Uptake and impact of facility‐based HIV self‐testing on PrEP delivery: a pilot study among young women in Kisumu, Kenya

Abstract

Introduction HIV testing is a required part of delivery of pre‐exposure prophylaxis (PrEP) for HIV prevention. However, repeat testing can be challenging in busy, under‐staffed clinical settings, which could negatively impact PrEP uptake and continuation. We prospectively evaluated optional facility‐based HIV self‐testing (HIVST) among young women using PrEP in an implementation programme. Methods Between February and November 2019, we collected data from young women receiving PrEP at two family planning facilities in Kisumu, Kenya. At each PrEP follow‐up visit, women were given the option to choose between provider‐initiated testing and HIVST. We assessed factors associated with HIVST uptake and compared satisfaction with HIV testing and clinic experience between acceptors and decliners of HIVST. Results A total of 172 women were offered HIVST at 202 PrEP follow‐up visits. The median age was 21 years, 27% had multiple partners and 15% reported previously using HIVST. HIVST was accepted at 34.7% (70/202) of visits. Age (adjusted relative risk (aRR) 1.09 per year, 95% CI (confidence interval) 1.01 to 1.18), never being married (aRR 1.81, 95% CI 1.11 to 2.95) and having more PrEP follow‐up visits (aRR 1.13 per visit, 95% CI 1.04 to 1.23) were associated with HIVST uptake. Compared to HIVST decliners, HIVST acceptors were more likely to be very happy with their overall testing experience (73% vs. 47% of visits, p = 0.003) and were more likely to say they would use HIVST in the future (96% vs. 76%, p < 0.001). Women who accepted HIVST had shorter visits than those choosing standard provider‐initiated HIV testing (median [IQR]: 33 [32, 38] vs. 54 [41.5, 81] minutes, p = 0.003). Conclusions In this pilot evaluation in Kenya, about one‐third of women using PrEP opted for HIVST over provider‐initiated testing, and those choosing HIVST spent less time in the clinic and were generally satisfied with their experience. HIVST in PrEP delivery is feasible and has the potential to simplify PrEP delivery and give clients testing autonomy. Additional studies are needed to explore optimal HIV retesting strategies in PrEP delivery, including the use of HIVST in PrEP at a larger scale and in different settings.

A one‐stop shop model for improved efficiency of pre‐exposure prophylaxis delivery in public clinics in western Kenya: a mixed methods implementation science study

“…In light of our finding that over half of client wait time was for travel to/from and queueing at an HTS point, future iterations of the OSS model should test additional interventions, such as HIV self‐testing, that could potentially expedite the HTS component. For example, a recent study at a subcounty hospital in Western province piloted the use of in‐room, oral fluid‐based HIV self‐testing (HIVST) for PrEP continuation and found that clients who opted for HIVST had significantly shorter clinic visits [62]. A randomized controlled trial currently underway in Central province is assessing whether dispensing clients a 6‐month supply of PrEP and allowing them to complete quarterly HIV testing at home via an oral fluid‐ or blood‐based HIVST leads to better adherence and continuation [63].…”

Introducing the Dapivirine Vaginal Ring in Sub-Saharan Africa: What Can We Learn from Oral PrEP?

“…Another promising innovation — use of HIV self-testing (HIVST) for PrEP follow-up — proved highly acceptable among HIV serodifferent couples in Kenya who were offered self-testing kits to use between quarterly clinic visits [ 30 ] and among female sex workers who expressed interested in using PrEP in Uganda and Zambia [ 31 ]. In a pilot evaluation among AGYW PrEP clients in Kenya, unassisted facility-based HIVST was feasible, reduced visit times, and was chosen over provider-initiated testing at almost 35% of clinic visits [ 32 ]. Ongoing studies on the use of HIVST to support delivery of oral PrEP will yield valuable insights [ 33 – 36 ].…”

Implementation strategies for integrating pre-exposure prophylaxis for HIV prevention and family planning services for adolescent girls and young women in Kenya: a qualitative study

“…Drawing again from Michie et al’s theory of behavior change, this finding suggests that, before asking providers to take on the additional work of PrEP delivery, implementers should ensure that the delivery environment affords providers sufficient “physical opportunity” [ 43 ], (p.63) (e.g., time, access to necessary resources) to adopt the desired behavior. For example, implementers could conduct time-and-motion studies [ 44 , 45 ] to measure how much, if any, available time providers have for PrEP delivery. If providers are at (or very close to) maximum capacity and clinics are unable to hire additional staff, then implementation is unlikely to succeed unless other clinical responsibilities are removed from providers’ workloads and/or inefficiencies eliminated from provider workflow.…”

“…If providers are at (or very close to) maximum capacity and clinics are unable to hire additional staff, then implementation is unlikely to succeed unless other clinical responsibilities are removed from providers’ workloads and/or inefficiencies eliminated from provider workflow. A variety of strategies, including some already in use in SSA, may be pursued to this end, including shifting PrEP tasks to lower-level cadres (e.g., peer educators) [ 46 ], modifying clinical practices (e.g., adopting multi-month scripting to reduce client volume) [ 46 – 48 ], and using client-facing interventions, such as HIV self-testing [ 49 ] and decision-support tools [ 50 ], to expedite the clinical encounter.…”