Risk assessment tool enables targeted testing for sustained HIV case finding among men who have sex with men in Lesotho'

BACKGROUND: As HIV programs mature, implementers increase their efforts to find undiagnosed individuals living with HIV. A recent shift from universal to targeted testing challenges implementers to improve risk identification and segmentation in programs for men who have sex with men (MSM) and increase the use of data to differentiate and prioritize individuals for HIV testing and other prevention services.
DESCRIPTION: The USAID/PEPFAR-supported EpiC Lesotho project developed a risk assessment screening tool (RAST) to identify risks using several variables: time since last HIV test, incorrect condom use/ condom unavailable during sex, insertive/receptive sex with incorrect condom use, pre-exposure prophylaxis use, sexually transmitted infection symptoms, medical circumcision status, and intergenerational sex. For each variable, response values were set for high, medium, or low risk. High, medium, and low values were totaled to determine an individual's risk category and testing priority. The RAST was piloted in three districts from February to March 2020 to validate the segmented risk. The RAST was then rolled out for routine programmatic use in April 2020 to further assess the validity of risk segmentation among MSM. We present results of the first 10 months of RAST implementation (April 2020'January 2021).
LESSONS LEARNED: The RAST was used to screen and categorize for HIV risk 2,780 MSM eligible for testing, with 52% (1,434) categorized as high risk, 42% (1,165) as medium, and 6% (181) as low. The HIV case-finding rate was 5.2% (75/1,434) in the high-risk category, 0.4% (5/1,165) in the medium, and 1.7% (3/181) in the low (p<0.001). The odds of testing positive were 3.3 times higher among MSM segmented as high risk than in the low-risk category (p=0.045).
CONCLUSIONS: Using the RAST enhances the client-centered approach and allows programs to successfully segment and intensify targeted HIV testing for those at elevated risk of exposure, facilitating more efficient use of peer outreach workers' time and efforts. Lesotho will intensify work to reach and prioritize high-risk MSM for testing, allow medium- and low-risk individuals to opt out of testing, and institute a yearly HIV testing screening algorithm to test every man who has sex with men.

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