Summary Background Identifying interventions to increase men’s uptake of HIV testing in sub-Saharan Africa is essential for the success of combination HIV prevention. HIV self-testing is an emerging approach with high acceptability, but limited evidence exists on optimal strategies for distributing self-tests. We explored a novel approach of providing multiple self-tests to women at high risk of HIV acquisition in order to promote partner HIV testing and facilitate safer sexual decision-making. Methods HIV-uninfected women aged 18–39 years were recruited at two sites in Kisumu, Kenya: a health facility with antenatal (ANC) and postpartum (PPC) clinics, and a drop-in center for female sex workers (FSW). Following informed consent and instructions on using the OraQuick Rapid HIV 1/2 Test, index participants (IPs) enrolled at the health facility and drop-in center received 3 and 5 self-tests, respectively. Structured interviews were conducted with IPs at enrollment and over 3 months to determine how self-tests were used. Key outcomes included the number of self-tests distributed by IPs, the proportion of IPs whose sexual partners used a self-test, couples testing, and sexual behavior following self-testing. Findings Between January 14, 2015 and March 13, 2015, 280 IPs were enrolled (61 ANC, 117 PPC, 102 FSW). Follow-up interviews were completed with 265 IPs (96%). Most IPs with a primary sexual partner distributed a self-test to that partner (53/58, 91% ANC; 91/106, 86% PPC; 64/85, 75% FSW). A vast majority of FSW IPs also distributed ≥1 self-tests to commercial sex clients (82/101, 81%). Among self-tests distributed to and used by IPs’ primary sexual partners, couples testing occurred frequently (27/53, 51% ANC; 62/91, 68% PPC; and 53/64; 83% FSW). Among self-tests distributed to and used by IPs’ sexual partners, an HIV-positive result was obtained for 3.8% (2/53), 2.2% (2/91), and 13.8% (41/298) of the tests in the ANC, PPC, and FSW participant groups, respectively. Sexual intercourse was significantly less likely after a sexual partner tested HIV-positive versus HIV-negative (18% vs. 62%, p<0.0001), while condom use was significantly more likely (100% vs. 44%, p=0.0018). Of 265 IPs with follow-up data, four reported intimate partner violence as a result of self-test distribution. No other adverse events were reported. Interpretation Provision of multiple HIV self-tests to women at high risk of HIV infection was successful in promoting HIV testing among their sexual partners and in facilitating safer sexual decisions. This novel strategy warrants further consideration as countries develop self-testing policies and programs.

BackgroundAchieving higher rates of partner HIV testing and couples testing among pregnant and postpartum women in sub-Saharan Africa is essential for the success of combination HIV prevention, including the prevention of mother-to-child transmission. We aimed to determine whether providing multiple HIV self-tests to pregnant and postpartum women for secondary distribution is more effective at promoting partner testing and couples testing than conventional strategies based on invitations to clinic-based testing.Methods and FindingsWe conducted a randomized trial in Kisumu, Kenya, between June 11, 2015, and January 15, 2016. Six hundred antenatal and postpartum women aged 18–39 y were randomized to an HIV self-testing (HIVST) group or a comparison group. Participants in the HIVST group were given two oral-fluid-based HIV test kits, instructed on how to use them, and encouraged to distribute a test kit to their male partner or use both kits for testing as a couple. Participants in the comparison group were given an invitation card for clinic-based HIV testing and encouraged to distribute the card to their male partner, a routine practice in many health clinics. The primary outcome was partner testing within 3 mo of enrollment. Among 570 participants analyzed, partner HIV testing was more likely in the HIVST group (90.8%, 258/284) than the comparison group (51.7%, 148/286; difference = 39.1%, 95% CI 32.4% to 45.8%, p < 0.001). Couples testing was also more likely in the HIVST group than the comparison group (75.4% versus 33.2%, difference = 42.1%, 95% CI 34.7% to 49.6%, p < 0.001). No participants reported intimate partner violence due to HIV testing. This study was limited by self-reported outcomes, a common limitation in many studies involving HIVST due to the private manner in which self-tests are meant to be used.ConclusionsProvision of multiple HIV self-tests to women seeking antenatal and postpartum care was successful in promoting partner testing and couples testing. This approach warrants further consideration as countries develop HIVST policies and seek new ways to increase awareness of HIV status among men and promote couples testing.Trial RegistrationClinicalTrials.gov NCT02386215.

IMPORTANCE Novel strategies are needed to increase the uptake of voluntary medical male circumcision (VMMC) in sub-Saharan Africa and enhance the effectiveness of male circumcision as an HIV prevention strategy. OBJECTIVE To determine whether small economic incentives could increase circumcision prevalence by addressing reported economic barriers to VMMC and behavioral factors such as present-biased decision making. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial conducted between June 22, 2013, and February 4, 2014, among 1504 uncircumcised men aged 25 to 49 years in Nyanza region, Kenya. VMMC services were provided free of charge and participants were randomized to 1 of 3 intervention groups or a control group. INTERVENTIONS Participants in the 3 intervention groups received varying amounts of compensation conditional on undergoing circumcision at 1 of 9 study clinics within 2 months of enrollment. Compensation took the form of food vouchers worth 200 Kenya shillings (≈US $2.50), 700 Kenya shillings (≈US $8.75), or 1200 Kenya shillings (≈US $15.00), which reflected a portion of transportation costs and lost wages associated with getting circumcised. The control group received no compensation. MAIN OUTCOMES AND MEASURES VMMC uptake within 2 months. RESULTS Analysis of data for 1502 participants with complete data showed that VMMC uptake within 2 months was higher in the US $8.75 group (6.6%; 95% CI, 4.3%–9.5% [25 of 381]) and the US $15.00 group (9.0%; 95% CI, 6.3%–12.4% [34 of 377]) than in the US $2.50 group (1.9%; 95% CI, 0.8%–3.8% [7 of 374]) and the control group (1.6%; 95% CI, 0.6%–3.5% [6 of 370]). In logistic regression analysis, the US $8.75 group had significantly higher VMMC uptake than the control group (adjusted odds ratio [AOR] 4.3; 95% CI, 1.7–10.7), as did the US $15.00 group (AOR 6.2; 95% CI, 2.6–15.0). Effect sizes for the US $8.75 and US $15.00 groups did not differ significantly (P = .20). CONCLUSIONS AND RELEVANCE Among uncircumcised men in Kenya, compensation in the form of food vouchers worth approximately US $8.75 or US $15.00, compared with lesser or no compensation, resulted in a modest increase in the prevalence of circumcision after 2 months. The effects of more intense promotion or longer implementation require further investigation.

