Insights into Potential Users and Messaging for HIV Oral Self Test Kits in Kenya Findings and Key Recommendations 2014 Ministry of Health

Study Objectives Main objective: Inform the design and implementation of a pilot project to increase the use of HIV oral self testing in Kenya. Specific objective: –Determine likely users of oral HIV self test kits among the General Population (GP) and Key Populations (KP) at risk in urban and rural settings; –Identify incentives for using oral HIV self test kits among the GP and KP at risk in urban and rural settings; –Identify and test key messages and approaches to increase demand and use of oral HIV self-test kits.

Sample Size Study ComponentTarget Population Quantitative Household Structured Survey Exit Interview at KP - Drop-in- Centers/Clinics A total of 353 women and 429 men (18-49 years), in both Mombasa and Siaya 100 MSM and 100 FSW (18-49 years) at drop-in centers of Mombasa Qualitative Focus Group Discussions (FGD) In-depth Interviews (IDI) 4 FGD’s of men and women years 10 IDIs of men and 10 IDIs of women years 10 IDIs of MSM and 10 IDIs of FSW years Message development and pretest 300 men and women in Mombasa and Siaya (GP and KP) Study location: Mombasa (urban setting) and Siaya, a rural district in Nyanza province

Findings General Population

Mombasa %(n=392) Siaya %(n=390) Total sample %(N=782) Ever tested for HIV (686) Tested for HIV in past 12 months (555) Knows place to do HIV test (692) Venue of last HIV test Public clinics/hospitals (407) Private clinics (141) HTC centers (108) Mobile clinics (190) HIV Testing Behaviour (1)

Mombasa %(n=392) Siaya %(n=390) Total sample %(N=782) Attitudes toward HIV testing and abilities to handle test results “I would be treated poorly by health workers at HTC center”: Agreed or strongly agreed (144) “I am confident in coping with test results”: Agreed or strongly agreed (782) “I am confident that I can reveal HIV status to partner”: Agreed or strongly agreed (682) HIV Testing Behaviour (2)

Mombasa %(n=392) Siaya %(n=390) Total sample %(N=782) Ever seen/heard of HIV test kit (41) Ever used HIV test kit (1) Would use if made available (750) Incentives for using HIV Oral self-test kit Easy to use (455) Convenient to use (207) Confidentiality/privacy (372) Do not have to visit a HF (238) HIV Oral Self-testing: Perceptions (1)

Mombasa %(n=392) Siaya %(n=390) Total sample %(N=782) Would seek confirmatory test Would recommend test to partner How can HIV Oral Self-test be promoted in Kenya Mass media Brochures Health workers Community Health Outreach workers Others HIV Oral Self-testing: Perceptions (2)

Mombasa %(n=392) Siaya %(n=390) Total sample %(N=782) What would you do if the test kit was sold and the price was too high Find free HTC services Find cheaper HTC services Not go for a test If the price was the same as HTC, what would you choose? Oral self testing Traditional HTC Mobile HTC HIV Oral Self-testing: Perceptions (3)

Further analysis show likely users among General Population as:  Ever tested for HIV  Have support from spouse/sex partner to be tested for HIV  Live in Mombasa (Urban)  Note: Most other factors were not statistically significant, mostly due to limited statistical power (due to having small # of non-likely users).

Preferred retail/distribution outlets (by city) Mombasa %(n=392) Siaya %(n=390) Total sample %(N=782) Public clinics Private clinics Private pharmacies/chemists Shops/super markets Note: If we add private clinics and privates pharmacies together, the private sector is the preferred channel: 83%

Mombasa %(n=392) Siaya %(n=390) Total sample %(N=782) Confidentiality (182) Friendly (36) Services always available (15) Easy to access (476) Others (41) Preference to get kit from mentioned outlet

Factors Influencing the 2 Key Incentives to Use Who chose the test for its ease of use? Residents of Siaya (Rural) Ever tested for HIV Tested for HIV in the previous 12 months Who chose the test for its confidentiality? Residents of Mombasa (Urban) Tested for HIV in the past 12 months Have higher education Could not reveal HIV status to partner/spouse

Messages General Population want to hear or see Mombasa %(n=392) Siaya %(n=390) Total sample %(N=782) Retail price Retail outlet Instructions how to use Benefits Advantages Safety features Referral services

