secondary distribution of hiv self-tests in kenya...

SecondarydistributionofHIVself-testsinKenya:opportunityforhealthfacilitiestopromotepartnerandcoupletesting

KawangoAgotImpactResearchandDevelopmentOrganization

PresentationOutline

• QuestionsmotivatingHVSTstudiesinKenya

• ResultsoftwostudiesonsecondarydistributioninKenya

• Ongoing/upcomingstudiesonsecondarydistributionstrategy

• OtherstudiesonHIVSTbyIRDOandcollaborators

QuestionsmotivatingrecentstudiesinKenya• WhatareoptimalHIVSTdistributionstrategiesforfurtheringkeyHIVpreventiongoals?Specifically:• Malepartnerandcouplestesting

• Testingofpriorityandkeypopulations

• TestingaspartofPrEP delivery???

• HowcanHIVSTbeusedincost-effective waystoachievepreventionobjectives?

• HowmightHIVSTaffectsexualdecision-making?• CanHIVSTreducenewinfectionsbecauseindividualsmakesafersexualdecisionsonthebasisoftestresults?

• Canthisleadtosero-sorting?Increasecondomuse?Reducepartners?

Secondarydistributionofself-tests– 2completedstudiesbyIRDO-UNCteam

• Provisionofmultipleself-teststoindexpersonsaccessingroutinehealthcaremaybeusefulinenhancingaccesstoHIVtestingwithinsocialnetworks

• PilotstudyinKenyatotestthisstrategyamongpregnantandpostpartumwomen,andFSW(Thirumurthy etalLancetHIV2016)

• Arandomizedtrialamongwomenseekingantenatalandpostpartumcare(MastersetalPLOSMedicine2016)

Self-testprovisionandfollow-up

• Indexparticipants(IPs)• GivenmultipleOraQuickRapidHIVTests

• Study1(Pilot):3kitsforANC/PPC,5forFSWs• Study2(RCT):2kitsforallparticipants• Educatedonhowtouseself-testsandprovidedwithwrittenandpictorialinstructions

• Someencouragementtodistributeself-teststopartnersandclients;others atowndiscretion

• Follow-upinterviewsat1,2,3months• Focusonself-testusageandexperience,violenceandadverseevents• Qualitativein-depthinterviewswithselectedppts

Aimsofthetwostudies• Bothstudies:Determinewhetherprovidingmultipleself-teststowomenwhoaccessroutinehealthcareservicescanpromotepartnerandcoupletestingandfacilitatesafersexualdecision-making

• Describewhoreceivesself-teststhroughsecondarydistribution(sexualpartners,FSWs’clients,friends,etc.)

• Describehowself-testsareused(independently,ascouple)• Describedecisionsonsexualbehaviorfollowingcoupletesting• Assessuptakeofconfirmatorytestingandlinkagetocare• Assesssafetyofsecondarydistributionstrategy

• Study2only:EvaluatetheimpactofHIVSTonuptakeofpartnerandcoupletestingcomparedtostandardinvitationcouponsfortestingataclinic

Study1:Keyfindings

Howself-testkitsweredistributedandused

93%

74%

33%

86%79%

17%

0%10%20%30%40%50%60%70%80%90%

100%

Primarypartner

Femalefriend

Malefriend

ANC PPC

DistributionbyANCandPPCwomen DistributionbyFSW

• 280enrolled(61ANC,117PPC,102FSW)

• Totalof901self-testsreportedusedbyIPsordistributedbyIPstoothers

• 192self-testsusedbyIPs

• 709self-testsdistributedtoothers(97%,691used)

• About20%ofkitsofferedweredeclined,and15%oftestkitsdistributeddidnotgetused

75%

32%

19% 17%

81%

0%10%20%30%40%50%60%70%80%90%

100%

• Foreachself-testgiventootherpersons,IPswereaskedhowself-testingtookplace(n=709)

• Couplestestingoccurredwith51-83%ofprimarypartnersinthe3studygroups• 4/280(1.4%)IPsreportedadverseevents

