Sending home HIV self-test kits from antenatal clinics improves partner testing in Malawi

In a randomized study in Malawi, women receiving antenatal care and patients with HIV were asked to bring HIV self-testing kits home to their sexual partners.

Although the administration of the kits did not help investigators identify significantly more patients with HIV — even when offered with a financial incentive — it did improve HIV testing uptake, they said.

Malawi has an estimated 9.2% prevalence of HIV among adults, and testing remains a challenge. One strategy for improving testing rates involves sending HIV self-test (HIVST) kits home with clinic patients for their sexual partners to take, author Augustine T. Choko, PhD, of The London School of Hygiene & Tropical Medicine, and colleagues wrote in The Lancet Global Health.

HIVST kits have been shown to improve testing rates in another randomized trial in Malawi, although they failed to increase ART initiation.

Building on previous research, Choko and colleagues investigated whether secondary administration of HIVST kits with or without financial incentives could increase testing among the male partners of women receiving antenatal care (ANC), which could potentially cut down on new HIV infections among pregnant women and vertical transmission.

The three-arm, open-label, pragmatic, cluster-randomized trial comprised 27 government health centers across four districts in Malawi. It enrolled women who were attending ANC (the ANC cohort) and people with newly diagnosed HIV during routine clinic HIV testing (the index cohort). The trial arms were standard of care, HIVST only or HIVST plus a financial incentive.

The women in the standard of care group received letters that invited male partners or sexual contacts to attend HIV testing services at the clinic. The women in the HIVST only group received invitation letters as well as oral HIVST kits that they could deliver to their male partners or sexual contacts. The third group received HIVST kits and offers of $10 for male partners or sexual contacts to retest at the clinic following self-testing regardless of HIV status.

The researchers determined the proportion of male partners reportedly tested for HIV through interviews with the women attending ANC 28 days after enrollment and by the geometric mean number of HIV-positive people diagnosed within 28 days of enrolling the index patient.

The 4,544 women in the ANC cohort included 1,447 (31.8%) in the standard of care group, 1,465 (32.2%) in the HIVST only group and 1,632 (35.9%) in the HIVST plus financial incentive group.

The 708 women in the index cohort included 234 (33.1%) in the standard of care group, 169 (23.9%) in the HIVST only group and 305 (42.9%) in the HIVST plus financial incentive group.

The mean proportion of reported partner testing per cluster within 28 days of enrollment was 35% in the ANC cohort (standard deviation [SD] = 10), 73% among the HIVST only group (SD = 13.1; adjusted risk ratio [RR] = 1.71; 95% CI, 1.48-1.98) and 65.2% in the HIVST plus financial incentives group (SD = 11.6; aRR = 1.62; 95% CI, 1.45-1.81).

For the index cohort, the geometric mean number of new HIV-positive sexual partners per cluster was 1.35 (SD = 1.62) in the standard care group, 1.91 (SD = 1.78) for the HIVST only group and 3.2 (SD = 3.81) for the HIVST plus financial incentive group.

Results also showed that providing HIVST plus $10 for retesting substantially increased male partner attendance, from a mean of 19.7% (SD = 7.6) in the standard care group to 76.5% (SD = 20) in the HIVST plus financial incentive group (adjusted RR = 2.84; 95% CI, 2.37-3.41).

Among sexual contacts in the index cohort, 51 (21.8%) of the 234 eligible patients in the standard care group, 17 (10.1%) of the 169 in the HIVST only group and 181 (59.3%) of the 305 in the HIVST plus financial incentive group attended the clinic for HIV services.

The researchers determined that rural health centers and district hospitals could readily integrate secondary distribution of HIVST kits into routine clinical practice with high participation and minimal harms.

Secondary distribution of HIVST kits also proved highly acceptable and substantially increased HIV testing of male partners of pregnant women, with high potential to help eliminate mother-to-child transmission of the virus.

The researchers noted that the low prevalence of undiagnosed HIV in Malawi and high clinic-level variability may have impacted their results. However, they added, the secondary distribution of HIVST kits for pregnant women should now be considered a regional best practice.

References:

• Choko AT, et al. Lancet Glob Health. 2021;doi:10.1016/S2214-109X(21)00175-3.
• Dovel K, et al. Abstract 93. Presented at: Conference on Retroviruses and Opportunistic Infections; March 4-7, 2019; Seattle.