referral points for different health services suitable for men.

Day 5
Description of adapted STEP Intervention.Phase IV (Production), which also occurred in 2018, entailed production of the adapted intervention manual.The adapted intervention included two components.The rst component, which is the peer-based HIVST promotion, consists of selecting and training CHBSPs to promote HIVST using the training modules.After training, CHBSPs promote HIVST among their social network members and create demand before helping to recruit network members to enroll in the study and receive HIVST kits from a study team member and HIV counselor.The second component of the intervention, which was also informed by the national HIVST demonstration project, includes nurse-led HIVST distribution to participants.A nurse trained on HIVST works closely with the CHBSPs to carry out the distribution of the HIVST kits at a tent located in the community near where participants live.Before providing the HIVST kit to the participant, the nurse demonstrates how to use the HIVST kit with a sample HIVST kit and con rms that the participants understand the instructions.In addition, the nurse informs the participants to seek follow-up services such as con rmatory testing and linkage to care, if needed, at nearby health facilities that provide HIV testing and treatment and the need to test again in three months since HIVST does not detect acute HIV infection.
In Phases V and VI (Topical experts and Integration), the research team collected feedback from topical experts and community stakeholders pertaining to the adapted STEP intervention manual.Phases VII and VIII (Training and Pilot Testing) occurred in 2019 and involved the selection and training of 25 CBHSPs within their camp communities (curriculum, training agenda, and recruitment criteria are detailed in Tables 1-3).During these phases, CBHSPs engaged in demand generation for HIVST through education and social in uence strategies, and eventual recruitment of participants to participate in the nurse-led HIVST distribution component.Table 4 further details the project activities related to each of the phases of the ADAPT-ITT model as they relate to the STEP intervention.

Inclusion of Participants (Phase VIII)
In June 2019, participants were recruited with the assistance of CHBSPs who referred potential participants to the study team.Based on a recommendation from our formative research that participants should be screened for suicidal ideation to prevent self-harm in case of a positive self-test result at home, camp members were screened for suicidal ideation.Individuals were excluded if they did not meet all inclusion criteria; were unable to participate due to psychological disturbance, cognitive impairment, or threatening behavior; or reported positive HIV status.Written informed consent was obtained from all participants.
Data collection and analysis (Phase VIII)

Baseline
The baseline survey was conducted during the month of June 2019 and covered demographic pro le, HIV-related risk behaviors, HIV testing history, reasons for not having tested, and self-perceived HIV risk.Each interview lasted 35 to 45 minutes.At baseline, the names (or nicknames) and contact information As shown in Table 7, very few participants 1.7% (n = 4) reported that it was di cult to understand the HIVST kit instructions whereas the majority 45.3% (n = 107) reported that it was normal.At least onequarter (27.1%, n = 64) reported that it was easy to understand the kit's instructions.Overall, most of the participants (93.2%, n = 220) reported that what they liked about using an HIVST kit was the con dentiality it offered.Approximately, half of the participants (52.5%, n = 124) were very satis ed with the HIVST kit and the majority (87.7%, n = 207) reported that they would like to use an HIVST kit in the future instead of the conventional HIV test and nearly all (92.4%, n = 218) of them would be willing to pay for an HIVST kit.As shown in Table 8, regarding mobile health and HIVST, most respondents (95.3%, n = 225) reported that they had mobile phones but the majority (91.5%, n = 216) did not use their phones to take pictures of their HIVST results.Of the 9 participants who reported taking a picture of their results, most (77%, n = 7) of them showed the picture of the results to someone.However, only 20% (n = 47) reported that they called someone to share the results and 11% (n = 27) sent text messages to share their HIVST kit results.

