Providing pregnant and postpartum women in sub-Saharan Africa with multiple HIV self-tests can make it more likely their male partners will be tested for HIV compared to a standard approach of distributing invitation cards for clinic-based testing, according to a randomised trial by Harsha Thirumurthy of the University of North Carolina at Chapel Hill and colleagues.
Low use of testing services in sub-Saharan Africa, particularly by men, is one of the key barriers to meeting targets that UNAIDS has set for HIV prevention. Moreover, efforts to encourage pregnant women and postpartum women to refer their partners for testing and to test as a couple, in order to help prevent mother-to-child transmission of HIV, have had limited success.
Between June and October 2015, Thirumurthy and colleagues enrolled in their study 600 women seeking pregnancy and postpartum care at three facilities in Kisumu County, Kenya. All women enrolled were 18-39 years old, had a partner that was not known to be HIV-positive, and agreed to participate. Half the women were given two oral fluid-based HIV self-test kits to take home, instructions on use, and were encouraged to give a test to their male partner or to test with their partner if they felt comfortable. The other 300 women were given invitation cards to give their partner for HIV testing at a clinic. Over the following three months, women were followed up to determine if their partner had self-tested or visited a clinic to test for HIV.
In the group that received HIV self-tests, 90.8% of partners were reported to have tested within 3 months of enrolment in the study. In the comparison group, 51.7% of partners were reported to have visited a clinic for HIV testing. Based on these results, self-tests led to 39.1% more partner testing than the control (95% confidence interval 32.4% to 45.8%, P<0.001). Moreover, 93 percent of women who had received the HIV self-tests said their partner found the test either “very easy” or “somewhat easy” to use.
Couples testing was also much more likely among women who received HIV self-tests; 75.4% of women given self-tests reported testing with their partner whereas only 33.2% in the comparison group tested with their partner (difference=42.1%, 95% confidence interval 34.7% to 49.6%, P<0.001). The study is limited, however, by its reliance on self-reported outcomes as well as the fact that roughly a third of women screened for participation in the trial declined to participate, in some cases because they reported a fear of violence that could result from offering a self-test to their partner.
“The promising results from this study suggest that secondary distribution of self-tests warrants further consideration as countries develop HIV self-testing policies and seek new ways to promote partner and couples testing,” the authors say.
Background: Achieving higher rates of partner HIV testing and couples testing among pregnant and postpartum women in sub-Saharan Africa is essential for the success of combination HIV prevention, including the prevention of mother-to-child transmission. We aimed to determine whether providing multiple HIV self-tests to pregnant and postpartum women for secondary distribution is more effective at promoting partner testing and couples testing than conventional strategies based on invitations to clinic-based testing.
Methods and Findings: We conducted a randomized trial in Kisumu, Kenya, between June 11, 2015, and January 15, 2016. Six hundred antenatal and postpartum women aged 18–39 y were randomized to an HIV self-testing (HIVST) group or a comparison group. Participants in the HIVST group were given two oral-fluid-based HIV test kits, instructed on how to use them, and encouraged to distribute a test kit to their male partner or use both kits for testing as a couple. Participants in the comparison group were given an invitation card for clinic-based HIV testing and encouraged to distribute the card to their male partner, a routine practice in many health clinics. The primary outcome was partner testing within 3 mo of enrollment. Among 570 participants analyzed, partner HIV testing was more likely in the HIVST group (90.8%, 258/284) than the comparison group (51.7%, 148/286; difference = 39.1%, 95% CI 32.4% to 45.8%, p < 0.001). Couples testing was also more likely in the HIVST group than the comparison group (75.4% versus 33.2%, difference = 42.1%, 95% CI 34.7% to 49.6%, p < 0.001). No participants reported intimate partner violence due to HIV testing. This study was limited by self-reported outcomes, a common limitation in many studies involving HIVST due to the private manner in which self-tests are meant to be used.
Conclusions: Provision of multiple HIV self-tests to women seeking antenatal and postpartum care was successful in promoting partner testing and couples testing. This approach warrants further consideration as countries develop HIVST policies and seek new ways to increase awareness of HIV status among men and promote couples testing.
Samuel H Masters, Kawango Agot, Beatrice Obonyo, Sue Napierala Mavedzenge, Suzanne Maman, Harsha Thirumurthy