Findings from the Todurujo Na Kadurok (Empowering Youth) HIV Self-Testing and Edutainment Comic Randomized Controlled Trial with Refugee Youth in a Humanitarian Setting in Uganda

Background and Purpose: HIV vulnerabilities among refugee youth are shaped by structural and social factors in humanitarian settings that constrain access to HIV prevention and testing. Although HIV self-testing (HIV-ST) is particularly promising among youth, humanitarian contexts are underserved by HIV-ST. Comic books, a form of graphic medicine whereby images are juxtaposed by text reflecting internal and external narratives to share health information (known as 'edutainment'), are understudied in the context of HIV-ST. Uganda is African’s largest refugee hosting nation with >1.5 million refugees. We evaluated the effectiveness of HIVST and edutainment comics in increasing HIV testing with refugee youth in Bidi Bidi refugee settlement, Uganda.

Methods: We conducted a qualitative formative phase with focus groups with refugee youth to create an edutainment comic informed by HIV prevention cascade dimensions (motivation, access, effective use) to address HIV testing barriers and facilitators in Bidi Bidi. We then conducted a randomized controlled trial in Bidi Bidi with a purposive sample of refugee youth aged 16-24. Arms included: (1) HIV-ST; (2) comics; (3) HIV-ST with comics; and (4) standard of care (SOC). Intervention effects on primary (HIV testing uptake) and secondary (e.g., HIV knowledge) outcomes at 3-month follow-up (T2) were assessed using generalized estimating equation (GEE) models. Open-ended textual feedback was collected on perceptions and experience with HIV-ST.

Results: There was 98% retention (n=117/120) of participants (n=120; mean age: 20, standard deviation: 2.3) at T2. In adjusted analyses, in comparison with the SOC at T2, HIV testing odds were highest in Arm 3 (adjusted odds ratio [aOR]: 8.46; 95% confidence interval [CI]: 2.87-24.97) followed by Arm 2 (aOR: 4.14; 95%CI: 1.58-10.87), with no significant differences with Arm 1 (aOR: 2.81; 95%CI: 0.96-8.16). Arm 1 at T2 reported lower HIV-related stigma (aβ: - 0.95, 95%CI: -1.9, -0.03), reduced condom use at last sex (aOR: 0.21, 95%CI: 0.07-0.65), and lower consistent condom use compared to the SOC (aOR: 0.010, 95%CI: 0.02-0.58). In secondary analyses including all participants, there were statistically significant T1 to T2 increases in HIV testing (aOR: 21.79; 95%CI: 4.57-103.93), HIV knowledge (aβ: 1.45; 95%CI: 0.93-1.97; p<0.001), and safer sex efficacy (aβ: 3.64; 95%CI: 2.09-5.19; p<0.001). We unexpectedly found that every HIV-ST arm participant sought clinic-based confirmatory testing, even with a negative HIV-ST result. Qualitative narratives revealed multi-faceted mistrust underlying this decision-making, including mistrust of the HIV-ST kit and one’s competence using it. Narratives identified perceptions of HIV-ST as private, convenient, and empowering, and self-testing increased confidence to visit health clinics. The comic was described as providing technical (e.g., information) and transformative (e.g. reducing HIV-related stigma) communication.

Conclusions and Implications: Findings indicate the benefits of HIV-ST and edutainment comics in meeting refugee youth’s HIV testing needs in Bidi Bidi. HIV testing uptake was higher for those who received either the HIV-ST kit alongside the comic, or the comic alone, compared with SOC. Future research can strengthen HIV prevention literacy with refugee youth. This intervention approach, combining HIV-ST with edutainment comics, can be considered for youth in other humanitarian settings to increase HIV testing.