Abstract:
Assisted partner services (aPNS) support HIV testing among partners of people diagnosed
with HIV. Integrating HIV self-testing (HIVST) into aPNS may improve testing uptake and
case detection. This study, conducted in western Kenya, assessed the acceptability and cost
effectiveness of aPNS-HIVST, addressing a gap in existing research. The socio-demographic
and behavioral characteristics of sexual partners offered HIVST or provider-delivered testing
through aPNS (n=3312) was evaluated. A subset of participants (n=24) and pharmacy staff
involved in HIVST distribution (n=6) were selected for in-depth interviews (IDIs), while
focus group discussions (FGDs) were conducted with HIV testing service providers (n=2, 6
participants per FGD). Descriptive and log-binomial regression analyses were performed for
quantitative data, and thematic analysis was applied for qualitative data using the theoretical
framework of acceptability. Micro-costing, time-and-motion studies, and provider surveys
assessed HIVST distribution costs, while a decision tree model estimated the incremental cost
per new diagnosis when compared to standard aPNS. The study found that 82.2% of
individuals offered HIV self-testing (HIVST) through assisted partner services (aPNS) opted
to use it. There was no significant association between demographic factors and HIVST
uptake, but casual (adjusted prevalence ratio (aPR) = 0.93; 95% Confidence Interval (CI)
0.88-0.98) or transactional (aPR = 0.90; 95% CI 0.87-0.94) partners were less likely to use
HIVST than those in defined relationships. Additionally, offering an extra HIVST kit led to
slightly lower uptake (aPR = 0.93; 95% CI 0.88-0.98). In-depth interviews with partners
revealed that HIVST was a viable option for those who found provider-delivered testing
inconvenient, with ‘intervention coherence’, ‘self-efficacy’, and ‘ethicality’ being key factors
influencing acceptability. HIV testing service (HTS) providers played a crucial role in
promoting HIVST, citing benefits such as improved testing efficiency, though they faced
challenges like confidentiality concerns, stigma, and limited awareness of HIVST. The
introduction of HIVST also led to unexpected effects, such as increased community awareness
and concerns about the capacity of pharmacy staff to offer proper counseling. The cost of
distributing each HIVST within aPNS was $8.97, with much of the cost attributed to testing
supplies (38%) and personnel (30%). HIVST integration into aPNS was found to be
potentially cost-effective under certain conditions, including facility-based testing uptake of
less than 91% or HIVST utilization rates below 27%. In a best-case scenario, HIVST
integration could save $3,037 and identify 11 additional HIV-positive individuals. The net
monetary benefit was sensitive to factors such as HIVST effectiveness, testing rates, and
personnel time. To optimize HIV testing for aPNS clients, increasing HIV self-testing
(HIVST) awareness, and offering tailored solutions are key. Providers should consider the
partner’s sexual context and provide counseling when recommending HIVST. Integration
should prioritize four of the five ‘Cs’ of HIV testing services (HTS): confidentiality,
counseling, correct results, and linkage to care. Pharmacy staff should be trained in HTS,
while HTS providers need training on remote counseling and aPNS procedures. Policymakers
should focus on facilities with low provider-delivered testing uptake and promote HIVST
among those who benefit from remote testing, while minimizing costs related to personnel
and supplies
