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HIV self-testing for couples in resource-poor contexts in urban Malawi

Nicola DesmondWellcome Trust Fellow

Liverpool School of Tropical MedicineMalawi-Liverpool-Wellcome Trust Major Overseas Programme

IAC, Melbourne, AustraliaJuly 21st -26th 2014

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Human Rights concerns• Increased risk of unmanaged anxiety

• Negative impacts by bypassing counseling

• Potential for coercive testing– 3% participants in Blantyre, Malawi

• Lower test accuracy

• Lower linkage to care

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HIVST in urban Malawi

• 16,600 adult residents

– free access to 1 HIVST per year– semi-supervised via community-

based counselors

• Testing in private – pre & post-test counseling– encouraged to include partner

• Linkage to confirmatory testing

& care via counsellors to direct to study clinics

28 clusters: ~ 1,200 adults (16+)

Primary clinics

District hospital

National HIV prevalence: 11.9%Doctors /1000 population: 0.02

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Methods: 2 cohort studiesKumwenda et al

• 51 couples• 12 months FU• Mixed methods• 12 months follow up

– Face to face survey– Audio computer assisted

self-interviews (ACASI)– Daily diary study– In-depth serial biographical

interviews with both partners individually

Desmond et al• 17 couples• 12 months FU• Serial in-depth interviews

– Both partners individually

“Couples-testing” HIVST: 14% participants

Malawi HTC: 14% clients

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EXPLORING NEGATIVE IMPACTS THROUGH BYPASSING COUNSELING

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Deconstructing couples HIVST: access & presentation

• Majority of couples came into HIVST through counselor-initiated approaches

• Most couples testers had previously tested with a partner

Men Women0%

20%

40%

60%

80%

100%

Client-initiatedDoor-to-door

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Deconstructing couples HIVST: steps taken together

• Majority of men & women in couples received pre-test counseling with a partner (69%)

• Men more likely have received both pre- AND post test counseling

Collection of test kit

Pre-test counseling

Testing Reading results

Post-test counselling

0102030405060708090

67.5 68.9

84.9 83.871.4

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Disclosure enhanced• High proportion (99%) of participants shared

results with partner– whether or not they read the results at the same time

• Use of HIVST to disclose previously known +ve status common and motivated by:– Guilt– desire to foster openness – mistaken assumption of concordance & ensuring

access to care

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Assumptions of HIV concordance

‘… this is why I invited the counselor to test us after realizing that it was not good that I should continue hiding that I am HIV+ve from her … I expected that she would also be positive. I did not believe it when her result was negative after all these years that I have lived with her’

Male partner, HIV positive, Discordant couple

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GENDERED NATURE OF DECISION-MAKING

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Decision-making: individual motivations for couples testing

Known to be positive• Self-checking “cure”: known HIV status

– Through beliefs in cure through prayer – Through long-term ART

• Linking back into HIV care after ‘defaulting’

From the perspective of being in a relationship• Assessing the strength and fidelity

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Evidence of coercive testing?• Coercive testing reported by 3% in parent

study

• 78% of individuals in couples study reported they had not been influenced at all to test

• Some felt pressure to test from partner & unable to ‘opt-out’– To show commitment to relationship– To remove existing mistrust

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Gendered response to acceptable force – Lower levels of coercion reported for women– Men *more* likely to report coercion from partner– Gender-based violence normalized and pervasive

Marital Status % of women who experienced physical violence since age 15

Number of women

Ever Past 12 mos

Currently married

28.3% 15.9% 6,856

Divorced / separated

42.2% 16.5% 5,832

Widowed 14.5% 2.1% 1,365

Never married 23.1% 10.8% 1,647

DHS Malawi 2010

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Male pressure to test

‘My husband just gave me the test-kit and told me to test. I feel that this is a problem … I did not have a choice to say no … my husband initially went to test alone. According to his test results, he also wanted me to get tested … so I was in a dilemma’HIV-ve wife in discordant partnership

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Female pressure to test

‘When I got the kit I took two days without testing, then my wife said that I won’t eat that day if I don’t test. She went to the bedroom and poured water on my clothes. There was force, I knew that if I don’t test then there won’t be sex for me’

Husband in concordant HIV –ve couple

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HIVST empowering women in relationships?

• Women able to break existing barriers– household decision-making– power dynamics– resident volunteers reinforce and

destigmatise testing and couples testing

• Gendered response to “acceptable” force – Men more likely to report coercion from

partner than women

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Conclusions to date

• Low levels of formal “couples HIVST” overall– How best to promote couples HIVST for “first-time” testers?

• The option of HIVST is empowering for women wanting to promote couples testing – Important social reinforcement from community counsellor

• Decisions shaped by gender and power relations within the household

• Need for more research on coercion– Unpacking the implications of gendered social norms and acceptability of

GBV

• Discordancy identified through HIVST presents complex challenges

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Acknowledgements

• Mr Moses Kumwenda - MLW• Dr Sally Theobald - LSTM• Dr Miriam Taegtmeyer - LSTM• Professor Liz Corbett – LSHTM• Dr Mavuto Mukaka – Johns Hopkins, US• Dr Ireen Namakhoma - Reach Trust• Dr Lignet Chepuka - LSTM• Mr Simon Makombe - MoH Malawi• Professor Janet Seeley - MRC Uganda• Professor David Lalloo - LSTM• Professor Rob Heyderman - LSTM• Ms Effie Chipeta - MLW• Ms Wezzie Lora - MLW

Community men & women in urban Blantyre

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Uptake since introduction of HIVST

Couples uptake • Round 1: 932 (14%) couples of 13,655 tests• Round 2 (Repeat testing): 1201 (16%) couples of 15,009

tests

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Exploring the social impacts of HIVST in couples

• Decision-making dynamics

• Nature & extent of coercive testing

• Sexual behaviour & risk compensation

• Gendered household relations

• Role of counseling