Is HIV Self-Testing a Strategy to Increase Repeat Testing Among Pregnant and Postpartum Women? A Pilot Mixed Methods Study

Preferences and uptake of home-based HIV self-testing for maternal retesting in Kenya

OBJECTIVE

To compare preferences, uptake, and cofactors for unassisted home-based oral self-testing (HB-HIVST) versus clinic-based rapid diagnostic blood tests (CB-RDT) for maternal HIV retesting.

DESIGN

Prospective cohort.

METHODS

Between November 2017 and June 2019, HIV-negative pregnant Kenyan women receiving antenatal care were enrolled and given a choice to retest with HB-HIVST or CB-RDT. Women were asked to retest between 36 weeks gestation and 1-week post-delivery if the last HIV test was <24 weeks gestation or at 6 weeks postpartum if ≥24 weeks gestation, and self-report on retesting at a 14-week postpartum.

RESULTS

Overall, 994 women enrolled and 33% (n = 330) selected HB-HIVST. HB-HIVST was selected because it was private (n = 224, 68%), convenient (n = 211, 63%), and offered flexibility in the timing of retesting (n = 207, 63%), whereas CB-RDT was selected due to the trust of providers to administer the test (n = 510, 77%) and convenience of clinic testing (n = 423, 64%). Among 905 women who reported retesting at follow-up, 135 (15%) used HB-HIVST. Most (n = 595, 94%) who selected CB-RDT retested with this strategy, compared to 39% (n = 120) who selected HB-HIVST retesting with HB-HIVST. HB-HIVST retesting was more common among women with higher household income and those who may have been unable to test during pregnancy (both retested postpartum and delivered <37 weeks gestation) and less common among women who were depressed. Most women said they would retest in the future using the test selected at enrollment (99% [n = 133] HB-HIVST; 93% [n = 715] CB-RDT-RDT).

CONCLUSIONS

While most women preferred CB-RDT for maternal retesting, HB-HIVST was acceptable and feasible and could be used to expand HIV retesting options.

Preferences and uptake of home-based HIV self-testing for maternal retesting in Kenya

Objective

To compare preferences, uptake, and cofactors for unassisted home-based oral self-testing (HB-HIVST) versus clinic-based rapid diagnostic blood tests (CB-RDT) for maternal HIV retesting.

Design

Prospective cohort.

Methods

Between November 2017 and June 2019, HIV-negative pregnant Kenyan women receiving antenatal care were enrolled and given a choice to retest with HB-HIVST or CB-RDT. Women were asked to retest between 36 weeks gestation and 1 week post-delivery if the last HIV test was <24 weeks gestation or at 6 weeks postpartum if ≥24 weeks gestation, and self-report on retesting at a 14 week postpartum.

Results

Overall, 994 women enrolled and 33% (n=330) selected HB-HIVST. HB-HIVST was selected because it was private (68%), convenient (63%), and offered flexibility in timing of retesting (63%), whereas CB-RDT was selected due to trust of providers to administer the test (77%) and convenience of clinic testing (64%). Among 905 women who reported retesting at follow-up, 135 (15%) used HB-HIVST. Most (94%) who selected CB-RDT retested with this strategy, compared to 39% who selected HB-HIVST retesting with HB-HIVST. HB-HIVST retesting was more common among women with higher household income and those who may have been unable to test during pregnancy (both retested postpartum and delivered <37 weeks gestation) and less common among women who were depressed. Most women said they would retest in the future using the test selected at enrollment (99% HB-HIVST; 93% CB-RDT-RDT).

Conclusions

While most women preferred CB-RDT for maternal retesting, HB-HIVST was acceptable and feasible and may increase retesting coverage and partner testing.

An implementation strategy package (video education, HIV self-testing, and co-location) improves PrEP implementation for pregnant women in antenatal care clinics in western Kenya

Background

Pre-exposure prophylaxis (PrEP) is recommended by the World Health Organization and the Kenyan Ministry of Health for HIV prevention in pregnancy and postpartum for women at risk for HIV. Integration of PrEP into antenatal care is promising, but delivery gaps exist in the face of healthcare provider shortages in resource-limited settings.

