1. Annette N. Brown, PhD
International Initiative for Impact Evaluation, 3ie
Presentation for the HIVST satellite session sponsored by WHO
IAC, Melbourne, July 2014
FIVE Studies on HIV Self-testing in Kenya: What We Learned From and About Formative Research

2. 3ie HIV self-testing grants program
Fund pilot programs using HIV self-tests accompanied by impact evaluations
Test for both intended positive outcomes and unintended negative outcomes
Implement country by country (3 countries)
Start with Kenya (12/2012)
Formative research
Impact evaluations

3. Formative research themes
Accuracy
Packaging and labeling
Potential users and messaging
Distribution outlets
Linkage to counseling and care
Potential social harms and abuses

4. Methods
Four of five studies used medium to large sample surveys, three of these used random sampling
One study used small sample qualitative data collection
Heterogeneous samples, but not population representative samples
Studies employed basic statistical analysis and some qualitative analysis
One of five used actual self tests as part of study
Our summary analysis is primarily narrative
Most summary findings include evidence from more than one formative study

5. Formative research findings
Do people want it?
Why? Why not?
Who?
Does it work?
Where would people get it?
Will people get counseling and/or care?
What are people worried about?
How can we address concerns?

6. Do people want it?
5/5 studies report near universal “acceptability”: >90%
3/5 studies report acceptability among never tested: 80% - 91%
FSW: 98%
MSM: 57%

7. Do people want it? One study [3] Another study [1] Men Women
Never tested would like to be tested: 70%
Never tested would purchase and use if available: 86%
Women
Never tested would like to be tested: 58%
Never tested would purchase and use if available: 80%
Another study [1]
Men never tested who would use a self-test: 90%

8. Why would people use self-tests?
[1]

9. Why would people self-test?
Reasons why self-test
Males
Females
Private
70.9%
56.7%
Early treatment
20.1%
24.7%
“No worry” if negative
9.0%
19.5%
Know status
13.8%
11.1%
Easy to use
13.0%
9.9%
Convenient
12.6%
9.5%
Test is accurate
5.9%
3.4%
Protect regular partners
6.7%
1.0%
Protect other partners
1.7%
1.4%
Other
3.6%
[3]

10. Why not self-test? % n [2] Reasons not to use the kit on their own
Mombasa
Siaya
Average Total
Reasons not to use the kit on their own %  n
Afraid of finding out positive result while alone
46.9
41.2
44.9 22
Health workers are more knowledgeable
18.8
17.6
18.4 9
Afraid of misinterpreting results
12.5
35.3
20.4 10
Other
21.9
5.9
16.3 8
[2]

11. Who would use it? Ever been tested more likely [2] [3]
Men more likely [3]

12. Does it work? Sensitivity: 92.9% (89.7%) Specificity: 97.8% (98.0%)
Unobserved sensitivity in US: 91.7%
Specificity: 97.8% (98.0%)
Invalids: 15% (men and never tested more likely)
[5]

13. Where would people get it?
Table 6: Percent distribution of survey respondents who would use HIV oral
self-test kits by main preferred distribution channels
[1]
Indicator
Women
(%)
Men
Both sexes
Main preferred distribution channel
Public health facility
63.2
59.0
61.8
Private health facility
4.6
3.0
4.1
Faith-based/NGO health facility
2.3
2.7
Stand-alone VCT center
0.3
0.0
0.2
Mobile clinic/tent/outreach
2.1
2.0
Private pharmacy
7.5
5.7
6.9
Community health worker
2.9
2.6
Community-based distributor
0.9
1.4
1.0
CBO/self-help group
Non-governmental organization
Local administration
6.8
11.3
8.3
Social marketing events
0.7
0.4
Local shops/supermarkets
8.2
5.4
Family member/relative/friend/neighbor
0.1
Traditional birth attendant
Other
3.9

