1. Developing understandable, culturally sensitive HIV self-test instructions: insights from cognitive interviewing among clients testing at two HIV testing sites in Zimbabwe Nancy Ruhode, Euphemia Sibanda, Claudius Madanhire, Karin Hatzold, Frances Cowan, Sue Napierala Mavedzenge

2. Background Access to and demand for HTC is sub - optimal HIV self-testing (HIVST) could increase uptake of HTC Understandable, culturally sensitive test instructions a prerequisite The aim of the study was to develop instructional materials to support accurate HIVST

3. Methods Participants purposively recruited from two HTC sites. New Africa House New Start Centre in Harare (Urban) Shamva District (Rural) Cognitive interviewing done to iteratively refine written instructions Participant asked to execute each step Discussion of each step in written instructions Interviews were audio recorded, transcribed, translated and analysed thematically

4. Results 8 participants recruited from Harare site in July 2014 6 recruited from Shamva District in January 2015 Participant characteristics All had just tested HIV negative 5/14 were female Age 22- 42 years Education Urban: 3 secondary education (Ordinary level), 1 A level, and 4 tertiary Rural: 4 primary school level, one part secondary school, one completed secondary school

5. Spatial descriptions are inadequate Bottom pouch and top pouch “…it was not easy for me… if I hold it this way… you can get confused…” (22 year old male student in college) ‘Bottom pouch’ replaced with ‘open the pouch with picture of vial’ ‘Top pouch’ replaced with ‘ open the pouch with picture of test device’

6. Inadequate pouch labelling confusing Problems identifying tear off point “… this side it is written “tear here” but the other side there is nowhere written… so someone can get confused and open here first… that’s why I opened here first.” (22 year old male student in college). “Tear here” labels were inserted to make it clearer

7. Unclear translations Unclear translation of vial opening instructions “ I think here they are saying clockwise and anticlockwise, I am not sure… there should be a pictorial illustration of how the bottle can be opened” ( 22 year old male) Pictorial illustration helped clarify

8. Difficulty identifying test kit items “I saw the little box in the picture with a hole in it” (39 year old female, primary level education) Pictures made it clearer Before After Identifying stand for developer vial a major problem - problem worse in rural sites “Where is the stand… these things are difficult to understand …”. (42 year old male, primary level education).

9. Aligning text to pictures Non- adjacent pictures and text Adjacent picture and text easily matched

10. Variations in symbol/ picture interpretation Before After a ‘no food’ symbol interpreted as a pot on a stove “no eating just before testing”

11. Pictorial instructions easier to comprehend

12. Conclusion/Recommendations Cognitive interviewing provided insight into user: - Interpretation of instructions -Understanding of instructions More pictorial instructions were easier to understand For more details on the formal HIV self - test accuracy study see poster THUPDCO82

13. Acknowledgements The study was funded by Zimbabwe’s Integrated Support Fund which receives funding from DfID, Swedish SIDA and IrishAID Thanks to the participants who took part in the study