Methods

Between May and November 2021, we conducted a difference-in-differences study (3 months pre-intervention data collection and 3 months post-intervention data collection) analyzing four intervention facilities, where the strategies were implemented, and four comparison facilities, where no strategies were implemented. We tested a combination of three implementation strategies-video-based PrEP information in the waiting bay, HIV self-testing, and dispensing of PrEP in the antenatal care rooms-to improve PrEP delivery. We compared absolute changes in the proportion of antenatal attendees screened for PrEP (PrEP penetration), the proportion receiving all PrEP-specific steps in a visit (HIV testing, risk screening, and PrEP counseling) (PrEP fidelity), and client PrEP knowledge, client satisfaction, and waiting time and service time (a priori outcomes); post hoc, we compared the proportion offered PrEP (PrEP offer) and completing HIV testing. We measured provider perceptions of the acceptability and appropriateness of the implementation strategies.

Results

We observed significant improvements in PrEP penetration, PrEP offer, satisfaction, and knowledge (p < 0.05) and improvements in fidelity that trended towards significance (p = 0.057). PrEP penetration increased 5 percentage points (p = 0.008), PrEP fidelity increased 8 percentage points (p = 0.057), and PrEP offer increased 4 percentage points (p = 0.003) in intervention vs. comparison facilities. Client PrEP knowledge increased by 1.7 out of 6 total points (p < 0.001) and client satisfaction increased by 0.7 out of 24 total points (p = 0.003) in intervention vs. comparison facilities. We observed no changes in service time (0.09-min decrease; p = 0.435) and a small increase in waiting time (0.33-min increase; p = 0.005). HIV testing among those eligible did not change (1.5 percentage point decrease, p = 0.800). Providers felt the implementation strategies were acceptable and appropriate (median acceptability: 20/20; median appropriateness: 19.5/20). However, absolute levels of each step of the PrEP cascade remained suboptimal.

Conclusions

An implementation strategy package with video information, HIV self-testing, and co-location of medication dispensing enhanced PrEP delivery across several implementation outcomes and client satisfaction, while not substantially increasing wait time or decreasing provider-client contact time.

Clinical trial registration

ClinicalTrials.gov , identifier, NCT04712994.

Pediatric HIV Pre-test Informational Video is Associated with Higher Knowledge Scores Compared to Counselor-Delivered Information

Video-based pre-test information is used in high resource settings to increase HIV testing coverage but remains untested in resource-limited settings. We conducted formative and evaluative focus group discussions with healthcare workers (HCWs) and caregivers of children in Kenya to develop and refine a pediatric HIV pre-test informational video. We then assessed HIV knowledge among caregivers sequentially enrolled in one of three pre-test information groups: (1) individual HCW-led (N = 50), (2) individual video-based (N = 50), and (3) group video-based (N = 50) sessions. A brief video incorporating information on national pediatric testing, modes of HIV transmission, and dramatized testimonials of caregivers who tested children was produced in three languages. Compared to individual HCW-led sessions (mean: 7.2/9; standard deviation [SD]: 1.3), both the group video-based (mean: 7.7; SD: 0.9) and individual video-based (mean: 7.6; SD: 0.9) sessions had higher mean knowledge scores. Video-based pre-test information could enhance existing pediatric HIV testing services.

Assessing young Kenyan women's willingness to engage in a peer-delivered HIV self-testing and referral model for PrEP initiation: A qualitative formative research study

Background

Pre-exposure prophylaxis (PrEP) is highly effective for HIV prevention, but uptake remains low, especially among adolescent girls and young women (AGYW) in Kenya. A model in which trained AGYW using PrEP deliver HIV self-tests to their close friends and refer them to PrEP may help increase PrEP uptake in this population. To understand AGYW's potential willingness to engage in such a model, we conducted a qualitative formative study in Kenya.

