Implementing and scaling up HIV self testing in Kenya Dr Sarah Masyuko NASCOP

Background In 2015, about 1.5 million Kenyans were living with HIV with 268,588 being young people About 1 million are currently on treatment About 500,000 are yet to be initiated on treatment ST a tool to reach the 90:90:90 goal

Knowledge of HIV status Percentage of women and men aged 15-49 who received an HIV test in the past 12 months and know their results As per last KAIS we still had not reached universal testing coverage and there was still a good percentage of HIV infected persons who were unaware of status.

HIV testing yield Despite an increase in number of HIV tests conducted, the positivity rate continues to decline with a positivity of 1.7% in 2016. Therefore targeted testing becomes more useful

Progress on the 90:90:90 cascade Those not identified are most likely Men and Adolescents and Youth: Adolescents and youth have 43% ART coverage compared to 68% for those above 25 years

Progress on the 90:90:90 cascade 46% gap compared to a national gap of 29% for those identified positive and in care 45% vs 23% gap for those on treatment Those not identified are most likely Men and Adolescents and Youth: Adolescents and youth have 43% ART coverage compared to 68% for those above 25 years

Journey to ST roll out HIVST first included in the national guidelines since 2009 However it has taken 7 years for it be implemented 7 years of formative research on ST 72% of respondents in last KAIS 2012 indicated that they would be willing to use a self test kit. Acceptability Packaging Social harms

Evidence on self testing High uptake of self-testing has been reported in Kenya by Health workers. High uptake of self -testing has specifically been reported among the youth, men and those who had tested before. Benefits: First time testers, privacy, convenience, reduced stigma. Pharmacies identified as point of distribution. Concerns on need for counselling. There is no significant harm associated with HIVST Health workers study 2005 Cross sectional study in urban and rural Kenya -91% of respondents were willing to use an oral fluid-based HIVST kit compared to other HIV testing alternatives (Sidze et al.2014) Cohort study among HIV-negative women 18-39 years old who presented at antenatal care (ANC) or post-partum care (PPC) settings and female sex workers presenting at drop-in centres were provided HIV self-test kits to deliver to their male partners and social networks.  -Four women reported IPV after self test kit distribution to their partners(1.5%) Thirumurthy et al 2016 -26 of 41 newly identified HIV positive partners of sex workers (65%) had sought confirmatory testing within the 3 month follow-up period and 23 (58%) were reported to have linked to care. Thirumurthy et al 2016

From Research to Practice

Progress made with adoption of HIV self testing Inclusion in Kenya HIV Testing Guidelines 2015 HIV Self Testing operational manual developed HIV Self testing to be launched together with PrEP at end of April Three HIV Self test kits registered in country by Pharmacy and Poisons Board Lab board listing ongoing Resource mobilization through PEPFAR, Global Fund and UNITAID

HIV ST Operational manual Programmatic Approaches and Models Package of services provided under HIVST Commodity management systems for HIVST Biosafety and infection control measures Quality assurance strategies in HIVST

Approaches Oral and Blood Based self tests

HIVST Service Delivery Approaches Facility based OPD, STI clinic, TB clinic, Pharmacy, ANC, CCC, Wards, maternity,Private clinics etc Community based VCT centres, DICEs, CHVs Others Pharmacy, Vending machines, Internet, dial-a-HIVST,

Algorithm This should be performed using approved national algorithm HIVST should however not be used for HIV diagnosis, all positives results should be confirmed as per the national protocols.

Support and Linkage tools Client information inserts Community based follow up Vouchers, coupons or rebates – applicable mostly to key populations Internet, computer based programs and applications include online audio or video counselling services Partner HIVST and couples who deliver test kits to partners and link them to care and treatment. Telephone hotlines for pretest and posttest counselling and can still offer linkage to HTS. Bulk mobile phone text message services Through public gathering (baraza’s)

Challenges or Unanswered questions Cost remains high- $7-8 retail price. Ex works price of $3-4 Private sector distribution of self test Linkage to care for those positive and linkage to prevention for those who test negative Lose of data on HIV testing Support systems for those who test HIV positive WHO prequalification of the test kits ERP approval As kits not available, Kenya is piloting scale up in private sector

Unanswered questions After ST, Confirmatory testing prior to ART initiation or do they follow the whole national algorithm Monitoring of HIVST usage using barcodes Use of the call centre to collect data and provide support vs use of a web app Reality of linkage within 90 days Monitoring of adverse events eg GBV, IPV

Public sector Limited distribution Key populations and their partners ANC and their partners Adolescents and Young people Men Health care workers Awaiting procurement after WHO prequalification

Pilot with the Private sector Operational framework/SOPs for roll out in private sector developed IEC materials drafted Pilot to simulate how ST will work in private sector Anonymous survey: models, client profile of early adopters, privacy, data, linkage Selected 16 pharmacies in Nairobi, Mombasa and Kisumu to pilot ST Linked to hotline managed by LVCT health Referral sites available for linkage

Next Steps Public private partnership Results from pilot to inform scale up for the launch of ST Capacity Building Launch of ST end of April 2017 Roll out to begin with private sector at a wider scale Procurement of test kits to kick off public sector self testing Continuous learning

Acknowledgements NASCOP HTS TWG WHO CHAI, PS Kenya, Pharmaceutical Society of Kenya, Kenya Pharmaceutical Association, LVCT Health