1. ASSESSMENT OF POSSIBLE OUTLETS FOR DISTRIBUTION OF HIV ORAL SELF-TEST KITS IN KENYA J. Okal 1, F. Obare 2, J. Matheka 1, W. Tun 3 1 Population Council, HIV, Nairobi, Kenya, 2 Population Council, Reproductive Health, Nairobi, Kenya, 3 Population Council, HIV, Washington, United States 20th International AIDS Society Conference Melbourne, Australia (20–25 July 2014)

2. Background Marked increase in HIV testing and counseling (HTC) levels from 34% 2007 to 72% – Only 47% of HIV-positive individuals know their status – Confidentiality concerns remain a barrier to facility-based HTC Rapid tests provide opportunity to overcome confidentiality and convenience barriers Use of HIV oral self-test kits already considered by Kenya government – Limited understanding of how well to distribute the kits

3. Study objectives Overall objective: – Generate evidence to inform the design and evaluation of programs using HIV oral self-tests in Kenya Specific objectives are: – Examine the possible outlets and/or networks for the distribution of HIV oral self-tests to potential users in Kenya – Explore how the distribution of HIV oral self-tests through various channels can be organized to better meet the needs of potential users – Examine the possible linkages to counseling and care for users of HIV oral self-tests given the choice of the distribution outlet

4. METHODS

5. Study design Cross-sectional exploratory design involving quantitative and qualitative data collection 3 components involving demonstration of use of the kits – Community survey – Service provider interviews – Key informant interviews (KIIs) Random and purposive selection of samples based on component – Community survey—random selection of samples – Service provider interviews Random selection of facility-based providers Purposive selection of community-based providers – KIIs—purposive selection of informants

6. Data collection: Community survey Mid to end October 2013 – 1,436 adults, 18–64 years (969 women, 467 men) – 4 counties—Kisumu, Uasin Gishu, Nyandarua and Kilifi – Information collected Background characteristics Potential use of the kits Preferred distribution outlet Linkage to counselling and care

7. Data collection: Service provider interviews Mid to end October 2013 – 317 service providers aged 20–65 years Public and private for- and not-for profit health facilities Stand-alone voluntary counselling and testing (VCT) centres Private pharmacies Community health workers (CHWs), traditional birth attendants (TBAs) and shop/supermarket owners – 5 counties—Kisumu, Uasin Gishu, Nairobi, Nyandarua, Kilifi – Information collected Background characteristics Services provided at outlet Potential use of HIV oral self-test kits by clients Possible channels for distributing the kits Readiness to give information and/or distribute the kits Linkage to counselling and care

8. Data collection: KIIs Mid to end October 2013 – 27 key informants Opinion leaders (chiefs and assistant chiefs) Representatives of community-based organisations (CBOs) Ministry of Health—DASCOs, PASCOs, NASCOP KEMSA Social marketing and outreach agencies Special groups (Key populations, FSWs, PWID, PWDs) – 5 counties—Kisumu, Uasin Gishu, Nairobi, Nyandarua, Kilifi – Information collected Potential use of the kits in the community Readiness to give information and/or distribute the kits How the distribution channel can be organized to meet clients’ needs Linkage to counselling and care

9. RESULTS

10. Prior testing for HIV 93% of survey women and 79% of survey men had previously tested for HIV Among those previously tested, 65% of women and 52% of men had last test in a public health facility

11. Potential use of HIV oral self-test kits Majority of survey respondents indicated that they would use the kits (94% of women and men) 91% of service providers also reported that their clients would use the kits KIIs also showed that many people would use the kits People want to know their status but the problem with the current HTC set up is that for me to know [my status] someone have to know [my status]. —NGO sector informant People will know their status, and through test that fear of sharing your status in public will be eliminated. —Service delivery organization

12. Possible distribution channels 83% of survey respondents mentioned public health facility as either the main or alternative source of HIV oral self-test kits 24% of the respondents mentioned private pharmacy Other the main or alternative sources of HIV oral self-test kits included local administration (20% of the women and 27% of the men), private health facilities (24% of the women and 18% of the men), and local shops or supermarkets

13. Possible distribution channels (cont’d)

14. Advantages of public health facilities noted among survey respondents, service providers and key informants – Widely spread thereby allowing for ease of access (distance) – Cost of services affordable – Quality of services—availability and interactions with clients Limitations of public health facilities mentioned by service providers and key informants – Red tape and bureaucracy – Lack of privacy and confidentiality – Inadequate staff – Lack of training – Long waiting time

15. Readiness to provide information and distribute kits 97% of providers would give information while 93% would distribute the kits Reasons for readiness to provide information: – Adequate human resources (52%) – Adequate infrastructure (35%) – Large clientele (34%) – Appropriate training (28%) Major reasons for readiness to distribute kits: – Providers had large clientele (59%) – Distribution does not require huge amounts of resources (26%) – Adequate human resources (25%) – Adequate infrastructure (24%)

16. Readiness to provide information and distribute kits (cont’d) Readiness to give information and/or distribute kits also evident from key informants I don’t foresee a challenge so long as everything has been worked out. As long as we have clear guidelines on, ‘after you test this is what will happen’, test kits are located here, this is the person mandated to give out the test kits, how do we do the returns— accountability, because right now if we have free test kits for which we are not charging the patients, there is bound to be some pilferage or something. Yeah, so long as all that is clear before we start, then I don’t foresee challenges. —Public health manager

17. Organization of distribution channels Support needed to provide information: – Training or updates on self-test (71%) – Adequate IEC materials (64%) – Community sensitization (52%) – Additional financial resources (47%) – Additional human resources (33%) Support needed to distribute: – Training or updates on self-test (54%) – Reliable supplies (52%) – Community sensitization (51%) – Adequate IEC materials and additional financial resources (47% each)

18. Linkage to counseling and care >70% of women and men indicated they would seek counseling services before/after performing HIV self-test 62% and 71% of providers felt that clients would seek counseling services before and after performing HIV oral self-test respectively Key informants had mixed views It will depend if I get I am negative, I will not need, there are those who will need it if they are positive, but also the other dimension was that if I take this kit two or three times in my house and find that am positive, naturally I will want to go to the hospital. —Key populations provider

19. Source of counseling services Public health facilities were the most preferred sources of counseling services before or after testing among survey women and men 75% of women and 71% of men who would seek counseling services before testing mentioned “public health facility” as the most convenient place to go for the services 79% of women and 76% of men who would seek counseling services after testing mentioned public health facility as the place where they would go for the services

20. SUMMARY OF FINDINGS/IMPLICATIONS

21. Summary of findings Near-universal acceptance of the use of HIV oral self-test kits among survey respondents – Service providers and key informants further confirmed that the test kits would be acceptable in the community Public health facilities were the most commonly mentioned outlets where clients would seek counseling and other services before or after performing HIV self-test Efficient organization of the distribution channel requires – Training and/or updates on self-test – Adequate IEC materials – Community sensitization – Reliable supplies of the test kits

22. Thank You International Initiative for Impact Evaluation (3ie) MoH/NASCOP Stakeholders who participated Respondents who shared information

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