ACCEPTABILITY AND COST-EFFECTIVENESS OF HIV SELF-TESTING IN THE CONTEXT OF ASSISTED PARTNER NOTIFICATION SERVICES IN KISUMU AND HOMA BAY, KENYA.

Abstract

Assisted partner services (aPNS) is a recommended public health approach to promote HIV testing for sexual partners of individuals diagnosed with HIV. Offering HIV selftesting (HIVST) within aPNS has the potential to increase HIV testing uptake and yield, yet it is not well studied. This thesis evaluated acceptability and cost-effectiveness of HIVST within the aPNS-HIVST study conducted in western Kenya. The sociodemographic and behavioral characteristics of aPNS identified sexual partners offered the choice of HIVST or provider-delivered testing were evaluated, with a sub-set of partners purposively selected for in-depth interviews (IDIs) (n=24). In addition, focus group discussions (FGDs) with HIV testing service (HTS) providers were conducted (n=2), including IDIs with pharmacy staff involved in dispensing HIVST to aPNS clients (n=6). Descriptive and log-binomial regression analyses were performed controlling for health facility clusters, while interviews were thematically analyzed applying the theoretical framework of acceptability (TFA). Further, we conducted micro-costing, time-and-motion, and provider surveys to determine incremental HIVST distribution cost. Using a decision tree model, we estimated the incremental cost per new diagnosis for HIVST incorporated into aPNS, compared to aPNS with provider-delivered testing only. Uptake of HIVST was determined to be 82.2%, with no association between partner demographics and HIVST uptake. HIVST use was less likely than provider-delivered testing among those identified as a casual (adjusted relative risk (aRR) = 0.93; 95% Confidence Interval (CI) 0.88-0.98) or transactional (aRR = 0.90; 95% CI 0.87-0.94) partner compared to those in a defined relationship. HIVST use was slightly lower among those offered the option of an additional kit when compared to those only offered one kit (aRR = 0.93; 95% CI 0.88-0.98). In the partner IDIs, HIVST was a viable option for individuals who do not find provider-delivered testing suitable or convenient. For them, ‘intervention coherence’, ‘self-efficacy’, and ‘ethicality’ presented as most significant TFA constructs. aPNS providers played a critical role in creating HIVST awareness and driving acceptability, and cited benefits such as increased efficiency in conducting HIV testing. They reported challenges including maintaining confidentiality, delivering procedures remotely, HIV-related stigma at dispensing pharmacies and low HIVST awareness. Successful integration was facilitated by training and motivation of HTS providers to focus on benefits of HIVST to clients. Unexpected effects of HIVST introduction included increased HIVST community awareness and testing at the dispensing pharmacy, with resulting concerns about dispensing staff’s ability to deliver counselling effectively. The cost per HIVST distributed within aPNS was $8.97, largestcomponent being testing supplies (38%) and personnel (30%). Under conditions of facility-based testing uptake of <91%, or HIVST utilization rates of <27%, HIVST integration into aPNS is potentially cost effective. At willing-to-pay threshold of $1,000, the net monetary benefit was sensitive to effectiveness of HIVST in increasing testing rates, phone call rates, HIVST sensitivity, HIV prevalence, cost of HIVST, space allocation at facilities, and personnel time during facility-based testing. In a best-case scenario, HIVST option was cheaper by $3,037 and diagnosed 11 more cases. Increasing HIVST awareness and providing tailored solutions will empower aPNS clients optimize their HIV testing decisions. Providers should consider context of the partner’s sexual encounter and extend counselling support when recommending HIVST within aPNS. The integration should carefully consider four components of the five ‘Cs’ of HTS: confidentiality, opportunity for counselling, correct results, and linkage to care. In addition, pharmacy staff dispensing HIVST must receive HTS training, and HTS providers must be trained on remote telephone delivery of counselling and aPNS procedures. Implementers and policy makers should ensure HIVST efficiency by focusing on facilities with low uptake for provider-delivered facility-based testing, while deliberately promoting utilization among those likely to benefit from remote testing. Additional measures should focus on minimizing costs relating to personnel and testing supplies.