Promoting Partner Testing and Couples Testing through Secondary Distribution of HIV Self-Tests: A Randomized Clinical Trial

Abstract

Background

Achieving higher rates of partner HIV testing and couples testing among pregnant and postpartum women in sub-Saharan Africa is essential for the success of combination HIV prevention, including the prevention of mother-to-child transmission. We aimed to determine whether providing multiple HIV self-tests to pregnant and postpartum women for secondary distribution is more effective at promoting partner testing and couples testing than conventional strategies based on invitations to clinic-based testing.

Methods and Findings

We conducted a randomized trial in Kisumu, Kenya, between June 11, 2015, and January 15, 2016. Six hundred antenatal and postpartum women aged 18–39 y were randomized to an HIV self-testing (HIVST) group or a comparison group. Participants in the HIVST group were given two oral-fluid-based HIV test kits, instructed on how to use them, and encouraged to distribute a test kit to their male partner or use both kits for testing as a couple. Participants in the comparison group were given an invitation card for clinic-based HIV testing and encouraged to distribute the card to their male partner, a routine practice in many health clinics. The primary outcome was partner testing within 3 mo of enrollment. Among 570 participants analyzed, partner HIV testing was more likely in the HIVST group (90.8%, 258/284) than the comparison group (51.7%, 148/286; difference = 39.1%, 95% CI 32.4% to 45.8%, p < 0.001). Couples testing was also more likely in the HIVST group than the comparison group (75.4% versus 33.2%, difference = 42.1%, 95% CI 34.7% to 49.6%, p < 0.001). No participants reported intimate partner violence due to HIV testing. This study was limited by self-reported outcomes, a common limitation in many studies involving HIVST due to the private manner in which self-tests are meant to be used.

Conclusions

Provision of multiple HIV self-tests to women seeking antenatal and postpartum care was successful in promoting partner testing and couples testing. This approach warrants further consideration as countries develop HIVST policies and seek new ways to increase awareness of HIV status among men and promote couples testing.

Trial Registration

ClinicalTrials.gov NCT02386215.

Abstract

In a randomized clinical trial, Harsha Thirumurthy and colleagues compare the efficacy of providing HIV self-tests to pregnant and postpartum women to conventional strategies using invitations to clinic-based testing.

Author Summary

Why Was This Study Done?

• Despite progress in recent years, men in sub-Saharan Africa have lower HIV testing rates than women, and nearly half of all HIV-positive individuals remain unaware of their HIV status; this represents a key barrier to meeting the UNAIDS 90-90-90 targets for HIV elimination.

• Among pregnant and postpartum women, male partner testing has been encouraged for HIV prevention purposes but remains uncommon in many countries.

• Recent WHO guidelines on HIV testing services have acknowledged the potential of HIV self-testing as a means to increase testing uptake among those not reached by other testing services, and have called for additional research to explore the potential benefits of self-testing.

• “Secondary distribution” of self-tests by women visiting health facilities has the potential to increase access to testing among their male sexual partners and to promote results disclosure and safer sexual decision-making.

What Did the Researchers Do and Find?

• We conducted a randomized trial among 600 women attending antenatal and postpartum clinics in western Kenya to determine whether providing them multiple HIV self-tests is more effective at promoting partner testing and couples testing than a conventional strategy based on partner invitations to clinic-based testing.

• In the three months of follow-up, male partner testing was reported to have occurred for 90% of women in the HIV self-testing group but only 52% of women in the comparison group, a difference that was statistically significant.

• Couples testing was more than twice as likely among women who received multiple HIV self-tests than women who received invitations for their partners (75% in the HIV self-testing group versus 33% in the comparison group).

• The self-testing intervention was safe and effective at promoting partner HIV testing among women whose partners had not tested in the past 12 months.

What Do These Findings Mean?

• The promising results of this study suggest that secondary distribution of self-tests warrants further consideration as countries develop HIV self-testing policies and seek new ways to promote male partner testing and couples testing.

• Additional research is recommended to explore uptake of clinic-based confirmatory testing among partners who self-test HIV-positive, which was beyond the scope of this research.

• The feasibility of secondary distribution strategies among other populations and settings should be explored, along with the potential of HIV self-tests to facilitate safer sexual behaviors.