FIVE STUDIES ON HIV SELF-TESTING IN KENYA: WHAT WE LEARNED FROM AND ABOUT FORMATIVE RESEARCH

Annette N. Brown, PhDInternational Initiative for Impact Evaluation, 3iePresentation for the HIVST satellite session sponsored by WHOIAC, Melbourne, July 2014

3ie HIV self-testing grants program

• Fund pilot programs using HIV self-tests accompanied by impact evaluations

• Test for both intended positive outcomes and unintended negative outcomes

• Implement country by country (3 countries)• Start with Kenya (12/2012)

• Formative research• Impact evaluations

Formative research themes• Accuracy • Packaging and labeling• Potential users and messaging• Distribution outlets• Linkage to counseling and care• Potential social harms and abuses

Methods• Four of five studies used medium to large sample

surveys, three of these used random sampling• One study used small sample qualitative data collection• Heterogeneous samples, but not population

representative samples• Studies employed basic statistical analysis and some

qualitative analysis• One of five used actual self tests as part of study• Our summary analysis is primarily narrative• Most summary findings include evidence from more

than one formative study

Formative research findings• Do people want it?

– Why? Why not?– Who?

• Does it work?• Where would people get it?• Will people get counseling and/or care?• What are people worried about?• How can we address concerns?

Do people want it?

• 5/5 studies report near universal “acceptability”: >90%

• 3/5 studies report acceptability among never tested: 80% - 91%

• FSW: 98%• MSM: 57%

Do people want it?• One study [3]

– Men• Never tested would like to be tested: 70%• Never tested would purchase and use if available:

86%– Women

• Never tested would like to be tested: 58%• Never tested would purchase and use if available:

80%

• Another study [1]– Men never tested who would use a self-test:

90%

Why would people use self-tests?Figure 3: Distribution of survey respondents and service providers by reasons for potential use of HIV oral self-test kits

Notes: Question allowed for multiple responses.

0 20 40 60 80

Easy/ simple/ convenient

Guarantees confidentiality

Can be done at home

Can save time/money

No blood/ pricking/ pain

Can know test results fast

Other

69.3

60.5

29.6

12.2

10.6

8.1

4.0

70.8

56.7

34.9

14.7

8.8

10.9

5.7

75.7

64.2

41.0

18.1

18.8

14.9

1.7

Percent

Service providers Survey men Survey women [1]

Why would people self-test?Reasons why self-test Males Females

Private 70.9% 56.7%

Early treatment 20.1% 24.7%

“No worry” if negative 9.0% 19.5%

Know status 13.8% 11.1%

Easy to use 13.0% 9.9%

Convenient 12.6% 9.5%

Test is accurate 5.9% 3.4%

Protect regular partners 6.7% 1.0%

Protect other partners 1.7% 1.4%

Other 3.4% 3.6% [3]

Why not self-test?

Mombasa Siaya Average TotalReasons not to use the kit on their own % % % nAfraid of finding out positive result while alone 46.9 41.2 44.9 22Health workers are more knowledgeable 18.8 17.6 18.4 9Afraid of misinterpreting results 12.5 35.3 20.4 10Other 21.9 5.9 16.3 8

[2]

Who would use it?

• Ever been tested more likely [2] [3]• Men more likely [3]

Does it work?• Sensitivity: 92.9% (89.7%)

– Unobserved sensitivity in US: 91.7%• Specificity: 97.8% (98.0%)• Invalids: 15% (men and never tested more

likely)

[5]

Where would people get it? Indicator

Women(%)

Men(%)

Both sexes(%)

Main preferred distribution channel Public health facility 63.2 59.0 61.8 Private health facility 4.6 3.0 4.1 Faith-based/NGO health facility 3.0 2.3 2.7 Stand-alone VCT center 0.3 0.0 0.2 Mobile clinic/tent/outreach 2.1 2.0 2.1 Private pharmacy 7.5 5.7 6.9 Community health worker 2.9 2.0 2.6 Community-based distributor 0.9 1.4 1.0 CBO/self-help group 0.3 0.2 0.3 Non-governmental organization 0.0 0.0 0.0 Local administration 6.8 11.3 8.3 Social marketing events 0.2 0.7 0.4 Local shops/supermarkets 4.1 8.2 5.4 Family member/relative/friend/neighbor 0.1 0.2 0.2 Traditional birth attendant 0.2 0.0 0.2 Other 3.9 4.1 3.9

Table 6: Percent distribution of survey respondents who would use HIV oral self-test kits by main preferred distribution channels [1]

Where would people get it?