Couplestestingoccurredfrequently

HIVSTandsafersexualdecision-making

• SexualintercourselesslikelyandcondomusemorelikelywhenpartnertestedHIV-positive

ThirumurthyetalLancetHIV2016

Study2:DesignandKeyfindings

Studydesign

• Womenrecruitedfrom3ANCandPPCclinicsinKisumu

• Randomizedtooneoftwogroups• Intervention:ShownhowtocorrectlyuseHIVself-tests(Oraquick)andgiventwoself-tests• Written&pictorialinstructionsprovidedwitheachself-test• Modestencouragementtodistributeself-teststomalepartnerattheirowndiscretion

• Control:GivenreferralcardsthatinvitedtheirpartnertoobtainHIVtestingatVCTclinics,aloneorasacouple

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Partnerinvitationgroup,

No.(%)(N=286)

Self-testinggroup,No.(%)

(N=284)

Absolutedifference,%(95%CI)*

RiskRatio,RR(95%CI)** P-value*

Primaryoutcome

MalepartnerHIVtesting 148(51.7) 258(90.8) 39.1%(32.4%to45.8%) 1.76(1.56-1.98) <0.001CouplestestingforHIV 95(33.2) 214(75.4) 42.1%(34.7%to49.6%) 2.27(1.90-2.71) <0.001

Abbreviations:CI,confidenceinterval*-EstimatesandCIaremarginaleffectsfromunadjustedmodifiedPoissonregression**-EstimatesandCIareriskratiosfromunadjustedmodifiedPoissonregression

ImpactofHIVSTonuptakeofpartnerandcoupletestinginKenya

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• Partnertestingwas90.8%inHIVSTgroupand51.7%inthecomparisongroup;theproportionofpartnerstestedwas39%higherintheHIVSTgroup• CouplestestingalsosignificantlyhigherinHIVSTgroup(75%vs.33%,p<0.01)MastersetalPLOSMedicine2016

InterventioneffectiveevenamongwomenwhoreportedIPVatbaseline

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ControlGroupN

Controlgroup,No.(%)(n=286)

Self-testinggroupN

Self-testinggroup,No.(%)(n=284)

Absolutedifference,%(95%CI)*

P-valueforsubgroup*

P-valueforinteraction*

*

Intimatepartnerviolenceatbaseline

No 210 114(54.3%) 206 185(89.8%) 48.9%(36.4%to61.3%) <0.001 -

Yes 76 34(44.7%) 78 73(93.6%) 35.5%(27.6%to43.4%) <0.001 0.111

Notes:*-EstimatesaremarginaleffectsfromamodifiedPoissonregressionofoutcomeonstudygroupforthesubsampledescribed.

**-P-valuefrominteractioncoefficientbetweensubsampleandfirstcategory(urbanclinic,ornoIPV)

Alsoeffectiveamongwomenwhosepartnerhadnottestedrecently

ControlGroupN

Controlgroup,No.(%)(n=286)

Self-testinggroupN

Self-testinggroup,No.(%)

(n=284)

Absolutedifference,%(95%CI)*

P-valueforsubgroup*

P-valueforinteraction*

*

PartnerHIVtestingin12monthspriortoenrollmentTested≥1time 173 102(59%) 149 142(95.3%) 36.3%(28.3%to44.4%) <0.001 -Didnottest 35 16(45.7%) 42 37(88.1%) 42.4%(23.1%to61.7%) <0.001 0.389Donotknowiftested 78 30(38.5%) 93 79(84.9%) 46.5%(33.5%to59.5%) <0.001 0.057

Notes:*-EstimatesaremarginaleffectsfromamodifiedPoissonregressionofoutcomeonstudygroupforthesubsampledescribed.**-P-valuefrominteractioncoefficientbetweensubsampleandfirstcategory(yesevertested oryestestedinpast12months)