14. Where would people get it?
Table 8: Percent distribution of survey respondents who would use
HIV oral self-test kits by other preferred distribution channels apart
from the main one mentioned
[1]
Other distribution channels
Women
(%)
Men
Both sexes
Other channels apart from public health facility
(N=574)
(N=260)
(N=834)
Private health facility
24.7
21.5
23.4
Mobile clinic/tent/outreach
16.0
13.9
15.4
Private pharmacy
23.2
22.7
Local administration
15.7
18.9
16.7
Local shops/supermarkets
11.0
13.1
11.6

15. What are people worried about?
70.7% of men and 54.9% of women feel there are disadvantages [3]
Might commit suicide
Anxious or depressed (men more than women)
Not disclose (men more than women)
Harm others (men more than women)
Counterfeit kits (men more than women)

16. What are people worried about?
66.2% of men and 54.7% of women feel that self-testing would be misused or abused [3]
Perceived abuses
Male
Female
Intentionally infecting others
70.7%
90.5%
Testing partner without consent
73.0%
59.5%
Parents testing children w/o consent
80.9%
49.5%
Testing people without consent
45.4%
52.0%
Testing potential employees
36.6%
46.9%
Schools testing children
31.7%
41.1%
Disclosing others’ HIV status
19.9%
53.9%
Don’t know
3.0%
5.0%

17. What would people do? What would people do if positive? [3]
Seek counseling: 41.4% | 35.8%
Confirm results: 22.0% | 19.5%
Seek medication: 10.7% | 18.9%
Go into depression: 9.0% | 8.3%
Keep results secret: 4.8% | 2.2% …
Commit suicide: 1.9% | 1.6%
Intentionally infect others: 0.2% | 0.0%

18. How to address concerns?
Ways to prevent abuses
Male
Female
Make non-consensual testing illegal
39.5%
22.2%
Self-testing kit used only by person who receives
30.9%
14.4%
Provide only one self-testing kit per person
21.5%
18.3%
Sensitization
17.7%
14.7%
Other ways
5.4%
11.1%
Don’t allow home self-testing
5.1%
10.8%
Pre-counseling
5.9%
6.2%
Restricted distribution points
3.2%
3.3%
Legal penalties for misuse
4.8%
0.3%
Age restrictions for purchase
1.3%
[3]

19. Messaging findings Mass media sensitization and awareness campaigns
Come from MOH
Inform: address concerns and advantages
Educate: importance of confirmatory test, disclosure, linkage to care, prevention
Prior to and during roll-out
[2]

20. Packaging and labeling findings
Packaging secure
Small size
Labeling—with quality seals, informative
Improved instructions—simple, explicit
Information about storage, expiration
May require point of distribution instruction
[4]

21. Linkage to care findings
Strong desire for face-to-face counseling [3]
Telephone hotline not preferred [3]
Public health facilities strongly preferred for counseling before and after [1]

22. Main conclusions High acceptability and likelihood of use
Accuracy not much different from US
Health facilities are a desirable outlet
Perceptions of disadvantages and abuses do exist
Big differences between men and women
Mass messaging important
Packaging and labeling important

23. What did we learn about formative research?
Sensitivity of findings to question formats and choices listed
High occurrence of priming
Useful, but no substitute for impact evaluation of pilot programs

24. Formative studies
[1] “Possible channels for distribution of HIV oral self-test kits in Kenya” Jerry Okal, Francis Obare, Waimar Tun, James Matheka
[2] “Insights into potential users and messaging for HIV oral self-test kits in Kenya” Rhoune Ochako, Lung Vu, Katia Peterson
[3] “Understanding perceived social harms and abuses of oral HIV self-testing in Kenya” Caroline W. Kabiru, Estelle M. Sidze, Thaddaeus Egondi, Damar Osok, Chimaraoke O. Izugbara
[4] “How HIV self-testing kits should be packaged in Kenya” Olivier LeTouzé
[5] “Accuracy of oral HIV self-tests in Kenya” Ann E. Kurth, Abraham M. Siika

25. HIV Evidence Initiative
Annette N. Brown
Anna Heard
Eric Djimeu
Nancy Diaz