For the DCE, price had a very strong influence on testing choices in both Malawi (U = −4.874, P < 0.01) and Zimbabwe (U = −1.691, P < 0.01). The strength of these preferences can be interpreted relative to changes in other attribute levels. For example an increased price of US$ 0.10 in Malawi would lead to a utility loss of −0.487. Including another attribute level with an equally large, but positive utility could compensate for the effect of such a price increase. In Malawi, the DCE did not identify any significant preferences between the specimen collection methods (e.g. oral fluid self-test, blood-based self-test and provider-delivered blood-based test).
The FGD and IDI results in both countries revealed that HIVST kits should be no to very low cost, with price acting as a barrier to testing. In Malawi, this was seen to be particularly important for those who were not working or financially dependent on their families. In terms of the self-testing product, young people across countries saw it as an innovative technology and appreciated the ability to control the testing and disclosure process.
I will choose when to test, where I want to test, and I can determine how private the place of testing is … 19-year-old man, FGD, Zimbabwe
Although there was strong consensus in FGDs around self-testing, views around performance and accuracy of the different specimen collection methods diverged. Participants expressed that they were more accepting of oral-fluid tests than older people and talked about benefits such as ease-of-use and painless specimen collection compared with finger prick for blood-based testing. There was, however, the perception that blood-based tests were more accurate, a view held more strongly in FGDs in Zimbabwe than Malawi as expressed here:
Many said [oral-fluid tests were not] reliable because … the virus is in the blood. So many were not satisfied with this self-testing. 16-year-old woman, FGD, Zimbabwe
When the results were triangulated across the DCE and qualitative methods, preferences for product characteristics were found to be consistent, with participants desiring for HIVST kits to be free of charge or very low cost. Preference between the different specimen collection methods was also similar: no strong preferences were revealed in the DCEs and the FGD and IDI findings were mixed, with stated benefits of oral-fluid self-tests offset by concerns around accuracy.
In Malawi, young people in the DCEs preferred to obtain an HIVST kit from a minimally trained community distributor (U = 0.085, P < 0.10) to a trained healthcare worker (HCW) (U = 0.037, P ≥ 0.10) or intimate partner (U = −0.122, P < 0.10). Meanwhile, participants in Zimbabwe were indifferent to the age group of providers and whether they came from the same community. Each of these provider attributes was country-specific and could therefore not be compared across settings.
FGD and IDI participants in both countries felt that HIVST would motivate young people to test in settings characterized by distrust in HCWs to convey the correct results and keep information confidential. There was a stated preference for lay community distributors, though there were some concerns raised in the Malawi FGDs around their counseling qualifications. In the Malawi FGDs and IDIs, peer groups were also suggested as important conduits for supporting young people. Further, participants in Zimbabwe expressed desire to have distributors residing in the same village, as this facilitated availability of support and assistance if needed:
[The distributor] could give the kit … and must come back again to provide support, which is easier if he is from our community. 20-year-old man, FGD, Zimbabwe.
The DCEs and qualitative results provided complimentary insights on preferences for provider characteristics. Young people preferred distribution of HIVST kits by lay community distributors across methods, with the FGDs and IDIs also revealing a lack of trust of HCWs. The Zimbabwe DCE did not reveal any strong preferences regarding the residence of distributors, which departed from some of the findings from the FGD results.
Service delivery characteristics
In terms of location of distribution, the DCE results revealed that access at home was favored in Malawi (U = 0.350, P < 0.01) and Zimbabwe (U = 0.699, P < 0.05). This was preferred over mobile clinics (Malawi: U = −0.170, P < 0.01; Zimbabwe: U = −0.669, P < 0.05) and health facilities (Malawi: U = −0.140, P < 0.10; Zimbabwe: U = −0.030, P ≥ 0.10). Compared to others these attribute levels were some of the most important drivers of demand for young people. Participants across countries were indifferent to the level of pretest assistance, which included instruction leaflets, telephone hotlines and in-person support. Other attributes relating to service delivery were explored separately in each country. In contrast to being indifferent to approaches for pretest support, participants in Malawi preferred in-person assistance following self-testing (U = 0.126, P < 0.05) rather than just the instruction leaflet (U = −0.141, P < 0.05). In Zimbabwe, participants did not have strong preferences for other service delivery characteristics, including hours of operation and distribution of batches of HIVST kits to the entire household.