Method

We conducted semi-structured in-depth interviews (IDIs) with AGYW (16 to 24 years) in Kiambu County who were determined at risk of HIV acquisition. We purposively recruited "PrEP-naïve" (no prior PrEP use) and "PrEP-experienced" AGYW who used PrEP for at least 1 month within the previous year. We solicited perspectives on initiating/engaging in conversations about HIV risk and PrEP, distributing/receiving HIV self-test kits, and referring/following through on a referral to clinic-based HIV services. We analyzed verbatim transcripts using rapid qualitative analysis and a combination of inductive and deductive approaches, with the latter informed by the Integrated Behavior Model (IBM).

Results

From August to December 2020, we conducted 30 IDIs: 15 with PrEP-experienced and 15 with PrEP-naïve AGYW. Participants' median age was 20 [interquartile range (IQR): 20-22]. Overall, most participants anticipated that they would be willing to engage in this model. PrEP-experienced AGYW emphasized the salience of their concerns about friends' HIV risk behaviors, with several noting that they are already in the habit of discussing PrEP with friends. Many additionally expressed positive attitudes toward the proposed target behaviors, perceived these to be normative among AGYW, and expressed confidence in their ability to carry out the behaviors with proper support. Although few participants had HIVST experience, nearly all anticipated they would be able to use an HIV self-test kit correctly if provided instruction.

Conclusion

The Kenyan AGYW who participated in this study generally anticipated that they would be willing to engage in a formal peer PrEP referral model enhanced with peer-delivered HIV self-tests. Future research is needed to pilot test this model to determine its acceptability, feasibility, and effect on HIVST and PrEP uptake within this population.

Brief Report: Pediatric Saliva-Based HIV Testing: Health care Worker and Caregiver Acceptability

BACKGROUND

Pediatric HIV testing remains suboptimal. The OraQuick test [saliva-based test (SBT)] is validated in pediatric populations ≥18 months. Understanding caregiver and health care worker (HCW) acceptability of pediatric SBT is critical for implementation.

METHODS

A trained qualitative interviewer conducted 8 focus group discussions (FGDs): 4 with HCWs and 4 with caregivers of children seeking health services in western Kenya. FGDs explored acceptability of pediatric SBT and home- and facility-based SBT use. Two reviewers conducted consensus coding and thematic analyses of transcripts using Dedoose.

RESULTS

Most HCWs but few caregivers had heard of SBT. Before seeing SBT instructions, both had concerns about potential HIV transmission through saliva, which were mostly alleviated after kit demonstration. Noted benefits of SBT included usability and avoiding finger pricks. Benefits of facility-based pediatric SBT included shorter client waiting and service time, higher testing coverage, and access to HCWs, while noted challenges included ensuring confidentiality. Benefits of caregivers using home-based SBT included convenience, privacy, decreased travel costs, increased testing, easier administration, and child comfort. Perceived challenges included not receiving counseling, disagreements with partners, child neglect, and negative emotional response to a positive test result. Overall, HCWs felt that SBT could be used for pediatric HIV testing but saw limited utility for caregivers performing SBT without an HCW present. Caregivers saw utility in home-based SBT but wanted easy access to counseling in case of a positive test result.

CONCLUSIONS

SBT was generally acceptable to HCWs and caregivers and is a promising strategy to expand testing coverage.

Interventions to Increase HIV Testing Uptake in Global Settings

Purpose of Review

HIV testing is the critical first step to direct people living with HIV (PLWH) to treatment. However, progress is still being made towards the UNAIDS benchmark of 95% of PLWH knowing their status by 2030. Here, we discuss recent interventions to improve HIV testing uptake in global settings.

Recent Findings

Successful facility-based HIV testing interventions involve couples and index testing, partner notification, and offering of incentives. Community-based interventions such as home-based self-testing, mobile outreach, and hybrid approaches have improved HIV testing in low-resource settings and among priority populations. Partnerships with trusted community leaders have also increased testing among populations disproportionally impacted by HIV.