From where/who GP want to see/hear about HIV Oral self-test kits Mombasa %(n=392) Siaya %(n=390) Total sample %(N=782) Doctor Nurse/Counselor Television Radio Community health/outreach worker Pharmacist

Findings Key Populations (FSW and MSM)

MSM %(N=100) FSWs %(N=100) Gender Male100 Female100 Age years years4761 Education Primary or less*6944 Secondary2449 Tertiary77 Demographics (1)

MSM %(N=100) FSWs %(N=100) Ever seen/heard of HIV test kit478 Ever used HIV test kit00 Would use if made available5798 Incentives for using HIV Oral self-test kit Easy to use Convenient to use Confidentiality/privacy Do not have to visit a HF Saves time HIV Oral Self-testing: Perceptions (1)

MSM %(N=100) FSWs %(N=100) Would seek confirmatory test Would recommend test to partner How can HIV Oral Self-test be promoted in Kenya Mass media Brochures Health workers Community Health Outreach workers Others (Community sensitization, road shows, seminars, churches/mosques) HIV Oral Self-testing: Perceptions (2)

MSM %(N=100) FSWs %(N=100) What would you do if the test kit was sold and the price was too high Find free HTC services Find cheaper HTC services Not going to test3.0 If the price was the same as HTC, what would you choose? Oral self testing Traditional HTC HIV Oral Self-testing: Perceptions (3)

Preferred retail/distribution outlets (by city) MSM %(N=100) FSWs %(N=100) Public clinics Private clinics Private pharmacies/chemists Shops/super markets NGOS19.3 Other (Drop-in-centers, clubs, bars & lodgings) Note: If we add private clinics and privates pharmacies, we get private sector as the preferred channel for both MSM and FSW

MSM %(N=100) FSWs %(N=100) Confidentiality Friendly Easy to access Why prefers to get kit from mentioned outlet

MSM %(n=57) FSWs %(n=94) Price point 50 KSH88 (50)99 (93) 100 KSH61 (35)82 (77) 150 KSH32 (18)56 (53) 200 KSH32 (18)46 (43) 250 KSH51 (12)32 (30) 300 KSH18 (10)25 (23) 350 KSH18 (10)23 (21) 400 KSH16 (9)22 (21) Median and mean maximum price 100/150150/250 Willingness to pay

MSM %(N=57) FSWs %(N=94) Age years years years Education Primary or less* Secondary Tertiary Willingness to pay by age and education

Messages Key Populations want to hear or see MSM %(N=100) FSW %(N=100) Retail price Retail outlet Instructions how to use Benefits Advantages Safety features Referral services

From where/who KP want to see/hear about HIV Oral self-test kits MSM %(N=100) FSW %(N=100) Doctor Nurse/Counselor Television Radio Community health/outreach Worker Pharmacist Street play Brochure/Magazine Post-Test Club16.0-

Note: During message testing phase, we found a number of frequently asked questions that should also be addressed in the promotion of messages

 Among Key populations, the samples were likely biased toward lower SES and frequent HIV testers  The extremely high levels of ever or recent testing for HIV, intention to use the self-test kits, and intention to buy the self-test kits made the effort to distinguish likely users from non-likely users difficult  The views of participants were only hypothetical - it is possible their views may have differed if test becomes available for use  HIV oral self-testing is not widely available for use in Kenya, assessing willingness to use or willingness to pay becomes difficult. Limitations

 Self testing should be introduced for GP and KP. Interest and intention to use overwhelmingly high especially for GP and FSW  Targeted communication on disclosure of test status to sex partner or health care provider and safe sex practices  Further HIV self testing programs to address self-efficacy issues  More efforts to reach never testers or those who tested less frequently as they indicated lower intention to use  The most frequent intentions to use: ease of use, convenience, don’t have to travel to HF and privacy Conclusion and Recommendations (1)

 HIV self testing preferred to be introduced through private and public sector (public clinics, pharmacies/chemist and private clinics)  Health care providers and community health workers are the most preferred sources for promoting oral self testing  Both TV and radio demonstrate potential for messaging channels for raising awareness and demand  Kiswahili is the most preferred language for radio advertisement  TV appears to be more effective than radio in helping viewers recall the key messages  Answers to frequently asked questions are important Conclusion and Recommendations (2)