 It's an honor to be here and present to you on behalf of our program. So a background on Swaziland or the Kingdom of Eswatini as it's been recently renamed. It's a small landlocked country in southern Africa, bordered by South Africa and Mozambique. There's a population of about 1.3 million and it's known worldwide as the country with the highest HIV prevalence. It's also known because it's the last absolute monarchy on the continent. So the HIV epidemic is generalized with a 27% prevalence and a 1.48% incidence as was measured in the Swaziland HIV Incidence Measurement Survey, the second round, which took place in 2016-2017. So MSF has been working in the country in the southern Mochisselwini region there at the bottom for almost over a decade actually. And together with the Ministry of Health has successfully decentralized HIV and TB care to the primary care level. Swaziland is well in its way to reaching the UN AIDS 90-90-90 targets by 2020. With an estimate of 85% of people living with HIV knowing their status, 87% of those on treatment and 92% of those on treatment have a suppressed viral load. So there are obviously gaps remaining and a large one is with the first 90 which has to do with HIV testing. So there are many opportunities to test for HIV in Swaziland both inside facilities and outside facilities. And MSF is supporting a large effort to bring community-based HIV testing to the community including door-to-door testing as well as hosting large testing events. However it's apparent that current testing strategies are still leaving some people behind, in particular males and youth aged 15-24. So what is HIV self-testing and why do we need it? It's self-explanatory but I will explain it anyway. It's a process in which an individual collects a specimen, performs a test and interprets the results by him or herself. So AuraQuick, the self-test that we use, is a WHO pre-qualified and FDA approved HIV-1-2 rapid antibody test which detects HIV antibodies in oral fluid obtained by swabbing the gums as shown by my colleague. It's considered a test for triage and we call it a screening test. So this means that any reactive result needs to be confirmed by further testing following a national algorithm. So there's two approaches. The first is assisted whereby an individual sees a demonstration of how to use the test and how to interpret the results. And then is accompanied by a trained provider while they do so. And the other is unassisted whereby the individual does the test on their own. So there are several barriers to current testing strategies such as access and confidentiality that HIV self-testing can help to overcome. And there's hope that self-testing can help to reach the remaining undiagnosed HIV cases in the country. So briefly some aims, objectives and methods of both the implementation and my presentation. Overall the aim of using HIV self-testing is to reach those undiagnosed cases and to do this by increasing testing. And the aim of our implementation was to demonstrate that it was feasible to use HIV self-testing in rural Swaziland. The objective of this presentation is to describe the pilot implementation which took place between May 2017 and January of this year. And to do this I will retrospectively analyze routinely collected data and present to you just some frequency and proportions. So I'll take you through the implementation process starting with a nice photo of one of our colleagues who's demonstrating how to use the HIV self-test. I have one here. He's showing how to use this kit to a group in a rural community. So HIV self-testing was integrated into the already existing HIV testing strategies in the facility and in the community. So in both of these approaches the clients had a choice of testing method either assisted or unassisted. Plus clients could also choose to take an additional kit home for their partner or for their peer. They were also made aware of various supportive tools. There was a hotline that was manned 24-7 by a trained counselor. There were also follow-up phone calls that were made to them to follow up and see if they were having any issues. There was information education and communication material that was translated into C SWATI and distributed with each test. As well there was an instructional video which was shown before distribution of tests and the video could also have been shared on WhatsApp if it was required. So the facility-based implementation took place in the Sangano Health Zone, which is one of three health zones that comprise the Shisselini region. And self-testing was offered at 10 health facilities in this zone. The community-based distribution was offered in all three health zones at events held at targeted workplaces. We have a lot of forestry and clothing factories, so we held some testing events there. We also had general testing events like sport days and also youth days. And these are shown in the three regions with the circles, the size of the circles proportional to the number of people who were tested. So now I'll just take you through some descriptive results of our implementation, showing you here some photos of the process. We have one photo of a colleague again demonstrating the self-testing in a rural community. We have another photo in the middle of another colleague who's showing the video to some potential