secondary distribution of hiv self-tests in kenya...
TRANSCRIPT
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
14
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