Perceived acceptability of a facility-based HIV self-test intervention in outpatient waiting-spaces among adult outpatients in Malawi: a formative study

Abstract

Background:

Facility-based HIVST offered to outpatients in clinic waiting spaces provides an ideal opportunity to take HIVST to scale in low-resource settings. We explore if outpatients are willing to use HIVST kits in outpatient waiting spaces before they receive routine services in Malawi.

Methods:

A formative qualitative study was conducted to inform the design of a multi-arm clustered randomized trial. In-depth interviews were conducted with 36 adults (≥ 15 years) seeking outpatient services at five high-burden health facilities in Central and Southern Malawi. Outpatients were purposively sampled on the day of clinic visit. Before the interview, research staff described a hypothetical facility-based HIVST intervention. Data were analyzed using constant comparison analyses.

Findings:

The vast majority of respondents believed facility-based HIVST in outpatient waiting spaces was acceptable and desired, especially among men. Participants believed the strategy may decrease potential stigma associated with testing due to an opt-out approach, and may increase clients’ willingness to test again in the near future because it will help overcome fears related to an unknown HIV test result. The strategy was also seen as confidential and convenient. A minority of clients believed private spaces for conducting HIVST in facilities were needed.

Conclusion:

Facility-based HIVST in outpatient waiting spaces is acceptable and desired among adult outpatients in Malawi. Notably, few respondents were concerned about lack of privacy.

To the editors:

Approximately 70% of people living with HIV in sub-Saharan Africa know their status,¹ with only 25% of adults testing for HIV in the past 12-months.² HIV self-testing (HIVST) is associated with increased coverage of HIV testing, especially among hard-to-reach populations such as men and adolescents.^10–12 HIVST largely overcomes common barriers related to traditional testing strategies by increasing testing privacy, confidentiality, and convenience.^{4, 13}

Facility-based HIVST among individuals attending outpatient departments provides an ideal opportunity to take HIVST to scale in resource-strained settings. Facility-based HIV testing is low cost and is scalable.¹⁷ Facility-based HIVST may be particularly effective in crowded outpatient waiting spaces where clients can use HIVST while waiting for routine health services. No studies to date have examined the acceptability of facility-based HIVST. Examining perceived acceptability of this strategy is critical to advancing HIVST in sub-Saharan Africa.

We conducted a formative qualitative study on the acceptability of facility-based HIVST, and key components for the intervention’s success, to inform the design of a cluster randomized controlled trial.

METHODS

Semi-structured, in-depth interviews (IDIs) were conducted with 36 adult outpatients (≥15 years of age) at 5 health facilities in Malawi between May 26 - June 26, 2017. Outpatients in clinic waiting spaces received a group demonstration of HIVST and a description of a hypothetical facility-based HIVST experience. The mock experience included six components: (1) 10-minute health talk about the importance of HIV testing; (2) 15-minute demonstration of Oraquick HIVST kits ©; (3) HIVST distribution in the outpatient waiting space whereby each adult outpatient was offered opt-out HIVST; (4) HIVST use in the outpatient waiting space whereby outpatients would use the HIVST kit and store the kit in the opaque bag while waiting for results to process; (5) private spaces for outpatients to interpret final HIVST results before they received routine heath consultations; and (6) optional post-test counseling and linkage to care for outpatients who chose to disclose their HIVST result.

After completing the mock HIVST demonstration, outpatients were purposively sampled by sex and age for in-depth interviews. IDIs lasted approximately 20 minutes and were conducted in a private location at the health facility in the local language (Chichewa) by trained interviewers. Interviewers were matched with sex of respondents. The interview guide explored respondent perceptions of group facility-based HIVST, with a specific focus on perceptions of group HIVST demonstration, distribution, and use; as well as location of private spaces for HIVST interpretation at the outpatient clinic.

Data were analyzed using ATLAS.ti v.8. Inductive and deductive coding were applied using constant comparison methods [21] by four investigators (FS, KP, PK and OO). Ethical approval was granted by the Malawi National Health Sciences Research Committee and the University of California Los Angeles Institutional Review Board.

RESULTS

Thirty-six clients participated in an IDI (18 males and 18 females). Men were older than women (median age 35.5 years for men and 29.5 years for women). We found that the vast majority of respondents believed facility-based HIVST in outpatient waiting spaces was acceptable, with most respondents reporting that they wanted to use the strategy and they would recommend the strategy to friends and family. Table 1 presents major themes related to the primary reasons driving acceptability of the strategy.

