To the Editors:
Increasing uptake of HIV testing and counseling (HTC) and identifying HIV-infected individuals are a priority for all countries that subscribe to the goal of World Health Organization/Joint United Nations Programme on HIV/AIDS of an HIV-free generation by 2030.1 HTC is thus a crucial step toward achieving the promise of HIV treatment as prevention and achieving the first of the 90-90-90 targets of the Joint United Nations Programme on HIV/AIDS.1 However, globally and in sub-Saharan Africa, more than 50% of HIV-infected individuals are unaware of their status.2 Moreover, knowledge of HIV-positive status is lower in men than in women,3 with 61.9% of men and 47.8% of women in Kenya not knowing they have HIV.4
New strategies are needed to increase HIV testing among men and other hard-to-reach populations. HIV self-testing (HIVST) is a strategy that is highly acceptable and feasible in many settings5,6 and among diverse populations.7–13 In particular, secondary distribution of self-tests in sexual networks is a promising approach to increasing partner and couples testing.10,13 However, in the absence of face-to-face counseling, there is a need to assess whether women who offer self-tests to their partners experience intimate partner violence (IPV) or other forms of social harm. This study examines the occurrence of IPV and self-test distribution among women who accepted an intervention in which they received multiple self-tests for distribution to their sexual partners.
We analyzed data from a larger observational cohort study that has been described elsewhere.10 We enrolled female sex workers (FSW) from a Drop-in Center, a facility dedicated to serving key populations, and women seeking antenatal care (ANC) and postpartum care (PPC) from a government health facility in Kisumu, Kenya. Eligibility criteria included being aged 18–39 years, HIV negative, having at least one current sexual partner, and not anticipating violence from offering the self-test to partners.
After informed consent, participants were administered a questionnaire that included questions about whether they had experienced IPV in the past 12 months. These questions were adapted from the Kenya Demographic and Health Survey,14 and participants were asked whether they experienced physical abuse, verbal or emotional abuse, and loss of economic support. In addition, each FSW was asked if in the past 12 months she had been forced by any partner or client to have unpaid sex or have sex without a condom or to have anal sex when she did not want to. For the statistical analyses, IPV was determined to have occurred if participants responded affirmatively to any of the IPV questions.
After the baseline questionnaire, participants were instructed on how to use the OraQuick Rapid HIV-1/2 antibody test (OraSure Technologies, Bethlehem, PA), an oral fluid-based test. Research assistants, who were trained HTC counselors, performed a mock demonstration of self-test use and then asked participants to do a demonstration as a confirmation that they understood the process well enough to test themselves and demonstrate to their partners. We developed a standard operating procedure for research assistants to prepare participants on how to minimize IPV risk when distributing self-tests to their partners. FSW were given 5 test kits while ANC and PPC women were given 3 test kits, each accompanied by written and pictorial instructions on usage in English, Kiswahili, and Dholuo languages. Participants were also given a study helpline number and contact information for locally available IPV services. Participants were then followed monthly for 3 months and asked about distribution of self-tests to sexual partners and about IPV. Those reporting any IPV since enrollment were asked if this was related to self-test distribution.
The primary outcome variable was experience of IPV because of self-test distribution in the 3 months after enrollment. We conducted descriptive analyses of the primary outcome and of IPV incidence during the 12 months before enrollment. We then used χ2 tests to determine whether participants who reported experiencing IPV at baseline had a higher probability of reporting IPV during the 3 months after enrollment in the study. We also examined whether women who reported experiencing IPV at baseline had a lower probability of distributing a self-test to their primary partner.
A total of 280 participants (61 ANC, 117 PPC, and 102 FSW) were enrolled and 265 (94.6%) completed follow-up interviews. Baseline characteristics of participants have been described previously.10 A large majority of the participants with a primary sexual partner who were followed up distributed a self-test to their partner (53/58, 91% ANC; 91/106, 86% PPC; 64/85, 75% FSW).10 Overall, IPV at baseline was 27% in the ANC group, 46% in the PPC group, and 44% in the FSW group. IPV occurrence at follow-up, over a 3-month recall period, was lower: 14% in the ANC group, 17% in the PPC group, and 21% in the FSW group. Among all the study participants, 2 in PPC, 2 FSW, and none in ANC reported experiencing IPV because of offering a self-test to a male partner.
Any IPV at baseline was strongly associated with any IPV at follow-up in each study group (Table 1; P-value < 0.001). Participants in the FSW and ANC group who had experienced IPV at baseline were 40 and 44 percentage points, respectively, more likely to have experienced IPV during the follow-up period than women who did not experience IPV at baseline. Among PPC participants, there was a 22 percentage point higher likelihood of experiencing IPV during the follow-up period for those who reported IPV at baseline as compared to those who did not. The proportion of participants who distributed a self-test to their primary partner was not significantly different between those who did and did not report IPV at baseline. Very few participants (4% FSW, 2% PPC, and 6% ANC) who experienced IPV during the follow-up period reported no IPV at baseline. Of the 4 IPV cases that were reported to be associated with self-testing, 2 were among women who had experienced IPV at baseline and 2 were among women who had not. These IPV cases involved physical abuse, verbal abuse, or loss of economic support.
Despite high underlying IPV prevalence in the study setting, a majority of women reported safely distributing self-tests to their primary sexual partner. A central finding of this study is that IPV risk during the 3-month intervention period was greatest among those who reported IPV before the intervention, and moreover, only 4 of the women who experienced IPV during the intervention period attributed it to the offer or distribution of self-tests to their sexual partners. These results underscore the reality that women are at very high risk of violence even in the absence of HIVST interventions and that the introduction of self-tests by women to their partners does not necessarily heighten the risk of IPV. Studies of other HIV testing strategies among couples show similar results. In Zambia, clinic-based couples testing did not lead to greater occurrence of IPV than individual testing15; in South Africa, there was no increase in IPV pre–post couples testing16; in Malawi, there was no IPV reported after couples testing but women who anticipated violence did not invite partners back for testing17; and in the United States, there was no difference in IPV preintervention to postintervention between individual testing and couples testing.18
Details of the 4 IPV cases that were related to study participation indicated that the violence experienced by women may have occurred even after regular, clinic-based HIV testing in the presence of a counselor. Given the high underlying prevalence of IPV in this population, a key lesson that emerges is that IPV experienced by women receiving self-tests should not directly be attributed to HIVST per se but rather to various relationship dynamics that arise when individuals suggest testing or learn their partner's status—dynamics that may arise even when counselor-administered HIV testing takes place.
An important factor that should be considered when interpreting our results is that women who self-selected to participate in the study may have been those who felt comfortable offering self-tests to their partners. This self-selection process is likely to closely resemble real-world outcomes once self-tests are widely available, as only the women with a high degree of comfort offering self-tests to their partner are likely to do so by obtaining self-tests. Consistent with other studies,7,19 our results dispel fears regarding safety of HIVST and further the case that women attending services at health facilities can offer self-tests to men, thereby increasing HIV testing among them.
The authors are grateful to women who participated in the study, Immaculate Akello and Eunice Omanga who oversaw the study, and staff at IRDO and health facilities who implemented the study.
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