In the FGDs and IDIs, young people appreciated the convenience and savings in time and transportation costs associated with home distribution of HIVST kits.
I thought it wise to go for [self-testing] when … introduced in this community, so I decided to test because I had access …. I was not supposed to walk a distance for testing. 23-year-old man, IDI, Malawi
Accessing HIVST and taking the test at home was also seen to provide greater privacy and encourage action among those who had procrastinated over testing. In both countries, where HIV testing and treatment services were often offered in the same location within health facilities, some participants felt young people were afraid of being seen as expressed in this quote:
People can’t be going to the hospital for an HIV test ... Once I go there today, the news is going to spread everywhere and people will know that so and so is HIV positive. 22-year-old woman, FGD with female youth peer group, Malawi
Compared with Zimbabwe, FGD and IDI participants in Malawi were more open to collecting kits from local clinics, mobile clinics or even community gatherings. There was also the view that hospitals ensured better safe-keeping of testing devices. In Zimbabwe, a minority of young men in one FGD reported wanting the autonomy of collecting the HIVST kit from a mobile or local clinic as this gave them more control over when to test, illustrated here:
I say no to a fixed date that they decide to come; I won’t want [the test kit] at that time. So if I collect at the clinic it is good; I will go and collect from the clinic when I want to. 19-year-old man, FGD, Zimbabwe
Despite some concerns about confidentiality, availability of in-person support was highly favored by participants from both countries and balanced this conflict by suggesting, ‘The counselor must be there but not during the entire process’ (22-year-old woman, FGD, Malawi). Providers were viewed as important in offering information and preparing users for dealing with HIV-positive results. Most FGD and IDI participants in both countries were against using a hotline, citing the value attached to in-person dialog especially for posttest support.
Young people across both methods and countries expressed that they were starting to become more independent, make decisions for themselves and, at the same time, were exploring their sexuality and boundaries, leading to some clashes in household dynamics, including decision-making about testing. In one FGD in Zimbabwe, young people said they disliked when community distributors spoke to their parents without consulting them directly despite being above the age of consent. Further, there were mixed views in the FGDs in both countries on whether kits should be given individually or distributed in ‘batches’ to the household. Although some young people worried that parents could deduce whether they were sexually active by their decision to accept a kit, others found it better if kits were offered to the whole household, so no attention was placed on the young person's choice. The reverse was also brought up with participants, mentioning that coercion of young people to test may be more likely to occur in situations where distribution was batched.
Evaluating the results from the DCE with the qualitative results, home access of HIVST was consistently preferred across methods. In contrast, FGD and IDI participants in Malawi were open to distribution through health facilities and mobile clinics, which differed from the DCE results. DCE participants in Malawi preferred more comprehensive support beyond the instruction leaflet after self-testing. This was also reflected in the FGDs and IDIs, where young people wanted the option of accessing in-person support if needed. In the Zimbabwe DCE, there were no strong preferences for batched distribution of HIVST kits, which complemented the mixed findings from the qualitative research.
This is the first study to explore young people's preferences for HIVST in Malawi and Zimbabwe and comes at a time when many countries are starting to scale-up HIVST as an additional approach to reach untested populations . We found that HIVST is highly acceptable to young people in these countries as it empowers them to choose the location and timing of the test and control disclosure around their results. Young people were attracted by the innovative new technology and appreciated the decision-making autonomy and control it gave them at a time of life when they were becoming more independent from their parents and more sexually active. Young people liked the convenience, confidentiality and perceived ease-of-use. Across methods, young people felt strongly that HIVST should be free and distributed at home, with some form of in-person support available if needed.
The high acceptability of HIVST has been described among young people in other settings in sub-Saharan Africa [15,29,30]; however, these studies provide limited information on young people's preferences around HIVST delivery characteristics. Previous studies have largely reported that oral-fluid tests were appealing because they were easy to use, painless and did not require a blood sample [15,16,31]; although a study in Tanzania reported dislike for this method due to lack of familiarity . Our study pointed to concerns by young people around accuracy of oral-fluid tests, a finding that has previously been cited in the United States [17,18]. HIVST programs promoting oral-fluid tests will need information about their functioning and performance to address these concerns. Given young people's low access to financial resources and strong aversion to price, the findings also show that uptake of HIVST may be limited if kits are not provided for free or at extremely low prices.