Summary

Recent HIV testing interventions span a breadth of facility- and community-based approaches. Continued research is needed to engage men in sub-Saharan Africa, people who inject drugs, and people who avoid biomedical care. Interventions should consider supporting linkage to care for newly diagnosed PLWH.

Implementation of HIV Retesting During Pregnancy and Postpartum in Kenya: A Cross-Sectional Study

INTRODUCTION

HIV retesting during pregnancy/postpartum can identify incident maternal HIV infection and prevent mother-to-child HIV transmission (MTCT). Guidelines recommend retesting HIV-negative peripartum women, but data on implementation are limited. We conducted a cross-sectional study in Kenya to measure the prevalence of maternal HIV retesting in programs and HIV incidence.

METHODS

Programmatic HIV retesting data was abstracted from maternal and child health booklets among women enrolled in a cross-sectional and/or seeking services during pregnancy, delivery, or 9 months postpartum in Kenya between January 2017 and July 2019. Retesting was defined as any HIV test conducted by MTCT programs after the initial antenatal care test or conducted as part of retesting policies at/after delivery for women not tested during pregnancy. Poisson generalized linear regression was used to identify correlates of programmatic retesting among women enrolled at 9 months postpartum.

RESULTS

Among 5,894 women included in the analysis, 3,124 only had data abstracted and 2,770 were enrolled in a cross-sectional study. Overall prevalence of programmatic HIV retesting was higher at 6 weeks (65%) and 9 months postpartum (72%) than in pregnancy (32%), at delivery (23%) and 6 months postpartum (28%) (P<.001 for all comparisons). HIV incidence was 0.72/100 person-years (PY) (95% confidence interval (CI)=0.43,1.22) in pregnancy and 0.23/100 PY (95% CI=0.09, 0.62) postpartum (incidence rate ratio: 3.09; 95% CI=0.97, 12.90; P=.02).

CONCLUSION

Maternal retest coverage was high at 6 weeks and 9 months postpartum but low during pregnancy. Strategies to ensure high retesting coverage and detect women with incident maternal HIV infection are needed.

HIV self-testing and repeat testing in pregnancy and postpartum in Northern Nigeria

OBJECTIVE

Incident HIV infections in pregnant and breastfeeding mothers pose significant challenges to prevention of mother-to-child HIV transmission efforts in sub-Saharan Africa. We identified the predictors of willingness to self-test for HIV when retesting in pregnancy and postpartum among antenatal clients in a tertiary hospital in Northern Nigeria.

METHODS

Structured and validated questionnaires were administered to a cross section of antenatal attendees (n = 370) in March 2021. Willingness to self-test and adjusted odds ratios of potential predictors were generated from logistic regression models.

RESULTS

Of the 317 respondents who agreed to repeat HIV test during pregnancy, 29.3% (n = 93) were willing to self-test. Similarly, of those (n = 350) willing to retest after delivery, 27.4% (n = 96) were willing to self-test. Willingness to self-test during pregnancy was higher among respondents who were multiparous (2-4 births) (adjusted odds ratio, aOR = 2.40, 95% confidence interval CI, 1.14-6.43), employed (aOR = 1.49, 95% CI, 1.13-4.53) and those with at least secondary education (aOR = 2.96, 95% CI, 1.43-11.47). In contrast, willingness to self-test was lower among those who were unaware of the husband's HIV status (aOR = 0.05, 95% CI, 0.02-0.13). Willingness to self-test after delivery was higher among respondents who were married (aOR = 15.41, 95% CI, 3.04-78.2), multiparous (aOR = 2.01, 95% CI, 1.27-5.63), employed (aOR = 1.59, 95% CI, 1.08-2.35) and had at least to secondary education (aOR = 6.12, 95% CI, 1.36-27.47). In contrast, willingness to self-test postpartum was lower among those who booked late (≥29 weeks) (aOR = 0.11, 95% CI, 0.022-0.52), those who were unaware of the risk of HIV transmission during breastfeeding (aOR = 0.29, 95% CI, 0.12-0.68) and participants who were unaware of the husband's HIV status (aOR = 0.076, 95% CI, 0.03-0.19).

