Acceptability and Cost-Effectiveness of HIV Self-Testing in the Context of Assisted Partner Notification Services in Kisumu and Homa Bay Counties, Kenya

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