Introduction

The 2022–2023 Tanzania HIV Impact Survey (THIS) found that only 82.7% of people living with HIV (PLWH) in Tanzania aged 15 years and older knew their status [1]. Men were less likely to know their HIV status compared to women (78.4% versus 84.8%) and less likely, upon knowing their status, to initiate antiretroviral therapy (ART) (96.7% versus 98.4%) [1]. Although these data show men are less likely than women to test for HIV, initiate ART, there has been an improvement in HIV testing and linkage to ART compared to the data from the 2016–2017 THIS that showed that only 46% of men were aware of their HIV status and of these, only 86% were on ART [2]. The efforts taken by the Government of Tanzania (GoT) and the implementing partners to increase HIV services among men have contributed to these improvements. For example, the 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 in 2018 to promote HIV Test and Treat services with a focus on reaching men [3, 4]. Additionally, the GoT supported the development of the 2020 Male Catch-Up Plan, which provided national strategies to reach heterosexual men with HIV services [5].

Although these efforts have been successful in increasing HIV testing services (HTS) 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 [6]. Global evidence had shown that HIVST, which allows individuals to test for HIV in privacy, is acceptable, feasible, and effective in increasing HIV testing [7,8,9]. However, the lack of country-specific 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 in December 2019, the 2008 National HIV Act required that HTS be conducted by a healthcare professional. In order to generate country-specific 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) [10]. 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 [10]. 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 girls and young women (AGYW) and offered comprehensive, evidence-based HIV prevention and treatment packages [11]. Services included HIV prevention, testing, care, and treatment, and were offered to Sauti beneficiaries through mobile outreach units working in hot spots such as truck stops, brothels, bars, mining centres, nightclubs, guest houses, and truck drivers’ parking places [10]. The services were designed to be stigma-free by utilizing health care providers trained to work with populations that experience barriers to accessing sexual health services [10]. To ensure improved linkage to care, the 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, the Sauti Project advocated in 2017 for the inclusion of HIVST in the HIV prevention portfolio in order to expand access to 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 HTS 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 was to provide services for FSWs, MSM, and AGYW, heterosexual men were reached through their sexual partners and not included as a priority population for the national HIVST demonstration project. Therefore, there was a lack of country-specific evidence for how best to reach heterosexual men directly 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 Sauti Project and 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 [12]. The 8 phases include the following: 1) Assessment; 2) Decision; 3) Adaptation; 4) Production; 5) Topical experts; 6) Integration; 7) Training; and 8) Testing [12]. The intervention is called Self-Testing Education and Promotion (STEP), locally referred to as Mate Yako Afya Yako [6]. The objective of this paper is to describe the development and feasibility assessment of the Self-Testing Education and Promotion (STEP) intervention served as one of the first HIVST research projects conducted in Tanzania to inform policy change and support the implementation and scale-up of HIVST in Tanzania.

Methods

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 [13]. 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 HTS and education [14]. The camps included in this study were identified through a cluster randomized controlled trial (cRCT) assessing the efficacy of a combined microfinance and HIV prevention intervention [15].

The contact information collected through the cRCT was used for recruitment in the STEP intervention. Participants from the camps were first recruited into the formative study (ADAPT-ITT Assessment Phase) [6], and later into the intervention following the recruitment and training of CBHSPs (ADAPT-ITT Decision, Adaptation, Production, Topical Experts, Training, and Testing Phases [6]). Ethical approval was obtained from institutional review boards at the University of South Carolina (#Pro00072005), the George Washington University (#NCR213554), as well as the National Institute of Medical Research of Tanzania (NIMR/HQ/R.8aNol. IX/2529) for the STEP intervention. The nine camps selected for the intervention were informed that all camp members would be offered the opportunity to receive peer-led HIVST education and promotion and camp members who enroll in the study would receive the nurse-led HIVST distribution component.

