Women are successful in promoting HIV self-testing in Kenyan men

Promoting male partner HIV testing and safer sexual decision making through secondary distribution of self-tests by HIV-negative female sex workers and women receiving antenatal and post-partum care in Kenya: a cohort study.

Thirumurthy H, Masters SH, Mavedzenge SN, Maman S, Omanga E, Agot K. Lancet HIV. 2016 Jun;3(6):e266-74. doi: 10.1016/S2352-3018(16)00041-2. Epub 2016 Apr 8.

Background: Increased uptake of HIV testing by men in sub-Saharan Africa is essential for the success of combination prevention. Self-testing is an emerging approach with high acceptability, but little evidence exists on the best strategies for test distribution. We assessed an approach of providing multiple self-tests to women at high risk of HIV acquisition to promote partner HIV testing and to facilitate safer sexual decision making.

Methods: In this cohort study, HIV-negative women aged 18-39 years were recruited at two sites in Kisumu, Kenya: a health facility with antenatal and post-partum clinics and a drop-in centre for female sex workers. Participants gave informed consent and were instructed on use of oral fluid based rapid HIV tests. Participants enrolled at the health facility received three self-tests and those at the drop-in centre received five self-tests. Structured interviews were conducted with participants at enrolment and over 3 months to determine how self-tests were used. Outcomes included the number of self-tests distributed by participants, the proportion of participants whose sexual partners used a self-test, couples testing, and sexual behaviour after self-testing.

Findings: Between Jan 14, 2015, and March 13, 2015, 280 participants were enrolled (61 in antenatal care, 117 in post-partum care, and 102 female sex workers); follow-up interviews were completed for 265 (96%). Most participants with primary sexual partners distributed self-tests to partners: 53 (91%) of 58 participants in antenatal care, 91 (86%) of 106 in post-partum care, and 64 (75%) of 85 female sex workers. 82 (81%) of 101 female sex workers distributed more than one self-test to commercial sex clients. Among self-tests distributed to and used by primary sexual partners of participants, couples testing occurred in 27 (51%) of 53 in antenatal care, 62 (68%) of 91 from post-partum care, and 53 (83%) of 64 female sex workers. Among tests received by primary and non-primary sexual partners, two (4%) of 53 tests from participants in antenatal care, two (2%) of 91 in post-partum care, and 41 (14%) of 298 from female sex workers had positive results. Participants reported sexual intercourse with 235 (62%) of 380 sexual partners who tested HIV-negative, compared with eight (18%) of 45 who tested HIV-positive (p<0.0001); condoms were used in all eight intercourse events after positive results compared with 104 (44%) after of negative results (p<0.0018). Four participants reported intimate partner violence as a result of self-test distribution: two in the post-partum care group and two female sex workers. No other adverse events were reported.

Interpretation: Provision of multiple HIV self-tests to women at high risk of HIV infection was successful in promoting HIV testing among their sexual partners and in facilitating safer sexual decisions. This novel strategy warrants further consideration as countries develop self-testing policies and programmes.

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Editor’s notes: This paper presents a novel approach to promoting HIV self-testing strategies among men and couples, by distributing self-tests through social and sexual networks of women. Women attending antenatal clinics, post-partum care, and sex workers were briefly trained on how to use the Ora-Quick self-test kit, and then given five kits to take with them and give to people in their networks. This strategy allowed women and their partners to choose when and where they tested, often together and in the comfort of their own environments. The majority of women reported having distributed self-test kits to partners/clients and undertaking couples testing. Further, according to participant’s report, 58% of people testing positive linked to HIV care (and linkage was unknown in 35%). Interestingly, the on-the-spot, or point-of-sex testing allowed individuals to decide whether to continue with sexual encounters according to status, which reportedly proved to be especially useful to the female sex workers. There were four reported cases of violence resulting from test use, and this should be closely watched in future research. This is the first study to assess the potential for secondary distribution of HIV self-test kits by multiple populations of women to promote HIV testing in their male partners, and overall, the results indicate that this model is a promising strategy for promoting further HIV-testing, leading the field closer to the UNAIDS 90-90-90 treatment target and improved HIV prevention as well. 

Africa
Kenya
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