Table 1:

Reasons for acceptability of Facility-based HIVST in outpatient waiting spaces

Reason	Quotation
Acceptable	With facility-based HIVST… I would encourage my friends that they could test him or herself for HIV and their test results would be confidential. I believe that my friends will be very happy when they hear about HIVST and I know they would like to use the method. … I would love if you told me when this [the intervention] will happen so I can come with them on that day and get tested. (Southern Malawi, Male, 17 Years)
Stigma Reduction	…….but HIVST here at the outpatient department will not be a shameful thing because even the test tool will not be something new which you would feel ashamed of holding. (Central Malawi, Male, 27 Years)
Prepare clients for Additional HIV Testing	I can encourage others to use HIVST at the outpatient [clinic] because it’s the only method that you can use when you feel that going to the doctor to get the shocking news [a test result] is hard. Self-testing is better because you know yourself and you are encouraged. (Southern Malawi, Female, 56 Years), I think it [facility-based HTC] is good because before you enter the doctor’s room [HTC clinic] you will be sure of your status. Most times we are worried to hear the results from the doctor. (Southern Malawi, Male, 30 Years)
Confidentiality	I remember this other day, we agreed with my four friends to come and get tested but one of them refused because he suggested that he would prefer being tested in private. When he said this, we all didn’t go for the test. So, I would encourage these friends about this strategy [facility-based HIVST.] (Southern Malawi, Male, 17 Years)
Convenience	[With traditional HTC clinics] you are expected to go to the outpatient doctor’s office and then after that, you should go to the HTC clinic. So basically, this [facility-based HIVST] is the simplest method and I would encourage others to use it because they will test themselves at the outpatient clinic, avoiding multiple trips between the outpatient and HTC clinics. (Central Malawi, Male, 25 Years), The [facility-based] HIVST procedure does not require a lot of time while waiting to receive drugs or testing [for outpatient services]. At the HTC clinic you can wait up to 1 hour [before being tested], but using this method you might need 30 minutes and you can test yourself while waiting to be assisted with other services. (Central Malawi, Male, 40 Years)

Stigma Reduction

Respondents believed facility-based HIVST could decrease stigma associated with HIV testing. By creating a universal opt-out environment for outpatients where HIVST kits are distributed openly, HIV testing could be considered normal and part of routine services. Participants felt that the group opt-out approach of demonstrating and distributing HIVST kits could help change community-level perceptions that HIV testing should be secretive and shameful.

Prepare clients for additional HIV testing

Respondents believed facility-based HIVST would help them prepare for testing at traditional HIV testing clinics. By completing a HIVST test, clients can prepare emotionally for traditional testing, and the result they should expect.

Confidentiality

Facility-based HIVST was perceived as more private and confidential because clients could test themselves and interpret their own results, effectively removing the need to involve health care providers who they feared may disclose their status to others within the community. This was a dominant theme across most respondents, despite the fact that HIVST kit distribution would take place in a group setting at outpatient waiting spaces.

Convenience

Facility-based HIVST was perceived as quick and convenient compared to traditional HIV testing, which often required multiple hours to wait for the next available health care worker. The strategy was especially appealing since HIVST could be used while waiting for other health services. Convenience was mentioned primarily by male respondents who had other demands on their time.

Key Components of Facility-Based HIVST

Respondents identified several key components for the intervention that they felt would be important in a real-world scenario: private spaces for kit interpretation within outpatient waiting spaces; detailed HIVST demonstrations and group pre-counseling; and community sensitization, so individuals coming to the facility would be emotionally prepared to use HIVST. Notably, very few clients were concerned about using HIVST in the outpatient waiting space – the vast majority believed they could use the test in the public waiting space and then go to a private space to interpret their results once it had processed. Some respondents believed that one-on-one demonstrations and post-counseling should also be available for clients who needed additional assistance.

DISCUSSION

Facility-based HIVST is perceived as highly acceptable. We found two novel benefits of the strategy. First, facility-based HIVST was believed to reduce stigma related to HIV testing. Universal opt-out testing with HIV education and HIVST kit distribution in an open, group environment was believed by some to help change perceptions that HIV testing is shameful and should be secretive, thus normalizing routine testing. Similar findings have been reported from Prevention of Mother-to-Child Transmission (PMTCT) programs where all female antenatal clients are expected to test for HIV, regardless of risk behavior.^{25, 26}

A second potential benefit of facility-based HIVST is to prepare clients for future testing by helping them overcome fears related to an unknown HIV test result. Studies have reported that individuals are not willing to test for HIV because of the fear of receiving or being told a positive HIV result from a health care worker.⁷ In our hypothetical intervention, some outpatients believed that by completing a HIVST test at the outpatient waiting space and interpreting their results on their own, clients can prepare emotionally for traditional HTC and the expected result. In sub-Saharan Africa, adults overestimate their risk for HIV infection.³² This overestimation may prevent individuals from testing due to fears of an assumed positive test result.³³ Our findings indicate that HIVST may help alleviate fears and empower clients to know their status.

Consistent with community-based HIVST^13,24,34 facility-based HIVST was perceived to be acceptable because it is both confidential and convenient. Outpatients believed the ability to interpret their own test results would decrease unwanted result disclosure, a common fear in Malawi and a major barrier to testing.⁷ Outpatients believed facility-based HIVST would also decrease wait times associated with testing, another dominant barrier to service utilization.^21,22

Clients in our study highlighted the importance of HIVST demonstration and one-on-one support as a component of a testing experience, and this finding has been shown in other HIVST studies, specifically for accurate use and interpretation of test results.^{29, 36}

Facility HIVST in outpatient waiting spaces was perceived to be highly acceptable. This strategy may provide a high-impact, sustainable, and scalable approach for improving HIV testing throughout sub-Saharan Africa. Further research is needed to understand real-world acceptability and use of the strategy.