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Conclusions• SecondarydistributionofHIVself-testsbywomenispromisingstrategyforpromotingmalepartnertestingcomparedtothecurrentpracticeofpartnerinvitationtoclinic-basedtesting• Facilitiescanutilizethisapproachgiventhatwomenaccesshealthservicesmorethantheirpartners

• Theapproachispotentiallycheaperthanfacility-basedorhome-basedpartnerandcoupletesting

• Thestrategyhaspotential forfacilitatingsafersexualdecision-makingandreducingHIVincidenceamonghigh-riskindividualshenceneedsfurthertesting

Ongoing/Upcomingstudies

ClusterrandomizedtrialamongFSWandwomeninfishingcommunitiesinKenya(startsinMay2017)• Condomless sexcanbemorelucrativeforFSWandwomeninfishingcommunitieswhoengageintransactionalsex,resultingingreaterrisk-takingforfinancialreasons(Jakubowski etalJAIDS2016)

• GiventhehighHIVincidenceamongwomeninNyanzaregion,self-testsmaybeusefulforfacilitatingsafersexual-decisionmaking

• Clusterrandomizedtrialplannedfor2017totestthishypothesis(R01MH111602)

• StudypopulationwillincludeFSWandwomeninfishingcommunities

• Multipleself-testkitstowomenininterventionclustersoveraperiodof18months

• Proposedactivitiesincludecost-effectivenessmodeling

Otherstudiestestingthesecondarydistributionstrategy• TwootherstudieshaveexploredthefeasibilityandimpactofsecondarydistributionofHIVSTtopromotepartnertesting:• FactorsAssociatedwithAcceptabilityofHIVSelf-TestingAmongHealthCareWorkersinKenya(Kalibala etal,AIDSBeh.)

• ProvisionofOralHIVSelf-testKitsTriplesUptakeofHIVTestingamongMalePartnersofAntenatalCareClients:ResultsofaRandomizedTrialinKenya(Gichangi etal,JHPIEGOandMedicalUniversityofSouthCarolina)

• ArandomizedcontrolledstudytodeterminetheimpactofHIVSTonuptakeofHIVtestingbypartnersofadolescentgirlsage15-19yearslivinginSiaya County,Nyanzaregion• Feasibilityphasecompleted;fundsbeingsoughtforthemainstudy(RCT)

• PartiallyfundedbytheUniversityofNorthCarolinaatChapelHill&implementedbyImpactResearchandDevelopmentOrganization(IRDO)

• DREAMSInnovationChallengeandotherNIH-fundedstudiesledbytheUniversityofWashington• In8publicsectorMCHandFPclinics,allwomenwillbeofferedmultipleself-tests– partnerself-testingwillbeusedto

refineidentificationofwomenathighriskforHIVthatcouldbenefitfromPrEP counselinginadditiontostandardofcarePrEP delivery• SimilarapproachtobetestedinUganda

OtherHIVSTstudiesinKenya• GIRLSstudy– differenttestingmodalities(HIVST,community-basedtesting,home-basedtesting)andlinkagestrategies(SMSvsincentive)willbetestedamongAGYWage15-24yearsinHomabay County

• TostartinApril,2017

• FundedbyNIH,throughYaleUniversity(implementedbyUniversityofNairobiandIRDO)

• KPISStudy– implementationsciencestudytoassesstheimpactofHIVSTonenrollmentofFSWstodrop-incenters(Kisumu,Siaya,Homabay,Migori,Kisii,Nairobi,Mombasa,Kilifi andKwale counties)

• Ongoing,tobecompletedinSeptember2017.

• FundedbyPEPFAR,throughCDC(ImplementedbyCDC,USAID,NASCOP,IRDO,UniversityofNairobi,IMCandICRH)

Acknowledgments• Collaborators• HarshaThirumurthy• EuniceOmanga• SueNapierala

Mavedzenge• SuzanneMaman• SamMasters• KateMurray• ImmaculateAkello• BeatriceObonyo

• Studyparticipantsandfacilitystaff• MinistryofHealth,KisumuCounty• Researchassistants• CarolinaPopulationCenter