Young people's strong preferences for home delivery of self-test kits and some in-person support by providers contrasted with the desire for total privacy. Home-based testing offered a way for young people to overcome issues of access and visibility associated with facility-based HTS [8,9,11,33–35]. Meanwhile, availability of in-person support was reported as being important if additional information or assistance was required in the case of a positive test. In Kenya, preference for posttest support was found to be more pronounced among young people than adults . This may be particularly important for young people, as studies suggest that linkage to care for this population has been suboptimal in the contexts of community-based HIV testing in Kenya and South Africa [36,37].
Being empowered to control one's own HIV testing process seems to be particularly appealing to young people . As they transition from childhood to adulthood, they are given or demand greater autonomy and independence. Being responsible and taking charge of one's own life and health motivates young people to test for HIV [8,11,39], which resonates with our findings that empowerment and control act as motivators for young people to test.
Confidentiality was one of the main reasons why young people preferred HIVST [15,16]. Young people's lack of trust of health workers and desire for confidentiality has been described elsewhere [11,33,40,41] and motivated young people's preference for HIVST in this study. Our study also shows preference for lay community distributors, with pilot studies under the STAR Consortium confirming this in practice [42,43]. In Kenya, where home-based HIV testing by lay counselors has been successful [39,44], the integration of HIVST onto existing community-health platforms could become a model for HIVST in the future. In the context of a gap between biological and psychosocial maturity, as well as discrepancies in cultural, social and legal definitions of maturity, promoting HIVST in young people may not be without conflicts, including denied or forced testing. Appropriate training of distributors and sensitization of parents and the wider community would therefore be needed.
There were a number of limitations to our study. The DCE and qualitative research were nested within country-specific cluster-randomized trials of community-based HIVST implementation, resulting in distinctive research designs and sampling methods in each country. Despite this, results were largely consistent and complementary. Sample size calculations for the DCE were based on the total population and did not provide enough degrees of freedom to robustly examine differences in preferences among subgroups of young people. Although participants were asked about preferences for oral-fluid and blood-based self-tests, none had seen a blood-based self-test, which may have influenced stated preferences for oral-fluid tests.
Our study adds to the evidence on preferences for HIVST delivery among young people, with potential implications for reducing current testing gaps among this hard-to-reach age group. Uptake of HIVST among young people is most promising if distribution of test kits is convenient, which is provided through home-based distribution at no cost, with respect for them as autonomous individuals.
The authors thank the Ministries of Health from Malawi and Zimbabwe for their support of this study, the communities in which data were collected for hosting our research, the participants who contributed to the study and the research teams from the two countries. Thanks to Professor Elizabeth Corbett and Professor Frances Cowan, the Principal Investigators, and to Dr Melissa Neuman for their support and comments. The study was undertaken in collaboration with UNITAID, Population Services International, WHO, London School of Hygiene and Tropical Medicine, and the rest of the STAR Consortium. Two networks of researchers in STAR contributed to the discussion and intercountry analysis: the qualitative and economics research networks and we are grateful for their insights and implementation perspectives.
Contributors: P.P.I., E.L.S., M.D. and F.T.P. designed the DCE study. P.P.I., E.L.S., M.K.K., L.J.N. and M.T. designed the qualitative study. P.P.I. and E.L.S. coordinated the studies. B.R. completed the literature review. P.P.I., M.D.E. and G.M. analyzed the DCE data, with F.T.P. advising on the direction of analysis. P.P.I., E.L.S. and M.K.K. analyzed the qualitative data, with M.T. advising on the direction of analysis. P.P.I. completed the first draft of the article with writing contributions by E.L.S., M.D., M.K.K., B.R. and L.J.N., F.T.P. and M.T. critically revised the article. All authors approved the final version of the article.
The current work is supported by UNITAID, grant number: PO#8477-0-600.
Conflicts of interest
There are no conflicts of interest.
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adolescents; discrete choice experiments; HIV self-testing; Malawi; preferences; young people; Zimbabwe
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