Download - 3ie HIV Oral Self Testing Summary February 2015

www.3ieimpact.orgAnna Heard

HIV SELF TESTING: MOVING FORWARD USING EVIDENCE

Anna Heard Sc.D.CROI Side EventBill and Melinda Gates FoundationFebruary 27, 2015


Improving lives through impact evaluation

International Initiative for Impact Evaluation


Outline

• 3ie and our IE philosophy• HIVST grants program• Results of formative research for HIVST

pilots in Kenya• Future work


3ie’s role

• Fund new studies• Synthesize evidence• Disseminate and broker knowledge• Provide incentives and resources


HIV self-testing grants program

• Fund pilot programs using HIV self-tests accompanied by impact evaluations

• Test for both intended positive outcomes and unintended negative outcomes

• Implement country by country (3 countries)• Start with Kenya (12/2012)

– Formative research– Impact evaluations

• Launched in Zambia in summer 2014


Formative research Kenya

• Accuracy • Packaging and labeling• Potential users and messaging• Distribution outlets• Linkage to counseling and care• Potential social harms and

abuses


Methods

• Five of six studies used medium to large sample surveys, three of these used random sampling

• One study used small sample qualitative data collection (packaging and labeling)

• Heterogeneous samples, but not population representative samples

• Studies employed basic statistical analysis and some qualitative analysis

• Two of six used actual self tests as part of study• Most summary findings include evidence from

more than one formative study


Formative research findings

• Do people want it?– Why? Why not?– Who?

• Does it work?• Where would people get it?• Will people get counseling and/or care?• What are people worried about?• How can we address concerns?


Do people want it?

• 5/6 studies report near universal “acceptability”: >90%

• 5/6 studies collected data on acceptability among never tested: 80% - 99%

• FSW: 98%• MSM: 57%


What about never tested?• One study [6]

– Men• Never tested would like to be tested: 70%• Never tested would purchase and use if available: 86%

– Women• Never tested would like to be tested: 58%• Never tested would purchase and use if available: 80%

• Another study [4]– Men never tested who would use a self-test: 90%– Women never tested: 86%

• Third [1]– Men never tested would recommend after using:

94%, women, 100%.


Uptake of HIVST among testers

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

General facility site Home-based testing Key population site Total

Uptake of HIVST by gender and testing site

Male Female

[5]


Who would use it (from surveys)?

• Ever been tested more likely [3] [6]• Men more likely [5][6]


Why would people use self-tests?

0%

10%

20%

30%

40%

50%

60%

70%

80%

Women Men Never Tested Total Providers [4]


Why would people self-test?Reasons why self-test Males Females

Private 70.9% 56.7%

Early treatment 20.1% 24.7%

“No worry” if negative 9.0% 19.5%

Know status 13.8% 11.1%

Easy to use 13.0% 9.9%

Convenient 12.6% 9.5%

Test is accurate 5.9% 3.4%

Protect regular partners 6.7% 1.0%

Protect other partners 1.7% 1.4%

Other 3.4% 3.6% [6]


Why not self-test?

Mombasa SiayaAverage

Total

% % % nAfraid of finding out positive result while alone 46.9 41.2 44.9 22Health workers are more knowledgeable 18.8 17.6 18.4 9

Afraid of misinterpreting results 12.5 35.3 20.4 10

Other 21.9 5.9 16.3 8

[3]


Does it work?

• Sensitivity: 92.9% (89.7%)– Unobserved sensitivity in US: 91.7%

• Specificity: 97.8% (98.0%)• Invalids: 15% (men and never tested more

likely)

[1]


Where would people get it?

Preferred distribution channelWomen

(%)Men(%)

Never Tested

Total(%)

Public health facility 63.2 59 53.1 61.8Private pharmacy 7.5 5.7 8.3 6.9Local shops/supermarkets 4.1 8.2 9.7 5.4Private health facility 4.6 3 4.1 4.1Local administration 6.8 11.3 13.8 8.3Faith-based/NGO health facility 3 2.3 0.7 2.7Mobile clinic/tent/outreach 2.1 2 0.7 2.1Community health worker 2.9 2 2.1 2.6Stand-alone VCT center 0.3 0 0 0.2Community-based distributor 0.9 1.4 2.8 1CBO/self-help group 0.3 0.2 0.7 0.3Non-governmental organization 0 0 0 0Social marketing events 0.2 0.7 0 0.4Relative/Friend/Neighbor 0.1 0.2 0 0.2Traditional birth attendant 0.2 0 0.7 0.2Other 3.9 4.1 3.5 3.9 [4]



All distribution channelsWomen

(%)Men(%)

Never Tested (%)

Total(%)

Public health facility 78 75 68 77Private health facility 22 16 19 20Private pharmacy 23 20 18 22Local administration 13 15 9 14Local shops/supermarkets 12 13 13 12Mobile clinic/tent/outreach 13 10 6 12Social marketing events 8 13 13 9CHW 10 9 6 9Faith-based/NGO health facility 9 9 7 9School/Church/Mosque 6 7 8 7Community-based distributor 4 4 3 4Relative/Friend/Neighbor 4 8 10 5VCT 5 2 1 4CBO/self-help group 1 1 1 1NGO 0 0 0 0Traditional birth attendant 1 0 0 0 [4]



PSI NYUNever

(%)Ever(%

Total (%)

Total (%)

Pharmacy 72 60 62 57Government Health Facility 56 70 68 42**Private clinic 27 21 22Supermarket 24 25 25 3Other* 9 17 16

*Other includes primarily Community-Based Organizations and NGOs **Does not distinguish between government and private


What are people worried about?

