FIVE Studies on HIV Self-testing in Kenya: What We Learned From and About Formative Research

1. Annette N. Brown, PhD International Initiative for Impact Evaluation, 3ie Presentation for the HIVST satellite session sponsored by WHO IAC, Melbourne, July 2014 FIVEStudies on HIV Self-testing in Kenya: What We Learned From and About Formative Research

2. 3ie 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

3. Formative research themes • Accuracy • Packaging and labeling • Potential users and messaging • Distribution outlets • Linkage to counseling and care • Potential social harms and abuses

4. Methods • Four of five studies used medium to large sample surveys, three of these used random sampling • One study used small sample qualitative data collection • Heterogeneous samples, but not population representative samples • Studies employed basic statistical analysis and some qualitative analysis • One of five used actual self tests as part of study • Our summary analysis is primarily narrative • Most summary findings include evidence from more than one formative study

5. 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?

6. Do people want it? • 5/5 studies report near universal “acceptability”: >90% • 3/5 studies report acceptability among never tested: 80% - 91% • FSW: 98% • MSM: 57%

7. Do people want it? • One study [3] • 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 [1] • Men never tested who would use a self-test: 90%

8. Why would people use self-tests? [1]

9. Why would people self-test? [3]

10. Why not self-test? [2]

11. Who would use it? • Ever been tested more likely [2] [3] • Men more likely [3]

12. 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) [5]

13. Where would people get it? Table 6: Percent distribution of survey respondents who would use HIV oral self-test kits by main preferred distribution channels [1]

14. Where would people get it? Table 8: Percent distribution of survey respondents who would use HIV oral self-test kits by other preferred distribution channels apart from the main one mentioned [1]

15. What are people worried about? 70.7% of men and 54.9% of women feel there are disadvantages [3] • 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)

16. What are people worried about? 66.2% of men and 54.7% of women feel that self-testing would be misused or abused [3]

17. What would people do? What would people do if positive? [3] • 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% | 0.0%

18. How to address concerns? [3]

19. Messaging findings • 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]

20. Packaging and labeling findings • Packaging secure • Small size • Labeling—with quality seals, informative • Improved instructions—simple, explicit • Information about storage, expiration • May require point of distribution instruction [4]

21. Linkage to care findings • Strong desire for face-to-face counseling [3] • Telephone hotline not preferred [3] • Public health facilities strongly preferred for counseling before and after [1]

22. 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

23. What did we learn about formative research? • Sensitivity of findings to question formats and choices listed • High occurrence of priming • Useful, but no substitute for impact evaluation of pilot programs

24. Formative studies [1] “Possible channels for distribution of HIV oral self-test kits in Kenya” Jerry Okal, Francis Obare, WaimarTun, James Matheka [2] “Insights into potential users and messaging for HIV oral self-test kits in Kenya” RhouneOchako, Lung Vu, Katia Peterson [3] “Understanding perceived social harms and abuses of oral HIV self-testing in Kenya” Caroline W. Kabiru, Estelle M. Sidze, ThaddaeusEgondi, DamarOsok, Chimaraoke O. Izugbara [4] “How HIV self-testing kits should be packaged in Kenya” Olivier LeTouzé [5] “Accuracy of oral HIV self-tests in Kenya” Ann E. Kurth, Abraham M. Siika

25. HIV Evidence Initiative Annette N. Brown Anna Heard Eric Djimeu Nancy Diaz