In an effort to achieve the UNAIDS 90-90-90 goals, public health officials need innovative ways to target key populations that have been hard to reach historically. This study investigates whether making HIV self-testing kits available as a testing option at North Star Alliance roadside wellness clinics in Kenya increased HIV testing rates in truckers and female sex workers who are considered hard-to-reach and are irregular testers. It also explores whether the additional step of advertising the availability of HIV self-testing kits via text message increases testing rates among those same target populations compared to sending text messages about HIV testing in general.
Truckers and female sex workers, are at higher risk of contracting HIV due to exposure to multiple partners. These populations also tend not to follow the recommended HIV testing schedule of every three months because of limited time, particularly in the case of truckers and social stigma. Thus, HIV self-testing is now being explored as a method that can increase testing by lowering the costs of testing (e.g. financial, social, time), yet providing increased privacy and agency. Self-testing does not incur a commensurate increased burden on the health care system resources to provide this option.
Does advertising the availability of HIV self-testing kits at participating clinics via multiple text messages increase HIV testing rates among truckers and female sex workers who are irregular testers?
What is the incremental cost-effectiveness ratio of advertising and offering HIV self-testing as an option for testing?
The intervention consisted of adding the choice of oral HIV self-testing to the standard of care (SOC) at roadside wellness centres. The intervention group received a text message informing participants that HIV self-test kits were available at all North Star Alliance clinics in Kenya. The message was sent three times a week; first in Kiswahili, then in English and then again in Kiswahili.
A second comparison, an enhanced standard of care received the SOC message reminding clients to come to a clinic for HIV testing, sent three times a week rather than just once: first in Kiswahili, then in English and then again in Kiswahili.
If a patient in the intervention arm came in for testing, they were given a demonstration of the self-testing kit and were offered: (1) the standard provider-administrated blood-based HIV test; (2) the self-administered oral HIV test for use in the clinic with provider supervision; or (3) a self-administered oral HIV test kit for home use. Those in the enhanced SOC arm were only offered the standard provider-administrated blood-based HIV test.
Theory of change
The authors theorised that HIV testing rates among truck drivers and female sex workers would increase when they are informed via text message that they have a new HIV testing option, specifically oral HIV self-testing. The theory is based on the idea that the barriers to HIV testing such as time, financial and social costs (e.g. stigma) can be mitigated by the increased privacy, ease of access, choice of testing method and ability to test at one’s convenience outside of the clinic.
The study was implemented in eight clinics among two different samples; one with male truckers and one with female sex workers. Both samples were randomised in a 1:1:1 ratio to one of the three study arms (intervention, enhanced standard of care, standard of care). Researchers used a logistic regression model to compare HIV testing during the two-month follow-up period among clients in the intervention arm versus those in the enhanced standard of care arm (primary comparison), as well as among those in the enhanced standard of care arm versus those in the standard of care arm (secondary comparison). Researchers also looked at whether there were differences in clinic contact for any reason and whether the differences by study arm in HIV testing were modified by HIV testing history (whether the client had had an HIV test at a North Star Alliance clinic in the past year or not). For those in the intervention arm, they describe the HIV testing choices made.
- The intervention group had greater odds of HIV testing compared to those in the enhanced SOC group (OR = 2.7, p=0.009).
- The differences by study arm in HIV testing were not modified by having tested in the past year (interaction p-value=0.669).
- The intervention arm had 1.1 times greater odds of clinic contact compared to those in the enhanced SOC arm; although the difference was not statistically significant (p=0.474).
- There was also no difference in clinic contact between the SOC and enhanced SOC groups (10.6% in the SOC arm, 10.7% in the enhanced SOC arm, OR=1.0, p=0.987).
Female sex workers
- Those in the intervention group had greater odds of HIV testing compared to those in the enhanced SOC group (OR = 1.9, p=0.001)
- The difference by study arm in HIV testing was not modified by having tested in the past year (interaction p-value=0.851).
- Those in the intervention arm had greater odds of clinic contact compared to those in the enhanced SOC arm (OR = 1.6, p=0.005).
- There was also no difference in clinic contact between the SOC and enhanced SOC groups (10.1% in the SOC arm, 9.3% in the enhanced SOC arm, OR=0.9, p=0.642).
- Those offered HIV testing choices varied in which test they selected, with about 40% choosing the standard test, 40% the self-test for use in the clinic with supervision, and 20% the self-test for home use among both truckers and female sex workers.
The cost per provider-administered HIV test was calculated at USD 5.01, while for HIV self-test, this cost was more than double, at USD 14.13 and USD 12.08 for the two self-testing options. This was mostly driven by the cost of the test kit itself (USD 7.95 + 16%VAT).
The intervention proved to be more cost-effective than either the enhanced SOC or the SOC, even though the HIV self-test kits cost much more than the standard provider-administered HIV test because of the higher testing rates in the intervention arm.
Specific findings for policy and practice
Offering HIV self-testing to high-risk populations, such as truckers and sex workers, and advertising their availability via text message may be a cost-effective way to increase HIV testing rates in these important groups.
The content of the text message and not the number of times it was sent was important, as there was no difference in testing rates when sending a message about HIV testing in general one time versus three times.
The wide variation in the HIV test selected by those offered choices when arriving in the clinics suggests that HIV testing is not one-size-fits-all and people vary in their preferences regarding HIV test characteristics.
- A Randomised controlled trial to increase HIV testing demand among female sex workers in Kenya through announcing the availability of HIV self-testing via text message, Springer, Aug 2018
- Announcing the availability of oral HIV self-test kits via text message to increase HIV testing among hard-to-reach truckers in Kenya: a randomised controlled trial, BMC, Jan 2019
- Offering self-administered oral HIV testing to truck drivers in Kenya to increase testing: A randomized controlled trial at the APHA meeting in Atlanta (November, 2017)
- HIV risk behaviours and their association with HIV testing among truck drivers seeking healthcare services at two roadside clinics in Kenya at the APHA meeting in Atlanta (November, 2017)
- Views about self-administered HIV testing among a sample of Kenyan truck drivers at the APHA meeting in Atlanta (November, 2017)
- The International AIDS Society 2017 conference in Paris, France July 24, 2017