Discussion
The aim of this paper was to describe the use of the ADAPT-ITT model to inform the development and feasibility assessment of the STEP intervention for social networks of men in Dar es Salaam, Tanzania.
There were several advantages to using the ADAPT-ITT model in this study.First, the phases of the of the ADAPT-ITT model which includes the engagement of key stakeholders enhanced the likelihood of the intervention being informed by the potential bene ciaries and the national stakeholders who have implemented community-based HIV prevention programs in Tanzania.Second, the ADAPT-ITT model encouraged researchers to consider the relevant theoretical and empirical information prior to embarking on the design and thereafter the integration into the eight-phase process in a systematic manner.Hence, the ADAPT-ITT model was useful for the context-speci c needs of the target population for the promotion and use of HIVST.Additionally, the model was critical in garnering precautions offered by the national stakeholders since HIVST was not yet included in the national HIV guidelines.
While previous studies have reported on the HIVST acceptability among men (17,18), this is one of the rst studies to develop a peer-led promotion and nurse-based distribution of HIVST intervention for men in Tanzania with their inputs and guidance from national stakeholders involved in national HIV testing and HIVST programs.This study provides additional evidence for collaboration between researchers and program implementers and demonstrates the acceptability and feasibility of an adapted peer-led promotion and nurse-based distribution of HIVST intervention among social networks of men.The decision to collaborate with national stakeholders and adapt existing community-based HIV and HIVST materials for the STEP intervention was to ensure that the national stakeholders who can use the ndings to inform policy change and dissemination and implementation science efforts for HIVST were involved from the beginning as recommended by researchers and policy makers in Tanzania (19).
The adapted STEP intervention also included the goals of the ADAPT-ITT model, which includes suitability of an intervention for adaptation, modi cation to t the local cultural settings, and maintaining successful recruitment and retention rates.These objectives were achieved based on the success of male CBHSPs in promotion of HIVST awareness among their peers and assistance with recruitment and follow-up of in their social networks for the intervention.This approach aligned well with the practice of engaging in formal and informal conversations, as well as continuing the practice of accompaniment to the clinic for HIV testing (13).It also builds on the success of prior recruitment of men from similar social networks as community health leaders in a prior intervention (20).Similar social network-based strategies for HIVST promotion and distribution have been reported with success in other parts of Tanzania and other countries (21)(22)(23)(24).The Ministry of Health in Tanzania, in collaboration with implementing partners such as FHI 360, has also adopted a social and sexual network-based approach during the scale up of HIV self-testing, which was also shown to be acceptable from the formative baseline research phases of the STEP project (15,25).

Limitations and future linkage to HIV care research
The study has several strengths and limitations worth highlighting.The rst strength of the study includes the combination of quantitative and qualitative data from the formative research and pilot of the intervention.Another strength is the use of the ADAPT-ITT framework to inform the adaptations of the existing intervention and program manuals for the context of the social networks of men we engaged for the project.Third, the study was also developed and implemented in collaboration with national as well as community-based stakeholders, including Ministry of Health and CSO representatives, HIV program implementing partners, and male CHBSPs.The limitations for the study include that the outcomes of interest such as HIVST use and follow-up behaviors after obtaining HIVST results were self-reported.
Thus, there may be an overstated report of HIVST use and lower reporting of HIV positive results.In addition, there was a lack of follow-up con rmatory blood-based testing and objective assessment of linkage to care for the participants who reported a positive self-test result.However, this limitation will be addressed a proposed study that will leverage an existing program in Tanzania called nurse-initiated management of ART (NIMART), which has also been implemented in South Africa for over a decade (26-28).The NIMART program can be expanded to allow nurses to provide follow-up services for self-testers at home or any other convenient, safe, and private location selected by a client.A prior study conducted in Tanzania has shown that it is feasible to for nurses to provide community-based antiretroviral therapy (cbART) initiation and that cbART services are preferable than facility-based ART services (29).
Therefore, the proposed study will create the STEP + cbNIMART intervention, which will allow nurses to provide self-testers community-based follow-up services and linkage to care or prevention services.There is evidence that nurses who provide health promotion activities in the eld (versus in the clinic) yield superior clinical outcomes than eld-based paraprofessional community health workers (30,31).In addition, evidence from Malawi suggests that when nurses provide home-based follow-up services for self-testers who receive a positive self-test result, they are more likely to start on ART than those who are instructed to seek follow-up services at the facility (32).The STEP + cbNIMART project aims to leverage the evidence from the cbART intervention (29) and the NIMART program to help address the gap for the follow-up services.While registered nurses' per-hour labor cost are generally higher than paraprofessional community health workers, nurses have been shown to produce overall cost savings through increased e ciency (e.g., effectively handling more cases in less time, addressing complex clinical questions in real-time to support's patient informed decision-making), higher program retention of patients, and behavioral outcomes that patients self-sustain over longer periods of time (30,33,34).Moreover, nurses' involvement in the STEP + cbNIMART project has the potential to enhance continuity of care following HIVST by serving as a direct conduit to ART for men whose positive self-test results are con rmed, as well as pre-exposure prophylaxis (PrEP) for men whose self-test results are con rmed to be negative but are at high risk for HIV acquisition through factors such as being uncircumcised, having sexually transmitted infection symptoms, and engaging in harmful drinking of alcohol before sex (35).Future studies that investigate potential diminishing economic returns of nurses can also provide important evidence to inform HIV policy, clinical practice protocols, and community-based linkage to ART or PrEP implementation.