CONCLUSION

Willingness to self-test for HIV in pregnancy and postpartum was low in this population and was influenced by risk perception, socio-demographic and obstetric attributes. Communication interventions and training of potential mentor mothers among early adopters could improve self-testing in this group and similar settings.

Pre-exposure Prophylaxis Recent Adherence With Real-Time Adherence Feedback and Partner Human Immunodeficiency Virus Self-Testing: A Pilot Trial Among Postpartum Women

Background

Pre-exposure prophylaxis (PrEP) is safe and effective in postpartum women. Human immunodeficiency virus self-testing (HIVST) for male partners combined with biofeedback counseling through real-time adherence measures may improve PrEP use among postpartum women.

Methods

Between August 2020 and April 2021, we randomized postpartum women who initiated PrEP in pregnancy 1:1 to the intervention group (HIVST + biofeedback counseling after urine tenofovir test) or to standard of care ([SOC] facility-based human immunodeficiency virus [HIV] tests and routine counseling without biofeedback). The outcomes of interest were PrEP adherence in the past 48–72 hours via urine tenofovir tests and partner HIV testing, measured 1-month after randomization. Secondary outcomes included the proportion of partners who tested for HIV and the discrepancy between self-reported PrEP adherence and urine tenofovir result.

Results

We enrolled 106 women (median age = 26 years). At enrollment, 72% of women reported missing <2 doses in the past 7 days; 36% of women had tenofovir present in her urine. One month after enrollment, 62% (n = 33) of women in the intervention arm had tenofovir present in their urine compared to 34% (n = 18) in SOC (risk ratio [RR] = 1.83; 95% confidence interval [CI] = 1.19–2.82; P = .001). Two thirds of women in the intervention arm reported that her partner tested for HIV (66%; n = 35), compared to 17% (n = 9) in SOC (RR = 3.89; 95% CI = 2.08–7.27; P < .001). Self-reported PrEP adherence (took PrEP >5 of last week) with no tenofovir in urine test was lower in the intervention group (17% vs 46%; RR = 0.33; 95% CI = 0.17–0.67; P = .03). No social or clinical adverse events were reported in the intervention arm.

Conclusions

The HIVST for partners and biofeedback counseling increased levels of recent PrEP adherence, pointing to the importance of these interventions to support PrEP use in this population.

Pregnant women, their male partners and health care providers' perceptions of HIV self-testing in Kampala, Uganda: Implications for integration in prevention of mother-to-child transmission programs and scale-up

Background

HIV status awareness is critical for HIV prevention and care but HIV testing rates remain low in Uganda, especially among men. One suggested approach to increase access and utilisation of HIV testing services is HIV self-testing. We explored perceptions of pregnant and lactating women and their male partners who attended antenatal care, and health care providers in a government hospital in Kampala, Uganda, about HIV self-testing for initial or repeat testing for women and their partners during pregnancy and postpartum We draw implications for scaling-up this new testing approach in Uganda.

Methods

This was a qualitative study conducted at Mulago National Referral Hospital, Kampala, Uganda, between April and December 2017. We conducted in-depth interviews with five pregnant or lactating women and their five male partners; five focus group discussions (two with women, two with health workers and one with male partners of women attending antenatal care) and five key informant interviews with health workers providing prevention of mother-to-child HIV transmission (PMTCT) services. Data were analysed using content thematic approach.

Results

There was limited awareness about HIV self-testing especially among pregnant or lactating women and their male partners. Study participants mentioned that HIV self-testing would enable people to know their HIV status faster, they thought the approach would be cost- and time-saving compared to health facility-based HIV testing, improve confidentiality and reduce stigma for those who test HIV positive. They expressed however, a general fear that HIV self-testing would lead to harm to self and others in case one tested HIV positive, including suicide, violence among couples, intentional transmission of HIV, and limited linkage to care due to lack of counselling. The likely misinterpretation of HIV test results especially among those with no or limited education, and possible coercion exerted by male partners on their wives were other potential concerns raised about the use of HIV self-testing.

