Confidential social network referrals for HIV testing (CONSORT) - Ending the HIV epidemic in the United States will require applying lessons from successful efforts in high-prevalence, low-resource settings such as Tanzania, a PEPFAR strategy country. In Tanzania, only 83% of people living with HIV (PWH) are aware of their status, and substantial testing gaps remain concentrated among populations at elevated risk of HIV acquisition. With the cost-effectiveness of traditional HIV testing approaches declining, we propose to evaluate a novel application of mobile health (mHealth) technology that leverages the ubiquity of mobile phones and the reach of social networks to increase rates of HIV testing, especially among higher-risk individuals. Specifically, we will evaluate the acceptability, efficacy, and cost-effectiveness of automated, confidential, SMS-based HIV testing referrals as a means of ‘nudging’ individuals to test. This study, conducted in northern Tanzania, will address the following aims: R21 Phase: Aim 1 will conduct qualitative, formative work with HIV counseling and testing (HCT) providers, HCT clients, PWH who are in care at HIV care and treatment centers (CTCs), and social network contacts of HCT and CTC clients, to identify desirable characteristics of an SMS-based HIV testing referral system. Aim 2 will adapt our mParis system to receive phone numbers of HIV testing referrals and autonomously send confidential HIV testing invitations. Aim 3 will pilot-test the Confidential Social Network Referrals for HIV Testing (CONSORT) system to collect preliminary data on the system’s acceptability, performance, and potential efficacy. R33 Phase: Aim 4 will evaluate the acceptability and efficacy of CONSORT in a pragmatic randomized controlled trial with 600 clients enrolled from HCT centers and CTCs. Arm 1 participants will be offered confidential SMS referrals and physical invitation cards (“card referrals”) to extend to any of their network contacts. Arm 2 participants will be offered card referrals alone. The primary outcome will be uptake of HIV testing. Secondary outcomes include the number of new HIV diagnoses, and the risk correlation within referral networks. Aim 5 will evaluate the incremental cost-effectiveness of CONSORT. Justification for foreign component: In Tanzania, only 78 percent of PWH reported knowing their status, a rate that is similar to that in the Southern United States. A randomized trial of digital social network referrals for HIV testing in Tanzania will provide rigorous evidence on whether an innovative, scalable, and potentially cost-efficient strategy can improve case-finding and testing uptake in a high-burden setting. Our existing mHealth system and strong relationships with all HCT and CTC providers in the study area allow us to evaluate the system’s acceptability and effectiveness in a nearly closed system. Owing to a higher HIV prevalence in Tanzania, the statistical power of the trial to identify undiagnosed PWH and link them to care is higher than if conducted in the US, while costs are substantially lower. Potential benefit to American health: Completing this study is critical for informing HIV prevention efforts in the United States — particularly in rural communities and in the southern United States, where stigma and access barriers remain substantial. The technologies developed through this project are readily deployed at minimal cost in the United States.