Conclusion
The pilot study has shown that it is acceptable and feasible for a combined peer-led promotion and nurse-based distribution of HIVST intervention for unsupervised use among networks of men in Dar es Salaam, Tanzania.Strategies for reaching men continue to be a priority and social network approaches should be scaled up.Stakeholder-led development, including the engagement of social networks of men and HIV implementing partners, and implementation as informed by the ADAPT-ITT model were important for successful dissemination and countries and programmes should consider this to maximize effectiveness of HIVST programming.Since the completion of the STEP intervention and the PEPFARfunded national HIVST demonstration project implemented through the Sauti project, the National Act was changed in December 2019 to allow HIVST to be offered and Tanzania is a leader in HIVST implementation and scale-up with the goal of increase HIV testing and reducing HIV infections at the population level.The national programme can continue to apply these ndings to strategically expand HIVST to close gap in reaching men which remains a priority.
35 group.Added Module V: Effective Communication and Counseling Skills.(a) de ne effective communication; (b) explain factors that facilitate effective communication; (c) explain barriers to communication; (d) de ne counseling; (e) describe the essential skills for counseling; (f) explain the traditional HIV riskreduction counseling, and (g) describe the recommended HIV risk reduction approach.Module V is focused on giving the participants effective communication and counseling skills.It begins with educating the participants on effective communication and basic counseling skills.SOLER, a technique for demonstrating interest and interest non-verbally, is introduced and the importance of immediacy and barriers to communication.

4 ) Day 1 •• 3 ••
To promote great awareness on men and heath • To discuss the sexual transmission of STIs and HIV and AIDS • To understand the basic facts about HIV and AIDS.• To Understand stigma and discrimination in relation to HIV testing and linkage to treatment and care.• Transmission of HIV and AIDS: A Signature Hunt (Module 2.5) • HIV and AIDS Myths and Facts (Module 2.7) • Men, Gender, and health -role-plays and re ections • Activity 3.2: HIV Testing and Counselling (MODULE 2 manual) • Activity 5.2: People Living with HIV-Antiretroviral Therapy (MODULE 2 manual) • Experience of being stigmatized and how it affects access to Health care services.• Stigma and discrimination associated with HIV/AIDS, access to care, treatment, and support services (Module 1.) • Are men interested in change?• Making change, taking action • Men and Health: Caring for Oneself: Men, Gender, De ne HIV Self Testing concepts • Discuss the bene ts of HIV Self Testing • Explain the methods of HIV Self Testing to be used in the pilot • Describe the types of HIV Self Testing available • Explain the bene ts of con rmatory HIV Testing • Describe the various service delivery approaches of HIV Self Testing.• HIV Self-Testing • Concept of HIV Self-Testing • De nition of HIV Self-Testing (HIVST) • Bene ts of HIVST • HIV Self Testing method • Triaging versus Con rmatory Tests • Approaches to HIVST Day Effective use and management of HIVST Kits • Strengthen Linkage to HIV Care and treatment services • HIVST Demonstration • Component of HIVST Kit • Steps to conduct the test • Interpretation of Results • Cross-cutting issues of HIVST • Barriers to linkage to care and treatment • Ways of promoting linkage • Linkage Mechanisms/Tools (Directory of referral sites/hotlines/mapping referral points for different health services suitable for men) To identify key groups and how to reach them • To identify the primary message that should be conveyed in community activities on male engagement and gender • To examine the possibility, advantages, and challenges of building a new alliance • To increase the effectiveness and reach of efforts to engage men in getting 95 95 95 • To understand monitoring and evaluation -HIVST • Understanding different strategies of reaching high-risk men AbbreviationsADAPT-ITT: Assessment, Decision, Adaptation, Production, Topical Experts, Integration, Training, Testing

Table 2 Training
Agenda for Community-based HIV Providers • I Am at Risk When (Module 2.

Table 3
Nomination Criteria for Community-based HIV Providers Research team met with 166 members of 9 "camps" in target area to discuss nomination of CBHSPs in accordance with recruiting practices and quali cations of CBHSPs utilized by Sauti project o cers • "Camp" members were instructed to nominate 2-3 members of their camp to be CBHSPs, which led to the nomination of 26 men across 9 camps • 25 men attended 5-day training session which included 6-module curriculum and opportunities for self-re ection, as well as discussion regarding stigma reduction and promotion of HIVST to camp members • 25 CBHPs had approximately one month to educate peers within their camps and recruit for participation in the STEP study using communication and social in uence strategies• Recruited participants who reported to the tent-site provided informed consent, took a baseline survey, and received HIVST education from a healthcare worker on how to use the HIVST kit, interpret results, and where to receive follow-up care • Theater-tested intervention and received feedback from experts to consider recruiting CBHSPs from local networks of men known as "camps"• Experts also recommended screening for suicidal ideation of participants prior to enrollment in study and receipt of HIVST

Table 5 :
Baseline survey characteristics for men in intervention group

Table 6
Self-reported HIV self-testing behavior of men in intervention group at 1-month follow-up (n = 236)

Table 7
Perceptions of HIV self-testing among participants who used the kits

Table 8
Mobile health and HIV self-testing