Other distribution channels

Women(%)

Men(%)

Both sexes

(%)Other channels apart from public health facility

(N=574) (N=260) (N=834)

Private health facility 24.7 21.5 23.4 Mobile clinic/tent/outreach 16.0 13.9 15.4 Private pharmacy 23.2 21.5 22.7 Local administration 15.7 18.9 16.7 Local shops/supermarkets 11.0 13.1 11.6

Table 8: Percent distribution of survey respondents who would use HIV oral self-test kits by other preferred distribution channels apart from the main one mentioned

[1]

What are people worried about?

70.7% of men and 54.9% of women feel there are disadvantages [3]• Might commit suicide• Anxious or depressed (men more than women)• Not disclose (men more than women)• Harm others (men more than women)• Counterfeit kits (men more than women)

What are people worried about?66.2% of men and 54.7% of women feel that self-testing would be misused or abused [3]Perceived abuses Male Female

Intentionally infecting others 70.7% 90.5%

Testing partner without consent 73.0% 59.5%

Parents testing children w/o consent 80.9% 49.5%

Testing people without consent 45.4% 52.0%

Testing potential employees 36.6% 46.9%

Schools testing children 31.7% 41.1%

Disclosing others’ HIV status 19.9% 53.9%

Don’t know 3.0% 5.0%

What would people do?What would people do if positive? [3]• Seek counseling: 41.4% | 35.8%• Confirm results: 22.0% | 19.5%• Seek medication: 10.7% | 18.9%

• Go into depression: 9.0% | 8.3%• Keep results secret: 4.8% | 2.2%…• Commit suicide: 1.9% | 1.6%• Intentionally infect others: 0.2% | 0.0%

How to address concerns?Ways to prevent abuses Male FemaleMake non-consensual testing illegal 39.5% 22.2%Self-testing kit used only by person who receives

30.9% 14.4%

Provide only one self-testing kit per person 21.5% 18.3%Sensitization 17.7% 14.7%Other ways 5.4% 11.1%Don’t allow home self-testing 5.1% 10.8%Pre-counseling 5.9% 6.2%Restricted distribution points 3.2% 3.3%Legal penalties for misuse 4.8% 0.3%Age restrictions for purchase 1.3% 1.3%

[3]

Messaging findings

• Mass media sensitization and awareness campaigns – Come from MOH– Inform: address concerns and advantages– Educate: importance of confirmatory test,

disclosure, linkage to care, prevention• Prior to and during roll-out

[2]

www.aids2014.org

Packaging and labeling findings

• Packaging secure• Small size• Labeling—with quality

seals, informative– Improved instructions

—simple, explicit– Information about

storage, expiration• May require point of

distribution instruction [4]

Linkage to care findings

• Strong desire for face-to-face counseling [3]

• Telephone hotline not preferred [3]

• Public health facilities strongly preferred for counseling before and after [1]

Main conclusions• High acceptability and likelihood of use• Accuracy not much different from US• Health facilities are a desirable outlet• Perceptions of disadvantages and abuses do

exist• Big differences between men and women• Mass messaging important• Packaging and labeling important

What did we learn about formative research?

• Sensitivity of findings to question formats and choices listed

• High occurrence of priming• Useful, but no substitute for impact

evaluation of pilot programs

Formative studies[1] “Possible channels for distribution of HIV oral self-test kits in Kenya” Jerry Okal, Francis Obare, Waimar Tun, James Matheka[2] “Insights into potential users and messaging for HIV oral self-test kits in Kenya” Rhoune Ochako, Lung Vu, Katia Peterson[3] “Understanding perceived social harms and abuses of oral HIV self-testing in Kenya” Caroline W. Kabiru, Estelle M. Sidze, Thaddaeus Egondi, Damar Osok, Chimaraoke O. Izugbara[4] “How HIV self-testing kits should be packaged in Kenya” Olivier LeTouzé[5] “Accuracy of oral HIV self-tests in Kenya” Ann E. Kurth, Abraham M. Siika

HIV Evidence Initiative

Annette N. BrownAnna HeardEric DjimeuNancy Diaz