testers before their testing. And we have our last photo here of four of our HIV testing counselors with their wearing our t-shirt that says test yourself in C SWATI. So this figure shows the distribution of HIV self-testing kits by model, so the community and the health facility model. In total, 1,933 people were reached. This is the orange bars. And in total, 2,468 self-testing kits were distributed. You'll see that more kits were distributed than people reached because about 27% of clients took a second kit for their partner. This happened more often in the community than in the health facility. And overall, more kits and people were reached in the community than in the health facility. So now I'll show you the distribution of people reached by gender. So this is disaggregating that orange bar just by gender. So overall, 46% of people reached were male with an almost equal distribution in our community testing events. And about 35% of people in the health facility using self-testing were male. The median age was 29 years with a range of 16 to 78. And almost one third of people reached with self-testing were youth. This figure shows the distribution of testing by method. I mentioned clients had a choice of the unassisted or the assisted. And there was an overwhelming preference for the unassisted testing with 87% overall. This was 95% in the community events and 64% in the health facility. Of the 258 tests that were conducted with the help of a trained provider, 13 were reactive, which is 5%. So we also, as I mentioned, had a hotline. So we recorded the calls we received to this hotline during the nine-month period. In total, we received 215 phone calls. A slight majority of the calls were by men, 54%. And the majority of the reason for calling was to report the actual results at 69%. And two people called to report that they'd had a positive HIV self-testing result. So during the pilot, we were also asked by the Ministry of Health to make some phone calls, follow-up phone calls to people to whom we distributed the test. So our counselors called 640 clients. After about two weeks of giving them the test to allow them to use it. Of those called, 84% reported that they'd already used the test. And of those 19, so 3.5% reported that the test results were reactive. So in total, we found 34 reactive HIV self-tests. Out of the 944 for whom we have somewhat good estimate of their result, this is about 3.5%. So 13 of these came from the assisted method and the remaining were from self-report. 19 from the follow-up phone calls we made. And two from the calls made to us. So of those 34, 21 went on to have a rapid test done. And 20 of those were concordant positive, so 95%. 19 of those were then linked to HIV care, meaning enrolled in pre-art or art. And this was confirmed at clinics. So I'll just take you through some limitations and lessons learned of our pilot. So the limitations come mostly from the rather light data collection approach, which leaves a few questions unanswered. Possibly the proportion of people testing for the first time with self-tests. Also there's a large proportion of results that we don't know. However, we can question whether or not it's entirely appropriate to call everyone after delivering a self-test in this implementation approach as one of the main added benefits of self-testing is the patient empowerment and autonomy and confidentiality that comes with this self-testing. An additional limitation is that it wasn't a main objective of our implementation to directly compare outcomes between self-testing and blood-based testing, so we don't have a solid comparison group. The last limitation I'll mention is that HIV self-testing was distributed by trained healthcare workers, both in the facility and also in the community, which has obviously higher HR costs and would somewhat limit the reach of how far we can go with our self-testing. However, we did have secondary distribution. So clients were given an additional test for their partner or peer, and this is a good avenue to reach those people who are not coming to the community events or to the facilities for testing. We found that more men tested in the community than in the health facility, and we found an overwhelming preference for the unassisted testing. No adverse events were reported via our hotline or via the follow-up phone calls. So in conclusion, we found that HIV self-testing was feasible in this rural setting, and it has actually been adopted as a national testing strategy and is being scaled up in the remaining three regions of Swaziland. In the future, we're planning to explore distribution through less trained or actually non-healthcare workers, for example, traditional healers, community workers or peer educators, to reach those who don't access the formal health system. And also we are planning to integrate HIV self-testing into our pre-exposure prophylaxis study giving HIV self-test to the prep clients for themselves to use in between their follow-up visits as well as to distribute to clients who have partners with unknown HIV status. So with that, I would like to say thank you very much to you, the audience for your attention and the community for their participation, and thank you very much to my colleagues in Swaziland for their hard work and the Ministry of Health for their support. Thank you.