Phases of ADAPT-ITT model for STEP intervention development

Completion of the eight phases of the ADAPT-ITT model for the STEP intervention development occurred over 4 years (2015–2019). Phase I (Assessment) involved conducting a cross-sectional survey [16] and in-depth interviews [14] as part of a formative research study in 2015 with networks of men from the camps in Dar es Salaam [6]. The data, analyzed between 2016 and 2017, revealed their perceptions of HIVST, willingness to self-test for HIV [16], and their recommendations for the intervention [6]. 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 community-based 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 [17]. 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 definition of HIVST, the benefits, 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 included using the test and interpreting the results. Next, participants received information about the benefits of engaging in HIV care and initiating treatment. In addition, the team decided to include a nurse-based HIVST distribution component to 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
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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 which were provided to all participants (Fig. 1). The first 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 confirms that the participants understand the instructions. In addition, the nurse informs the participants to seek follow-up services such as confirmatory testing and linkage to care at nearby health facilities that provide HIV testing and treatment and reiterates the need to test again in three months since HIVST does not detect acute HIV infection. All participants in the STEP intervention received both CBHSP-led education and nurse-led HIVST kit distribution in succession. The initial CBHSP-led education was designed to increase the comfortability and knowledge of HIVST prior to interacting with a formal healthcare provider.

Fig. 1
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Dual components of STEP intervention

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Theory of change

The STEP intervention’s approach to increasing HIVST uptake among networks of men is grounded in a multi-layered theory of change that integrates two key behavior change models: the Socio-Ecological Model (SEM) [18], the Information-Motivation-Behavioral Skills (IMB) Model [19]. Together, these models offer a comprehensive framework that addresses individual, social, and community-level influences on behavior. The first model, SEM, underscores the importance of social and environmental contexts in shaping health behaviors [18]. The STEP intervention was designed to tap into existing social networks, specifically young men’s peer groups or “camps,” to promote HIVST. By selecting and training CBHSPs from within these camps, the intervention sought to normalize HIV testing and reduce barriers like stigma and fear [5, 14]. SEM posits that individuals are more likely to engage in health-promoting behaviors when those behaviors are reinforced by their immediate social circle and the broader community [20]. This model aligns with the STEP intervention’s peer-led approach, ensuring that behavior change is supported interpersonally.

IMB informs the practical design of the intervention by emphasizing three key factors aligned with the three components of the model: providing accurate information about HIVST, motivating individuals to test, and building the necessary skills for effective self-testing [19]. Within the STEP intervention, CBHSPs not only disseminate critical knowledge about HIVST but also foster motivation by creating a supportive, stigma-free environment. Additionally, the training sessions equip participants with the practical skills required to correctly use HIVST kits. This combination of accurate information, motivation, and skill-building is essential for ensuring that individuals follow through with HIV testing and are prepared to act upon the results [21].Through the combination of these models, the theory of change underlying the STEP intervention assumes that embedding HIVST within existing social structures will lead to a higher uptake of testing among men.

Remaining phases of the ADAPT-ITT model

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, 2 and 3). During these phases, CBHSPs engaged in demand generation for HIVST through education and social influence 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.

Table 2 Training agenda for community-based HIV providers
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Table 3 Nomination criteria for community-based HIV providers
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Table 4 Phases of the ADAPT-ITT model for the STEP intervention
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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, a research assistant screened camp members for suicidal ideation by asking if they ever had any suicidal thoughts (Yes/No). In addition, camp members were asked their age, the name of their camps, how long they have been a camp member, how often they visit the camp, and how long they plan to reside in Dar es Salaam. Individuals were excluded if they did not meet all inclusion criteria, which were: 1) Being a male camp member from one of the 9 selected camps for longer than 6 months; 2) 18 years or older; 3) Expect to live in Dar es Salaam for the next 12 months and 4) Not reporting suicidal thoughts. Assessment of these qualifiers for exclusion was conducted by a research assistant from the study team. Written informed consent was obtained.

from all participants.

Data collection and analysis (Phase VIII)

Baseline survey

In total, we recruited 252 participants from 9 camps for the HIVST feasibility study. This sample size was largely determined by resource constraints but is considerably larger than many feasibility studies [22]. In addition, the sample size was sufficiently large to determine feasibility of the intervention and if there was an indication for progression to a full-scale trial [23]. The baseline survey was conducted during the month of June 2019 and covered demographic profile, HIV-related risk behaviors, HIV testing history, reasons for not having tested, and self-perceived HIV risk. Each interview lasted 35 to 45 min. At baseline, the names (or nicknames) and contact information (mobile number) of the participants were collected to ensure successful follow-up with participants for the one-month survey.

