Gichangi, A, Korte, JE, Wambua, J, Vrana, C and Stevens, D, 2017. Increasing male partner HIV testing using self-test kits in Kenya, 3ie Impact Evaluation Report 62. New Delhi: International Initiative for Impact Evaluation (3ie)
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The study uses a randomised controlled design to measure the impact of oral HIV self-tests offered at antenatal care (ANC) clinics on the acceptability and uptake of male partner testing in Kenya.
Over the last decade, the country has made significant strides in increasing uptake in HIV testing and counselling (HTC), particularly in the realm of preventing mother to child transmission (PMTCT). Today, PMTCT services are offered as a routine element of ANC for pregnant women. While women are more likely to ever be tested (79.8%), their male counterparts have lagged behind (62.5%). In the former eastern and central provinces, the rates are even lower. To address this issue, Jhpiego tested the impact of providing free self-test kits to pregnant women on uptake of male partner testing. Evidence from this study provided significant information on how best to increase HIV testing amongst men and couples.
The primary outcome of interest is self-reported uptake of male partner testing. The secondary outcomes of interest are linkage to care, HIV test results, and information provided by the male partner. The research questions include:
- Can the provision of oral HIV self-test kit intervention to new ANC clients for use at home with their partners result in a net increase in HIV testing for partners of these women?
- What proportion of the test kits were used as intended and what happened to the remaining ones?
- What proportion of partners testing HIV-positive are confirmed to be enrolled in an HIV care centre?
- Can the programme immediately identify and address incidents of social harm that may be related to the use of the self-test kits?
The intervention aimed to measure the impact of oral HIV self-tests offered at ANC clinics on the acceptability and uptake of male partner testing. The intervention group received standard ANC including a standard HIV test administered on site, an improved invitation letter describing the benefits of HIV testing to take home to a partner and two self-testing kits (comprising an instruction sheet and a demonstration of how to use the kit) for the client to take home and use with her partner. Women in the “enhanced” control group received standard care and the improved invitation letter. The regular control group received standard care and a standard letter with a simple request to come with their partner to her next visit “for the health of the family.” Women in all three groups received counselling on PMTCT, linkage to care and to support groups if they tested positive, and on partner testing in general. Additional follow-up included text message reminders and an endline questionnaire sent out at 12 weeks post enrolment.
Theory of change
Based on Prospect Theory, the theory of change posits that the likelihood of an outcome is based on a cost-benefit analysis. Barriers to HIV testing such as time, financial costs, and social norms surrounding male participation in health care are weighed against the benefits of knowledge of own and partner’s HIV status. By offering a free, home-based alternative to traditional HTC, the benefits will outweigh the costs. The researchers hypothesise that pregnant and post-partum women can convey this benefit to their partners and partners will see that increased benefits outweigh costs. This in turn will increase HTC uptake and awareness of couples’ status.
The study used randomisation to assign approximately 1,425 pregnant women who visited an ANC clinic within 14 high-volume hospitals. The intervention was implemented over 14 months and participants were randomised into three different groups: two of control; comprising of standard control and enhanced control group and one intervention group. The study used a mixed-method approach, as well as an intent-to-treat analysis. Furthermore, protocols and questionnaires were introduced to assess, identify, and mitigate social harms as a result of this intervention, especially gender-based violence. Quantitative and qualitative data were collected using questionnaires (pre-enrolment, enrolment, and return visit surveys) and in-depth interviews.
The provision of HIV self-tests increased partner testing rates by 46 percentage points compared to the enhanced control group (83% versus 37% respectively) and by 55 percentage points compared to standard control (28%), based on men’s self-report. In the HIV self-testing group, 82 per cent of men reported testing with their partner. Over 80 per cent of men found the instructions easy to read, easy to collect the oral swab, and easy to interpret the results. Women reported that privacy and being able to test at home with their partners were key drivers for their partners to take the test.
This study was cited in the WHO HIV self-testing guidelines within their systematic review. One of the researchers has been engaged by the Kenyan Ministry of Health to assist with writing the HIV self-testing guidelines. HIV self-testing will be rolled out more widely in Kenya in 2017. Due to the WHO HIV self-testing guidelines, most PEPFAR supported countries have decided to include HIV self-tests in their Country Operational Plans, as well as their Global Fund concept notes.