Elsevier

The Lancet HIV

Volume 3, Issue 6, June 2016, Pages e266-e274
The Lancet HIV

Articles
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

https://doi.org/10.1016/S2352-3018(16)00041-2Get rights and content

Summary

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.

Funding

Bill & Melinda Gates Foundation.

Introduction

About half of HIV-positive individuals in sub-Saharan Africa are unaware of their serostatus.1 Increasing the uptake of HIV testing among these individuals is essential to ensure the success of HIV treatment as prevention and to meet the UNAIDS 90-90-90 targets. Although wider availability of facility-based HIV testing and counselling services and community-based HIV testing and counselling strategies have helped to increase testing coverage,2, 3 achieving high levels of testing coverage has proven challenging in many countries. Men in particular are far less likely to test than are women.1 There is also a dearth of HIV testing and counselling interventions targeted to key populations such as female sex workers, who can benefit from regular repeat testing.3 Couples testing is particularly rare, even though it can have substantial health effects through improved sexual decision making and increased antiretroviral therapy (ART) use to prevent HIV transmission.4, 5

HIV self-testing is a promising approach that has the potential to substantially increase access to testing for individuals and couples in a manner that is confidential and empowering for users.6, 7 Rapid testing technologies include simple-to-use oral HIV tests that offer high sensitivity and specificity, ideal for HIV self-testing strategies. Previous studies have documented high interest in and acceptability of HIV self-testing among a wide range of populations, including those with lower likelihood of testing in other HIV testing and counselling strategies or higher risks of being HIV-positive.6, 8, 9 Some countries, such as Kenya, have already included regulated HIV self-testing in their national HIV testing and counselling guidelines and several are considering scaling up the availability of self-tests.10, 11

Research in context

Evidence before this study

We searched PubMed for studies published until March 1, 2016, with the terms “HIV” AND (“self-test*” OR “home test”). Several studies have noted high acceptability, accuracy, and safety of HIV self-testing in sub-Saharan Africa among individuals who directly receive a self-test. Community-based studies in Malawi have shown high uptake of self-testing, as well as linkage to HIV care that is comparable to what is found in other testing strategies. However, little is known about optimal distribution strategies to facilitate self-test use by high-risk, hard-to-reach individuals and to identify HIV-positive individuals. As opposed to primary distribution strategies that directly reach these individuals, secondary distribution is a strategy in which easier-to-reach individuals are given multiple self-tests to distribute to harder-to-reach individuals such as sexual partners or others in their social network. One pilot study involving a sample of high-risk men who have sex with men in the USA explored the feasibility of secondary distribution of HIV self-tests. 27 participants documented high acceptability and showed potential for use of self-tests to screen sexual partners. No studies in sub-Saharan Africa have explored secondary distribution of self-tests by pregnant and post-partum women or other key populations such as female sex workers.

Added value of this study

To our knowledge, this is the first assessment of the potential for secondary distribution of HIV self-tests by multiple populations of women to promote HIV testing among male sexual partners and among couples. This is also the first study to show that secondary distribution of self-tests by female sex workers can result in HIV testing among their high-risk commercial sex clients and that this strategy can identify a high proportion of HIV-positive individuals. Another important contribution of this study is its identification of a major potential for a secondary distribution strategy to facilitate point-of-sex HIV testing and lead to safer, better informed sexual decision making. The study shows that secondary distribution of self-tests is a safe and efficient way to promote HIV testing among hard-to-reach individuals and also achieve other HIV prevention objectives.

Implications of all the available evidence

These findings suggest that secondary distribution of HIV self-tests is a promising strategy for increasing HIV testing among populations that are traditionally hard to reach, including male partners of pregnant and postpartum women and clients of female sex workers. It may also facilitate safer sexual decisions by removing some barriers to mutual disclosure of HIV status. Further implementation and evaluation of this strategy is warranted as countries are developing HIV self-testing policies and considering how these technologies can be used to prevent new HIV infections. Along with other community-based HIV testing strategies implemented recently, secondary distribution of self-tests can be part of a multipronged approach to achieving the first of the UNAIDS 90-90-90 targets.

Although HIV self-testing can be a good alternative for those not engaged in regular repeat testing, little is known about the best distribution strategies to facilitate self-test use by hard-to-reach and high-risk individuals. One such strategy is secondary distribution of HIV self-tests, whereby an individual who is given multiple self-tests can distribute them to sexual partners or to others in their social network. In addition to promoting HIV testing, secondary distribution of self-tests also has potential to facilitate point-of-sex testing, which can lead to results disclosure and safer, better informed sexual decisions. To date, no data exist for the feasibility of secondary distribution of self-tests in sub-Saharan Africa; however, a few qualitative studies done among men who have sex with men (MSM) in the USA have shown that this strategy might help to increase individuals' knowledge of their partner's status and promote safer sexual decisions.12

We aimed to assess whether secondary distribution of self-tests can promote HIV testing among partners of pregnant women, post-partum women, and female sex workers in a high HIV prevalence setting in Kenya. We also assessed whether secondary distribution of self-tests led to couples testing and more informed, safer sexual decisions by women.

Section snippets

Study design and participants

This cohort study was done at several sites in the Kenyan city of Kisumu, where adult HIV prevalence is 20·6% among women and 17·8% among men.13 The study explored secondary distribution of self-tests by several different populations of HIV-negative women. Women seeking antenatal care or post-partum care were recruited because there is a high risk of HIV transmission in these populations and male partner testing can help to reduce this risk.14, 15, 16 In addition, female sex workers were

Results

Between Jan 14, 2015, and March 13, 2015, 280 participants were enrolled (61 in antenatal care, 117 post-partum clinic, and 102 female sex workers). At the facility where participants receiving antenatal care and post-partum care were recruited, clinic staff referred 78 women seeking antenatal care and of these, 12 (15%) declined to participate in the study and five (6%) were deemed ineligible on further screening. Clinic staff referred 148 women seeking post-partum care, among whom 14 (9%)

Discussion

Provision of multiple self-tests to women for secondary distribution seems to be a safe, viable, and promising strategy to promote HIV testing among male sexual partners and to facilitate safer sexual decisions. A high proportion of pregnant and post-partum women as well as female sex workers were able to distribute self-tests to other individuals, particularly their sexual partners. This strategy also resulted in high levels of couples testing. Among female sex workers in particular, secondary

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