One-month follow-up survey

A follow-up interview was conducted in August 2019 to determine whether participants had used the HIVST kits provided and their experience using it, their self-reported test result, potential harms, confirmatory testing (if positive), linkage to ART, and willingness to pay for an HIVST kit. The questionnaires were administered by a research assistant in the Kiswahili language on Qualtrics via a Samsung Tablet. All participants provided written informed consent and were reimbursed approximately 10,000 Tanzanian Shillings/USD 4.28 for each of the baseline and follow-up surveys. Data were analyzed using STATA software version 15.0 (Stata Statistical Software: Release 15. 2017. College Station, TX: StataCorp LLC.) Following data cleaning and checking for consistency and completeness, descriptive statistics were summarized, and frequency and percentages were used to describe the characteristics of the study population, and their perceptions and behaviors related to self-testing. The study team selected four components of feasibility that were measured through the baseline and follow-up surveys. These components were 1.) participant recruitment; 2.) retention; 3.) participation; and 4.) acceptability. Participant recruitment was measured as the total number of camps recruited into the trial and the corresponding number of men in those camps. Participation was defined as the percentage of men within those camps who chose to participate in at least some elements of the STEP intervention, beginning with receiving peer education and followed by receipt and utilization of an HIVST kit. Retention was measured by whether the participant was able to be reached for follow-up, as well as their behavior after receiving a self-test result, such as reporting to a healthcare facility for follow-up. Acceptability was measured through the number of participants who received an HIVST kit and actually conducted the self-test, participants’ perceptions of its ease of use, and overall satisfaction with the self-testing experience.

Results

Demographics and participation

In total, 252 men received HIVST kits and 236 men were reached for the one-month follow-up. Men who did not report for the one-month follow-up were excluded from the baseline and follow-up survey data (Table 5). Of the 236 men in the final sample, over half (54.3%) were under the age of 28, which is indicative of the overall Tanzanian population which skews young, as over half of the population (53.6%) is under 35 years old [24]. Similarly, over half (52.1%, n = 123) of the participants had either completed primary school or received less education, which is consistent with the national average where just 1 in 4 Tanzanians complete secondary school or higher education (23.6%) [25]. Most participants (60.2%, n = 142) had never been married and just over half (56.8%, n = 134) had a paying job. The majority of the participants surveyed (83.9%, n = 198) had sexual partners. Approximately half (52.5%, n = 124) of men reported never using condoms, while 18.2% (n = 43) always use condoms during sexual intercourse. Less than half of the men 46.6% (n = 110) reported that they knew their partner’s HIV status. More than half (53.8%, n = 127) of the participants reported having heard of HIVST and the majority (84%, n = 200) reported being encouraged by a peer to take an HIVST kit, potentially due to the CBHSP-led activities prior to receiving their HIVST kit.

Table 5 Baseline survey characteristics for men in intervention group (n = 236)
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Self-testing behaviors

Table 6 shows the self-reported behavior of HIVST among participants at 1-month follow-up. Most participants (93.2%, n = 220) used the self-test kit at a private space away from the tent. Only 5.1% (n = 12) used the HIVST kit at the tent and 1.7% (n = 4) reported that they did not use the self-test kit. The majority of the participants 92.4% (n = 218) received a negative result while 4.2% (n = 10) received a positive result, close to the national HIV prevalence of 4.4% [26]. Approximately half of participants 53.0% (n = 125) reported that they did nothing after they received the results. Only 3.0% (n = 7) went to the health facility while 40.3% (n = 95) visited the study tent after receiving their results. Regarding the length of time participants took to use the self-test kit, 67.8% (n = 160) reported that they used the HIVST kit on the same day they received it and 30.5% (n = 72) used it after the first day.

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

As shown in Table 7, very few participants 1.7% (n = 4) reported that it was difficult to understand the HIVST kit instructions whereas 45.3% (n = 107) reported that it was normal. More than one-quarter of participants (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 confidentiality it offered. Approximately, half of the participants (52.5%, n = 124) were very satisfied 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.

Table 7 Perceptions of HIV self-testing among participants who used the kits (n = 236)
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Mobile technology use

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) 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.

Table 8 Mobile health and HIV self-testing (n = 236)
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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 beneficiaries and 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-specific 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.

Previous studies have reported on HIVST acceptability among men [27, 28], and men have cited the ease of use, privacy, convenience, and low cost of HIVST as advantages of HIVST over traditional HTS [29,30,31,32]. However, this study built on previous acceptability studies by investigating how peer-led promotion can drive acceptability and demand when combined with nurse-led distribution of HIVST in community settings. This intervention for men in Tanzania was also developed closely with inputs and guidance from national stakeholders involved in national HTS and HIVST programs, which make it uniquely positioned to contribute to national implementation science efforts. As a result, this study also provides additional evidence for collaboration between researchers and program implementers. 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 findings 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 [33].

