HIV self-testing for couples in resource-poor contexts in urban Malawi

1. HIV self-testing for couples in resource-poor contexts in urban Malawi Nicola Desmond Wellcome Trust Fellow Liverpool School of Tropical Medicine Malawi-Liverpool-Wellcome Trust Major Overseas Programme IAC, Melbourne, Australia July 21st -26th 2014

2. Human Rights concerns • Increased risk of unmanaged anxiety • Negative impacts by bypassing counseling • Potential for coercive testing • 3% participants in Blantyre, Malawi • Lower test accuracy • Lower linkage to care

3. HIVST in urban Malawi National HIV prevalence: 11.9% Doctors /1000 population: 0.02 • 16,600 adult residents • free access to 1 HIVST per year • semi-supervised via community-based counselors • Testing in private • pre & post-test counseling • encouraged to include partner • Linkage to confirmatory testing & care via counsellors to direct to study clinics Primary clinics District hospital 28 clusters: ~ 1,200 adults (16+)

4. Methods: 2 cohort studies Kumwenda et al Desmond et al 17 couples 12 months FU Serial in-depth interviews Both partners individually • 51 couples • 12 months FU • Mixed methods • 12 months follow up • Face to face survey • Audio computer assisted self-interviews (ACASI) • Daily diary study • In-depth serial biographical interviews with both partners individually “Couples-testing” HIVST: 14% participants Malawi HTC: 14% clients

5. Exploring negative impacts through bypassing counseling

6. Deconstructing couples HIVST: access & presentation • Majority of couples came into HIVST through counselor-initiated approaches • Most couples testers had previously tested with a partner

7. Deconstructing couples HIVST: steps taken together • Majority of men & women in couples received pre-test counseling with a partner (69%) • Men more likely have received both pre- AND post test counseling

8. Disclosure enhanced • High proportion (99%) of participants shared results with partner • whether or not they read the results at the same time • Use of HIVST to disclose previously known +ve status common and motivated by: • Guilt • desire to foster openness • mistaken assumption of concordance & ensuring access to care

9. Assumptions of HIV concordance ‘… this is why I invited the counselor to test us after realizing that it was not good that I should continue hiding that I am HIV+ve from her … I expected that she would also be positive. I did not believe it when her result was negative after all these years that I have lived with her’ Male partner, HIV positive, Discordant couple

10. Gendered nature of Decision-making

11. Decision-making: individual motivations for couples testing Known to be positive • Self-checking “cure”: known HIV status • Through beliefs in cure through prayer • Through long-term ART • Linking back into HIV care after ‘defaulting’ From the perspective of being in a relationship • Assessing the strength and fidelity

12. Evidence of coercive testing? • Coercive testing reported by 3% in parent study • 78% of individuals in couples study reported they had not been influenced at all to test • Some felt pressure to test from partner & unable to ‘opt-out’ • To show commitment to relationship • To remove existing mistrust

13. Gendered response to acceptable force • Lower levels of coercion reported for women • Men *more* likely to report coercion from partner • Gender-based violence normalized and pervasive DHS Malawi 2010

14. Male pressure to test ‘My husband just gave me the test-kit and told me to test. I feel that this is a problem … I did not have a choice to say no … my husband initially went to test alone. According to his test results, he also wanted me to get tested … so I was in a dilemma’ HIV-ve wife in discordant partnership

15. Female pressure to test ‘When I got the kit I took two days without testing, then my wife said that I won’t eat that day if I don’t test. She went to the bedroom and poured water on my clothes. There was force, I knew that if I don’t test then there won’t be sex for me’ Husband in concordant HIV –ve couple

16. HIVST empowering women in relationships? • Women able to break existing barriers • household decision-making • power dynamics • resident volunteers reinforce and destigmatise testing and couples testing • Gendered response to “acceptable” force • Men more likely to report coercion from partner than women

17. Conclusions to date • Low levels of formal “couples HIVST” overall • How best to promote couples HIVST for “first-time” testers? • The option of HIVST is empowering for women wanting to promote couples testing • Important social reinforcement from community counsellor • Decisions shaped by gender and power relations within the household • Need for more research on coercion • Unpacking the implications of gendered social norms and acceptability of GBV • Discordancy identified through HIVST presents complex challenges

18. Acknowledgements • Mr Moses Kumwenda - MLW • Dr Sally Theobald - LSTM • Dr Miriam Taegtmeyer - LSTM • Professor Liz Corbett – LSHTM • DrMavutoMukaka – Johns Hopkins, US • DrIreenNamakhoma - Reach Trust • DrLignetChepuka - LSTM • Mr Simon Makombe - MoH Malawi • Professor Janet Seeley - MRC Uganda • Professor David Lalloo - LSTM • Professor Rob Heyderman - LSTM • Ms Effie Chipeta - MLW • MsWezzie Lora - MLW Community men & women in urban Blantyre

19. Uptake since introduction of HIVST • Couples uptake • Round 1: 932 (14%) couples of 13,655 tests • Round 2 (Repeat testing): 1201 (16%) couples of 15,009 tests

20. Exploring the social impacts of HIVST in couples • Decision-making dynamics • Nature & extent of coercive testing • Sexual behaviour & risk compensation • Gendered household relations • Role of counseling