Access to HIV self-tests in Kenya

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World AIDS Day has been held every Dec. 1 since 1988, an opportunity for people across the globe to unite in the fight against HIV, to show support for people living with HIV, and to remember those who have died from an AIDS-related illness. 

Marking the day, Penn Today features new research led by Harsha Thirumurthy, associate professor of medical ethics and health policy at the Perelman School of Medicine and co-director of the Penn Development Research Initiative. Published in The Lancet HIV, the study by Thirumurthy and co-authors examined the effect on male partner testing, couples testing, and HIV incidence in Kenya by providing women sustained access to HIV self-tests. 

The five-year project funded by the National Institutes of Health was a cluster-randomized trial conducted among 2,090 women who self-reported multiple sexual partners and lived in areas with high prevalence of transactional sex and HIV. It is the first study to evaluate whether access to free HIV self-tests for an extended period of time enables women to become more aware of their current and potential partners’ HIV status and to reduce their risk of acquiring HIV.

The researchers found that providing women with sustained access to HIV self-tests had no significant effect on HIV incidence, but that women who received self-tests were much more likely to learn their male partners’ HIV status and get tested as a couple. Women in the intervention group were also more likely to report that they declined sex or used a condom after a partner either tested HIV-positive or refused to test for HIV. 

Thirumurthy offers four takeaways from the study and HIV awareness generally.

Tapping into social networks and sexual networks can help to achieve public health objectives

In health care and public health, we’re often trying to affect behavior change in populations that are hard to reach or engage. What this study shows is that working through communities and people’s own social networks and sexual networks can yield much more success than trying directly to go to those individuals as a health care provider. 

The usefulness of this approach extends beyond HIV testing. At the beginning of the COVID pandemic we were trying to encourage people to test for COVID. For a variety of reasons, there are many who would be unlikely to visit a testing facility to get tested. But if you could send someone home with two or three COVID tests, that person may be able to distribute the COVID test to other people they know who might be at high risk. So that’s another example of how networks could be used to achieve public health objectives. 

Providing HIV self-tests increased testing among male partners and subsequently women’s awareness of their partners’ HIV status

There is an enormously high HIV risk among adolescent girls and young women in eastern and southern Africa. This is an especially important problem because in many countries with high HIV prevalence nearly 50% of the population is under 16 years of age. It will be difficult to reduce new HIV infections if a large number of individuals who are entering their sexually active years face an environment in which there’s such a high risk of HIV.

As HIV self-testing is scaled up in sub-Saharan Africa, secondary distribution of self-tests could be viewed as being useful not only for increasing testing coverage among men, who are less likely to be aware of their own HIV status, but also for increasing women’s awareness of their partners’ HIV status. In other research we have completed based on this study, we find that the intervention improves women’s ability to make informed decisions regarding sexual behavior, and that it is particularly relevant in settings where transactional sex presents women with trade-offs between income and risky sexual behavior.

Increasing awareness of HIV status among people living with HIV is a top priority for ending the epidemic globally

On World AIDS Day, this study draws attention to the fact that increasing awareness of HIV status among people living with HIV and those at high risk of HIV exposure is very important for ending the HIV epidemic. The study we conducted with our colleagues in Kenya reveals a promising approach for achieving the goal of increasing HIV-testing coverage, one that can complement various facility- and community-based approaches. Despite traditional, counselor-administered HIV testing being widely available in many places, we still are not at the high levels of HIV testing coverage that are desirable. That’s why these new approaches are relevant for ongoing efforts to address HIV/AIDS. 

Providing women with sustained access to HIV self-tests had no significant effect on HIV incidence

The study also looked at a potentially new way to reduce the risk of acquiring HIV for women in sub-Saharan Africa who are at extremely high risk of HIV infection. Unfortunately, we found that sustained access to HIV self-tests alone did not affect HIV incidence. In fact, we found that women in both the intervention and comparison groups faced very high HIV-infection risk. Annual HIV-infection rates were about 1%, much higher that the UNAIDS targets for HIV elimination. Our study underscores the urgent need for proven approaches to reducing HIV risk among adolescent girls and young women.

One reason for the lack of effect on HIV incidence could be that the intervention didn’t necessarily increase testing coverage among the highest risk partners that women had. If women didn’t succeed in testing those partners and engaging in safer sexual behavior with them, then that might explain our main finding.

Despite the lack of effect on HIV incidence, the finding that sustained access to self-tests greatly enhanced women’s ability to learn their male partners’ status and promote couples testing shows why the intervention should be part of a combination approach to HIV prevention. Once men learn their HIV status, there is greater potential for them to seek HIV services, such as treatment if they are HIV-positive. Particularly in settings with a high prevalence of transactional sex and for women who face a high risk of HIV exposure, sustained access to self-tests and secondary distribution to sexual partners, when coupled with available HIV prevention and care services, is a potentially powerful tool that can help support HIV-elimination goals.

Harsha Thirumurthy is associate professor of medical ethics and health policy at the University of Pennsylvania Perelman School of Medicine, co-director of the Penn Development Research Initiative, and associate director of the Center for Health Incentives and Behavioral Economics.

Thirumurthy’s co-authors on the study were Elizabeth Bair, Noora Marcus, and Mary Putt of the University of Pennsylvania Perelman School of Medicine; Perez Ochwal and Kawango Agot of the Impact Research and Development Organization, Kisumu, Kenya; Suzanne Maman of the University of North Carolina at Chapel Hill; and Sue Napierala of RTI International, Women’s Global Health Imperative, Berkeley, California.

Learn more about the paper in this policy brief by the Penn Development Research Initiative.