The adapted STEP intervention also included the goals of the ADAPT-ITT model, which includes suitability of an intervention for adaptation, modification to fit 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 [14]. This study also builds on the success of prior recruitment of men from similar social networks as community health leaders in a prior intervention in Dar es Salaam [34]. Moreover, similar social network-based strategies for HIVST promotion and distribution have been reported with success in other parts of Tanzania and other countries [35,36,37,38] indicating that the feasibility of implementing similar interventions is likely generalizable to other parts of Tanzania. The MoH 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 [16, 39].

Limitations and future linkage to HIV care research

The study has several strengths and limitations worth highlighting. The first 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 developed and implemented in collaboration with national as well as community-based stakeholders, including MoH and CSO representatives, HIV program implementing partners, and male CHBSPs, which led to a rigorous investigation of the feasibility of STEP for national scale-up.

One limitation of this study is the possibility for selection bias among camps recruited. The camps recruited into the STEP study had been engaged in a previous public health study [40], and represent just 3.8% of the total camps we’ve previously mapped [40]. The possibility for selection bias could be mitigated by expanding the geographic area and increasing the sample size. An additional limitation of the study is the use of self-report to measure the outcomes of interest such as HIVST use and follow-up behaviors after obtaining HIVST results. Thus, there may have been an overstated report of HIVST use and lower reporting of HIV positive results. Future studies may mitigate the potential for inaccuracies in self-reported outcomes by combining self-report with objective biomarkers measurements of HIV status and ART adherence through both hair and blood [41,42,43,44]. In addition, there was a lack of follow-up confirmatory 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 through a recently funded study (STEP+cbNIMART) by the National Institute of Nursing Research (R01NR021169) 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 [45,46,47]. 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 compared to facility-based ART services [48, 49].

The results from the STEP study are significant given the dearth of research investigating the use of HIVST among Tanzanian men, despite the inclusion of HIVST in the National Guidelines for the Management of HIV and AIDS since 2019 [50]. HIVST implementation science studies in Tanzania have largely focused on other high-risk groups, such as FSWs and AGYW [51, 52], and have not included men as the target population. However, in Tanzania men lag behind women on all three 95–95-95 goals including knowing their HIV status among PLWH (84.8% vs 78.4%), initiating ART after receiving an HIV diagnosis (98.4% vs. 96.7%) and achieving viral load suppression (94.9% vs. 92.9%). Therefore, these results will expand the HIVST implementation science knowledge base in Tanzania, including to create the STEP + cbNIMART intervention, which will allow nurses to provide self-testers community-based follow-up services including ART for those who test positive and PrEP for those who test negative but are at high-risk for HIV. There is evidence that nurses who provide health promotion activities in the field (versus in the clinic) yield superior clinical outcomes than field-based paraprofessional community health workers [53, 54]. 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 [55].

The recently funded STEP + cbNIMART project, which is being implemented from 2024-2029 in collaboration with the Tanzania MoH, has the potential to be particularly impactful among men in regions where the HIV prevalence far outpaces the national average of 4.4%, such as Njombe (12.7%), Iringa (11.1%) and Mbeya (9.6%) [1]. The STEP + cbNIMART project may help Tanzanian men overcome the barriers that have been shown to inhibit their uptake of HIV care including long wait times at HIV clinics, distance, cost, and fears over confidentiality [56, 57]. Additionally, the intervention may help to mitigate the impact of stigma, which has been shown to inhibit HIV care in sub-Saharan Africa, particularly among heavily stigmatized populations such as men who have sex with men and people who use drugs [58,59,60,61,62,63].

The STEP + cbNIMART project will leverage the evidence from the cbART intervention [48] 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 efficiency (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 [53, 64, 65]. 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 confirmed, as well as PrEP for men whose self-test results are confirmed 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 [66]. 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 both governmental and non-governmental actors should consider this to maximize effectiveness of HIVST programming. Since the completion of the STEP intervention and the PEPFAR-funded Sauti project, the National Act was changed in December 2019 to allow HIVST to be offered in the country, and Tanzania has become a regional leader in HIVST implementation and scale-up. The national HIVST program will be informed by the findings of the new STEP+cbNIMART, which can the expansion of HIVST and linkage to follow-up services to close the gap in reaching men which remains an urgent priority.