• 27% of people said HIV self-testing “could be open to abuse” [3]– Kinds of abuse were more related to

problems, not abuses• 36% of people said that if available, it is

“possible that people could abuse it” [5]


What are people worried about?

70.7% of men and 54.9% of women feel there are disadvantages [6]• Might commit suicide• Anxious or depressed (men more than women)• Not disclose (men more than women)• Harm others (men more than women)• Counterfeit kits (men more than women)


What are people worried about?66.2% of men and 54.7% of women feel that self-testing “is open to abuse” [6]Perceived abuses Male FemaleIntentionally infecting others 70.7% 90.5%

Testing partner without consent 73.0% 59.5%

Parents testing children w/o consent 80.9% 49.5%

Testing people without consent 45.4% 52.0%

Testing potential employees 36.6% 46.9%

Schools testing children 31.7% 41.1%

Disclosing others’ HIV status 19.9% 53.9%

Don’t know 3.0% 5.0%


What would people do?

What would people do if positive? [3]

Men Women

Seek counseling 41.4% 35.8%Confirm results 22.0% 19.5%Seek medication 10.7% 18.9%Go into depression 9.0% 8.3%Keep results secret 4.8% 2.2%….Commit suicide 1.9% 1.6%Intentionally infect others 0.2% 0%


What evidence of harms?

Is there evidence of harms from self-tests? A rapid evidence search By Annette N. Brown, Eric W. Djimeu, and Drew B. Cameron

“After an extensive search and broadly inclusive screening process, we find very little evidence of any harms occurring in practice. There is evidence that BSE is linked to anxiety, but the evidence is not specific to receiving the test result and the cost cited for the anxiety is resistance to BSE rather than emotional or psychological damage.”


How to address concerns?Ways to prevent abuses Male FemaleMake non-consensual testing illegal 39.5% 22.2%Self-testing kit used only by person who receives

30.9% 14.4%

Provide only one self-testing kit per person

21.5% 18.3%

Sensitization 17.7% 14.7%Other ways 5.4% 11.1%Don’t allow home self-testing 5.1% 10.8%Pre-counseling 5.9% 6.2%Restricted distribution points 3.2% 3.3%Legal penalties for misuse 4.8% 0.3%Age restrictions for purchase 1.3% 1.3%

[3]


Messaging

• Mass media sensitization and awareness campaigns – Come from MOH– Inform: address concerns and advantages– Educate: importance of confirmatory test,

disclosure, linkage to care, prevention• Prior to and during roll-out

[2]


Packaging and labeling

• Packaging secure• Small size• Labeling—with quality

seals, informative– Improved

instructions—simple, explicit

– Information about storage, expiration

• May require point of distribution instruction [4]


Instructions


Linkage to care

Counseling Confirmatory testingIntent if positive 91.1% 84.3%Intent if negative 41.4% 50.0%Actual 31.6% 29.6%

• Those choosing HIVST as part of home-based testing more like to express intent to seek both counseling and confirmatory testing.

• Women, those divorced, widowed, or separated, and those testing at key population sites more likely to access confirmatory testing


Linkage to care

• Strong desire for face-to-face counseling [3]

• Telephone hotline not preferred [3]

• Public health facilities strongly preferred for counseling before and after [1]


Main conclusions

• High acceptability and likelihood of use• Accuracy not much different from US• Health facilities are a desirable outlet• Perceptions of disadvantages and abuses do

exist• Big differences between men and women• Mass messaging important• Packaging and labeling important


Formative studies

[1] “Accuracy of oral HIV self-tests in Kenya” Ann E. Kurth, Abraham M. Siika[2] “How HIV self-testing kits should be packaged in Kenya” Olivier LeTouzé[3] “Insights into potential users and messaging for HIV oral self-test kits in Kenya” Rhoune Ochako, Lung Vu, Katia Peterson[4] “Possible channels for distribution of HIV oral self-test kits in Kenya” Jerry Okal, Francis Obare, Waimar Tun, James Matheka[5] “Exploring potentially effective methods for counselling and linkage to care in the context of HIV self-testing in Kenya” Wanjiru Mukoma, Miriam Taegtmeyer, Anna Heard, Hisham Esper, Kara Ingraham, Annette N. Brown[6] “Understanding perceived social harms and abuses of oral HIV self-testing in Kenya” Caroline W. Kabiru, Estelle M. Sidze, Thaddaeus Egondi, Damar Osok, Chimaraoke O. Izugbara


What’s next?Three pilot interventions and impact evaluations in Kenya• A Randomized Controlled Trial to Evaluate

Adding Self-Administered Oral HIV Testing as a Choice in Clinic and Non-Clinic Settings to Increase HIV Testing Uptake Among Truck Drivers in Kenya

• Distribution of HIV Oral Self-Tests at Antenatal Clinics in Kenya

• The Use of HIV Self-tests to Promote Partner and Couples Testing: A Randomized Trial


What’s next?

• Feasibility Study for HIV Self-Testing in Zambia

• Then two-three pilot interventions with impact evaluations in Zambia

• Now looking for third country—will start with pilot interventions and impact evaluations


HIV Evidence Initiative

Annette BrownAnna HeardEric DjimeuNancy Diaz

Download - 3ie HIV Oral Self Testing Summary February 2015

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