Conclusions

There was limited knowledge about HIV self-testing among pregnant and lactating women, their partners and health workers. While the self-testing modality was perceived to be critical for helping people, especially those in casual and distant relationships, to know their HIV status and that of their partners, most study participants believed that HIV self-testing could potentially result in a multitude of negative outcomes in the absence of pre- and post-test counselling. Successful scale-up and integration of self-testing in HIV programs requires community education, provision of information materials and making self-test kits accessible and affordable, especially in rural areas.

Implementation outcomes of HIV self-testing in low- and middle- income countries: A scoping review

INTRODUCTION

HIV self-testing (HIV-ST) is an effective means of improving HIV testing rates. Low- and middle-income countries (LMIC) are taking steps to include HIV-ST into their national HIV/AIDS programs but very few reviews have focused on implementation in LMIC. We performed a scoping review to describe and synthesize existing literature on implementation outcomes of HIV-ST in LMIC.

METHODS

We conducted a systematic search of Medline, Embase, Global Health, Web of Science, and Scopus, supplemented by searches in HIVST.org and other grey literature databases (done 23 September 2020) and included articles if they reported at least one of the following eight implementation outcomes: acceptability, appropriateness, adoption, feasibility, fidelity, cost, penetration, or sustainability. Both quantitative and qualitative results were extracted and synthesized in a narrative manner.

RESULTS AND DISCUSSION

Most (75%) of the 206 included articles focused on implementation in Africa. HIV-ST was found to be acceptable and appropriate, perceived to be convenient and better at maintaining confidentiality than standard testing. The lack of counselling and linkage to care, however, was concerning to stakeholders. Peer and online distribution were found to be effective in improving adoption. The high occurrence of user errors was a common feasibility issue reported by studies, although, diagnostic accuracy remained high. HIV-ST was associated with higher program costs but can still be cost-effective if kit prices remain low and HIV detection improves. Implementation fidelity was not always reported and there were very few studies on, penetration, and sustainability.

CONCLUSIONS

Evidence supports the acceptability, appropriateness, and feasibility of HIV-ST in the LMIC context. Costs and user error rates are threats to successful implementation. Future research should address equity through measuring penetration and potential barriers to sustainability including distribution, cost, scale-up, and safety.

Ease of understanding and performing HIV self-tests by pregnant women and their male partners in Uganda: a cross-sectional study

INTRODUCTION

Understanding and following HIV self-testing (HIVST) instructions is a critical step in the use of HIVST kits. We analyzed data on pregnant women and their partners' self-assessment on the usability of kits delivered by their pregnant women.

METHODS

Quantitative data were collected on 399 pregnant women and 238 male partners enrolled in the intervention arm of a large cluster-randomized HIVST trial. Each pregnant woman received HIVST demonstrations, detailed pictorial instructions on how to use OraQuick HIVST kits, and two kits; for herself and her male partner. Follow-up was at one month (baseline for male partners) and 3 months. Descriptive statistics were conducted to compare understanding and following of HIVST instructions by age and education level.

RESULTS

The proportion of those who understood HIVST instructions was almost the same (98%) for women and their partners, although partners (26.5%) were nearly twice as likely than women (16.0%) to report needing pretest counseling (Odds ratio [OR] = 1.9, 95% CI: 1.27-2.79). Partners' understanding of the HIVST instructions did not vary by education level, but 4.4% of women with primary education reported difficulty in understanding HIVST instructions compared with 0.5% and 0% of those with secondary and university education, respectively (p = 0.05). However, 5.6% of women aged 30-68 years and 3.3% of partners aged 20-24 years found it more difficult to understand the HIVST instructions.

CONCLUSION

Both pregnant women and their male partners were correctly able to perform an HIVST without or (with minimal) support suggesting that this mode of delivery will help the national program reach more men. Because more male partners than women required HIVST pretest counseling support, male-targeted HIVST promotional messages may be needed to increase men's self-efficacy to perform HIVST unsupported.