Social response to the delivery of HIV self-testing in households: experiences from four Zambian HPTN 071 (PopART) urban communities

Abstract

Background: Door-to-door distribution of HIV self-testing kits (HIVST) has the potential to increase uptake of HIV testing services (HTS). However, very few studies have explored the social response to and implications of door-todoor including secondary distribution of HIVST on household relations and the ability of individuals to self-test with or without supervision within households. Methods: A CRT of HIVST distribution was nested within the HPTN 071 (PopART) trial, in four Zambian communities randomised to receive the PopART intervention. The nested HIVST trial aimed to increase knowledge of HIV status at population level. Between February 1 and April 30, 2017, 66 zones (clusters) within these four communities were randomly allocated to either the PopART standard of care door-to-door HTS (33 clusters) or PopART standard of care door-to-door HTS plus oral HIVST (33 clusters). In clusters randomised to HIVST, trained Community HIV care provider (CHiPs) visited households and offered individuals aged ≥ 16 and eligible for an offer of HTS the choice of HIV testing using HIVST or routine door-to-door HTS (finger-prick RDT). To document participants' experiences with HIVST, Interviews (n = 40), observations (n = 22) and group discussions (n = 91) with household members and CHiPs were conducted. Data were coded using Atlas.ti 7 and analysed thematically. Results: The usage and storage of HIVST kits was facilitated by familiarity with and trust in CHiPs, the novelty of HIVST, and demonstrations and supervision provided by CHiPs. Door-to-door distribution of HIVST kits was appreciated for being novel, convenient, private, empowering, autonomous and easy-to-use. Literacy and age influenced accurate usage of HIVST kits. The novelty of using oral fluids to test for HIV raised questions, some anxiety and doubts about the accuracy of HIVST. Although HIVST protected participants from experiencing clinic-based stigma, it did not address self-stigma. Within households, HIVST usually strengthened relationships but, amongst couples, there were a few reports of social harms. Conclusion: Door-to-door distribution of HIVST as a choice for how to HIV test is appreciated at community level and provides an important testing option in the sub-Saharan context. However, it should be accompanied by counselling to manage social harms and by supporting those testing HIV-positive to link to care.

Changes over time in HIV testing and counselling uptake and associated factors among youth in Zambia: a cross-sectional analysis of demographic and health surveys from 2007 to 2018

“…In addition to the latter, other community-based strategies that are specific to youth should be explored given their promising results, such as adolescent-focused case finding implemented in Kenya and home-based HTC [ 48 , 49 ]. HIV self-testing (HST) is also part of interventions in Zambia and has shown some acceptance and the potential to improve access to HIV testing [ 50 – 53 ]. However, our study found that HST was unknown to most youth (85 and 80% among women and men, respectively).…”

The role of context in shaping HIV testing and prevention engagement among urban refugee and displaced adolescents and youth in Kampala, Uganda: findings from a qualitative study

“…First, our study reflected the need for technical information to be provided in creative ways for refugees with low literacy, including pictures, radio and demonstrating in-person how to use HIV self-testing kits. In other global regions, people with low literacy levels were willing to access HIV testing [26], yet also struggled with technologies such as HIV self-testing [27], signalling the need to prepare low literacy service delivery [26]. Second, transportation costs were a barrier to travelling to clinics for SRH services, yet some participants wanted SRH Literacy and a lack of access to formal education is a barrier 'There are people who know how to read and those who don't know how to read, so I think during the period of distribution, you first teach them so that they can also use without reading those instructions.…”

“…Police violence and criminalisation targeting sex workers in other contexts was associated with constrained access to condom use and increased HIV vulnerabilities [37,38]. A large body of research describes gender-based stigma and discrimination, and its intersection with other stigmatised health concerns such as HIV, and social identities such as sex work, as profound barriers to HIV testing and prevention [27], including with young refugees in Kampala [3].…”

“…Overcrowded living spaces produced privacy challenges for HIV self‐testing and disposal of test kits, reinforcing the challenges that youth have realising optimal SRH outcomes in slums in Uganda [29] and other contexts [30]. Alternative means of HIV self‐test kit disposal can be explored, such as lay health worker pick‐up [27]. Language barriers are a well‐established barrier to realising SRH among young refugees [31].…”

Changes over time in HIV testing and counselling uptake and associated factors among youth in Zambia: A cross-sectional analysis of Demographic and Health Surveys from 2007 to 2018

“…In addition to the latter, other community-based strategies that are speci c to youth should be explored given their promising results, such as adolescent-focused case nding implemented in Kenya and home-based HTC (49,50). HIV self-testing (HST) is also part of interventions in Zambia and has shown some acceptance and the potential to improve access to HIV testing (51)(52)(53)(54). However, our study found that HST was unknown to most youth (85% and 80% among women and men, respectively).…”