www.aids2014.org hiv self-testing for couples in resource-poor contexts in urban malawi nicola...
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www.aids2014.org
HIV self-testing for couples in resource-poor contexts in urban Malawi
Nicola DesmondWellcome Trust Fellow
Liverpool School of Tropical MedicineMalawi-Liverpool-Wellcome Trust Major Overseas Programme
IAC, Melbourne, Australia
July 21st -26th 2014
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Human Rights concerns
• Increased risk of unmanaged anxiety
• Negative impacts by bypassing counseling
• Potential for coercive testing– 3% participants in Blantyre, Malawi
• Lower test accuracy
• Lower linkage to care
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HIVST in urban Malawi
• 16,600 adult residents
– free access to 1 HIVST per year– semi-supervised via community-
based counselors
• Testing in private – pre & post-test counseling– encouraged to include partner
• Linkage to confirmatory testing
& care via counsellors to direct to study clinics
28 clusters: ~ 1,200 adults (16+)
Primary clinics
District hospital
National HIV prevalence: 11.9%Doctors /1000 population: 0.02
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Methods: 2 cohort studiesKumwenda et al
• 51 couples• 12 months FU• Mixed methods• 12 months follow up
– Face to face survey– Audio computer assisted
self-interviews (ACASI)– Daily diary study– In-depth serial biographical
interviews with both partners individually
Desmond et al
• 17 couples• 12 months FU• Serial in-depth interviews
– Both partners individually
“Couples-testing” HIVST: 14% participants
Malawi HTC: 14% clients
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EXPLORING NEGATIVE IMPACTS THROUGH BYPASSING COUNSELING
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Deconstructing couples HIVST: access & presentation
• Majority of couples came into HIVST through counselor-initiated approaches
• Most couples testers had previously tested with a partner
Men Women0%
20%
40%
60%
80%
100%
Client-initiatedDoor-to-door
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Deconstructing couples HIVST: steps taken together
• Majority of men & women in couples received pre-test counseling with a partner (69%)
• Men more likely have received both pre- AND post test counseling
Collection of test kit
Pre-test counseling
Testing Reading results
Post-test counselling
0102030405060708090
67.5 68.9
84.9 83.8
71.4
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Disclosure enhanced• High proportion (99%) of participants shared
results with partner– whether or not they read the results at the same
time
• Use of HIVST to disclose previously known +ve status common and motivated by:– Guilt– desire to foster openness – mistaken assumption of concordance & ensuring
access to care
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Assumptions of HIV concordance
‘… this is why I invited the counselor to test us after realizing that it was not good that I should continue hiding that I am HIV+ve from her …
I expected that she would also be positive. I did not believe it when her result was negative after all these years that I have lived with her’
Male partner, HIV positive, Discordant couple
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GENDERED NATURE OF DECISION-MAKING
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Decision-making: individual motivations for couples testing
Known to be positive• Self-checking “cure”: known HIV status
– Through beliefs in cure through prayer – Through long-term ART
• Linking back into HIV care after ‘defaulting’
From the perspective of being in a relationship• Assessing the strength and fidelity
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Evidence of coercive testing?
• Coercive testing reported by 3% in parent study
• 78% of individuals in couples study reported they had not been influenced at all to test
• Some felt pressure to test from partner & unable to ‘opt-out’– To show commitment to relationship– To remove existing mistrust
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Gendered response to acceptable force
– Lower levels of coercion reported for women– Men *more* likely to report coercion from partner– Gender-based violence normalized and pervasive
Marital Status % of women who experienced physical violence since age 15
Number of women
Ever Past 12 mos
Currently married
28.3% 15.9% 6,856
Divorced / separated
42.2% 16.5% 5,832
Widowed 14.5% 2.1% 1,365
Never married 23.1% 10.8% 1,647
DHS Malawi 2010
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Male pressure to test
‘My husband just gave me the test-kit and told me to test. I feel that this is a problem …
I did not have a choice to say no … my husband initially went to test alone. According to his test results, he also wanted me to get tested … so I was in a dilemma’HIV-ve wife in discordant partnership
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Female pressure to test
‘When I got the kit I took two days without testing, then my wife said that I won’t eat that day if I don’t test.
She went to the bedroom and poured water on my clothes. There was force, I knew that if I don’t test then there won’t be sex for me’
Husband in concordant HIV –ve couple
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HIVST empowering women in relationships?
• Women able to break existing barriers– household decision-making– power dynamics– resident volunteers reinforce and
destigmatise testing and couples testing
• Gendered response to “acceptable” force – Men more likely to report coercion from
partner than women
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Conclusions to date
• Low levels of formal “couples HIVST” overall– How best to promote couples HIVST for “first-time” testers?
• The option of HIVST is empowering for women wanting to promote couples testing – Important social reinforcement from community counsellor
• Decisions shaped by gender and power relations within the household
• Need for more research on coercion– Unpacking the implications of gendered social norms and acceptability
of GBV
• Discordancy identified through HIVST presents complex challenges
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Acknowledgements
• Mr Moses Kumwenda - MLW• Dr Sally Theobald - LSTM• Dr Miriam Taegtmeyer - LSTM• Professor Liz Corbett – LSHTM• Dr Mavuto Mukaka – Johns Hopkins, US• Dr Ireen Namakhoma - Reach Trust• Dr Lignet Chepuka - LSTM• Mr Simon Makombe - MoH Malawi• Professor Janet Seeley - MRC Uganda• Professor David Lalloo - LSTM• Professor Rob Heyderman - LSTM• Ms Effie Chipeta - MLW• Ms Wezzie Lora - MLW
Community men & women in urban Blantyre
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Uptake since introduction of HIVST
Couples uptake • Round 1: 932 (14%) couples of 13,655 tests• Round 2 (Repeat testing): 1201 (16%) couples of 15,009
tests
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Exploring the social impacts of HIVST in couples
• Decision-making dynamics
• Nature & extent of coercive testing
• Sexual behaviour & risk compensation
• Gendered household relations
• Role of counseling