Targeting truckers for HIV testing and care is essential to ending the epidemic in Sub-Saharan Africa. Drivers often have multiple sex partners—including sex workers—in different locations along their routes.
In the mid-2000s, research by the World Food Programme (WFP) found that transport companies in Sub-Saharan Africa had lost more than 50 percent of their truck drivers to HIV and AIDS. Due to the transient lifestyle associated with their profession, along with the high prevalence of HIV and AIDS in the region, an entire generation of truck drivers was at risk.
In light of this health crisis, the WFP and TNT, a commercial transport and logistics company, founded the North Star Alliance, a non-profit that runs a network of roadside clinics created out of blue-painted shipping containers located at truck stops across the continent. These clinics originally focused primarily on HIV counseling and testing (HTC) services but later expanded to offer a diverse menu of primary and secondary healthcare services.
Elizabeth Kelvin, CUNY SPH Associate Professor of Epidemiology and Biostatistics and Interim Assistant Dean for Curriculum Innovation and Implementation, read about the “blue-box clinics” and was intrigued. She knew that stigma was a major factor preventing many people in the region from getting tested, and she wondered if truck drivers might be more likely to test if they could privately use an HIV self-test kit, such as the one recently approved by the FDA for use in the United States.
Previously, tests required a drop of blood drawn from a patient. The innovation of self-testing kits which use a saliva sample created the opportunity for evaluating how much privacy factors into the overall screening equation.
Kelvin consulted her colleague Gavin George, senior researcher at HEARD, a division of the University of KwaZulu-Natal in South Africa that conducts research on the socio-economic aspects of public health. They discussed designing a study on HIV self-testing among truck drivers with the North Star Alliance Southern Africa, which has its headquarters in Durban. Shortly thereafter, the International Initiative for Impact Evaluation (3IE) put out a call for proposals on HIV self-testing in Kenya, where the North Star Alliance East Africa headquarters are located and where they have eight clinics.
“So North Star in Southern Africa introduced us to Eva Mwai, the Regional Director for North Star in East Africa, and the rest is history,” Kelvin said.
The team was joined by Kaymarlin Govender from HEARD, Joanne Mantell from the HIV Center at the NYS Psychiatric Institute and Columbia University, and CUNY SPH doctoral student Matthew Romo, who served as the Project Director. They conducted a small trial in which 305 truck drivers were recruited from two North Star clinics in Kenya and randomized to be offered either the standard HIV test (a provider-administered rapid blood test) or a choice between the standard test and a rapid oral HIV self-test.
This map shows the majority of the Blue Box clinics and clinics established by North Star that are operated by other service providers.
The researchers found that those in the choice arm were significantly more likely to test for HIV. However, as study participants had been recruited from clinic waiting rooms, the team still questioned whether making HIV self-testing available could increase the number of truck drivers coming to the clinics for HIV testing. Therefore they conducted a second trial that took advantage of the North Star Alliance electronic health record system to select a sample of 2,262 Kenyan truck drivers who had a mobile phone number registered in the system and who had not been accessing HIV testing on a regular basis and randomized them to receive text message announcements about the availability of HIV self-test kits at North Star clinics in Kenya versus text reminders that HIV testing in general was available at the clinics. Those receiving the text about self-testing were significantly more likely to come to a North Star clinic for HIV testing.
One of the factors that puts truck drivers at risk for HIV infection is their patronage of sex workers. In 2016, the group conducted a similar trial among a sample of 2,196 female sex workers registered in North Star’s heath record system and found similar increases in HIV testing rates among those receiving text messages about HIV self-testing.
Kelvin and her colleagues are currently exploring mechanisms to make HIV self-testing available in the North Star Alliance East Africa clinic system and have submitted an Implementation Science grant proposal to the National Institute of Health to study the impact of various HIV self-testing program designs in this real-world healthcare setting.
Maps drawn by outreach workers of “hotspots” for sexual networks, where individuals are likely to engage in risky behaviors that can result in HIV transmission.
The North Star Alliance’s roadside wellness clinics provide access to HIV testing and medication as well as general primary care.
North Star’s electronic health record system is unique in that it tracks the use of healthcare service in a multinational clinic system. The potential for the system as a resource for further health research is currently being explored by CUNY SPH doctoral student Elizabeth Ortiz, who is using data from the system to examine the burden of chronic disease among clients across the continent. Aside from HIV and AIDS, mobile populations are also at risk for noncommunicable diseases such as diabetes, hypertension and obesity.
Ortiz received the Dean’s dissertation travel award last year to travel to North Star Alliance headquarters in South Africa and Kenya in August to continue her research. She conducted site visits and interviewed clinicians to gain a better understanding of service delivery. She worked with data managers in the regional offices to review the electronic health record data that she will use for her dissertation.
“While I began working with the electronic health record extracts in New York, it was helpful to meet with my research partners on-site to address data quality issues,” Ortiz said.
The research is mutually beneficial, Ortiz says, because the findings could help inform the North Star Alliance’s programming going forward.
Doctoral student Elizabeth Ortiz and Associate Professor Elizabeth Kelvin.