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Background:Effective demand creation strategies are needed to increase uptake of medical male circumcision and reduce new HIV infections in eastern and southern Africa. Building on insights from behavioral economics, we assessed whether providing compensation for opportunity costs of time or lottery-based rewards can increase male circumcision uptake in Kenya.Methods:Uncircumcised men aged 21–39 years were randomized in 1:1:1 ratio to 2 intervention groups or a control group. One intervention group was offered compensation of US $12.50 conditional on circumcision uptake. Compensation was provided in the form of food vouchers. A second intervention group was offered the opportunity to participate in a lottery with high-value prizes on undergoing circumcision. The primary outcome was circumcision uptake within 3 months.Results:Among 903 participants enrolled, the group that received compensation of US $12.50 had the highest circumcision uptake (8.4%, 26/308), followed by the lottery-based rewards group (3.3%, 10/302), and the control group (1.3%, 4/299). Logistic regression analysis showed that compared with the control group, the fixed compensation group had significantly higher circumcision uptake [adjusted odds ratio 7.1; 95% CI: 2.4 to 20.8]. The lottery-based rewards group did not have significantly higher circumcision uptake than the control group (adjusted odds ratio 2.5; 95% CI: 0.8 to 8.1).Conclusions:Providing compensation was effective in increasing circumcision uptake among men over a short period. The results are consistent with studies showing that such interventions can modify health behaviors by addressing economic barriers and behavioral biases in decision making. Contrary to findings from studies of other health behaviors, lottery-based rewards did not significantly increase circumcision uptake.Trial Registration:Registry for International Development Impact Evaluations: RIDIE-STUDY-ID-530e60df56107.

ObjectiveTo examine the associations between perceived quality of care and patient satisfaction among HIV and non-HIV patients in Zambia.SettingPatient exit survey conducted at 104 primary, secondary and tertiary health clinics across 16 Zambian districts.Participants2789 exiting patients.Primary independent variablesFive dimensions of perceived quality of care (health personnel practice and conduct, adequacy of resources and services, healthcare delivery, accessibility of care, and cost of care).Secondary independent variablesRespondent, visit-related, and facility characteristics.Primary outcome measurePatient satisfaction measured on a 1–10 scale.MethodsIndices of perceived quality of care were modelled using principal component analysis. Statistical associations between perceived quality of care and patient satisfaction were examined using random-effect ordered logistic regression models, adjusting for demographic, socioeconomic, visit and facility characteristics.ResultsAverage satisfaction was 6.9 on a 10-point scale for non-HIV services and 7.3 for HIV services. Favourable perceptions of health personnel conduct were associated with higher odds of overall satisfaction for non-HIV (OR=3.53, 95% CI 2.34 to 5.33) and HIV (OR=11.00, 95% CI 3.97 to 30.51) visits. Better perceptions of resources and services were also associated with higher odds of satisfaction for both non-HIV (OR=1.66, 95% CI 1.08 to 2.55) and HIV (OR=4.68, 95% CI 1.81 to 12.10) visits. Two additional dimensions of perceived quality of care—healthcare delivery and accessibility of care—were positively associated with higher satisfaction for non-HIV patients. The odds of overall satisfaction were lower in rural facilities for non-HIV patients (OR 0.69; 95% CI 0.48 to 0.99) and HIV patients (OR=0.26, 95% CI 0.16 to 0.41). For non-HIV patients, the odds of satisfaction were greater in hospitals compared with health centres/posts (OR 1.78; 95% CI 1.27 to 2.48) and lower at publicly-managed facilities (OR=0.41, 95% CI=0.27 to 0.64).ConclusionsPerceived quality of care is an important driver of patient satisfaction with health service delivery in Zambia.

The allocation of funding for new anticancer treatments within the UK has not kept pace with demand. Clinicians find themselves restricted in the use of licensed drugs which they feel are in the best interests of individual patients. Against this, health authorities have a duty to ensure that scarce resources are used equitably to meet the needs of the local population as a whole. Differential levels of funding for new treatments across the country have led to concerns about rationing by postcode. This paper outlines an approach to the prioritization of new treatment for advanced cancer developed jointly by clinicians and health authorities in South London. The approach involves evidence reviews and consensus meetings. Existing and new treatments are rated on a four-point ‘relative effectiveness scale’, which takes account of the impact of the treatment on quality of life and on survival. The strength of evidence supporting each effectiveness rating is also classified. Health Authorities have used these ratings to determine overall funding levels, while leaving decisions on individual patients to the relevant Trusts. © 2000 Cancer Research Campaign

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