1. #AIDS2016 | @AIDS_conference "Not without us…" - Views on the introduction of HIV self-testing among health care workers providing integrated HIV and sexual & reproductive health services Claudius Madanhire 1, Euphemia Sibanda 1, Nancy Ruhode 1, Karin Hatzold, Frances M Cowan 1,2, Sue Napierala Mavedzenge 3 1. Centre for Sexual Health and HIV/AIDS Research (CeSHHAR Zimbabwe), Harare, Zimbabwe 2. Research Department of Infection and Population Health, University College London, London, United Kingdom 3. Women’s Global Health Imperative, RTI International, San Francisco, USA 4. Population Services International Zimbabwe (PSI Zimbabwe), Harare, Zimbabwe

2. #AIDS2016 | @AIDS_conference Background Access to and demand for HTC is sub-optimal HIV self-testing (HIVST) has the potential to increase knowledge of HIV status Its success depends on stakeholder support, including health care workers (HCW) Study aim: To explore HCW views on HIVST in preparation for adoption and scale-up of HIVST in Zimbabwe.

3. #AIDS2016 | @AIDS_conference Methods HCWs were recruited from 2 urban non- governmental HTC sites and also from government rural health centres to participate in FGD Discussion topics included: – understanding of HIV ST – views about ST – perceived impact of ST on their roles – suggestions for setting up a successful ST program FGDs were audio recorded, transcribed, translated and analysed thematically

4. #AIDS2016 | @AIDS_conference Results 8 FGDs were held each with 10-13 HCWs (total=83) – 18 nurses, 15 counsellors, 4 medical lab scientists, and 6 administrative staff (NGO) – 28 nurses, 6 Primary care counsellors 6 administrative staff (HCWs public health centre) – The level of experience ranged from 1 to 15 years – Their roles Included: HIV counselling and testing SRH – (cervical cancer screening and family planning) clinical nursing duties Manning the outpatient department

5. #AIDS2016 | @AIDS_conference Results “… I think men are going to be major beneficiaries. Because you find at most health care facilities or even at most testing centres very few men come..” Nurse counsellor New start centre

6. #AIDS2016 | @AIDS_conference Poor knowledge of HIVST HCW had little knowledge of HIVST “At one time I tuned into this radio program and they were discussing self-testing”. Female counsellor, New Start Centre “Personally I am not comfortable to give the information (on HIVST) because I myself don’t have adequate information to give a client…”Female nurse counsellor, NAH New Start Centre Confusion over use of oral fluids for testing “…you have been saying that in saliva there is no virus, so if you are going to test using the saliva where would the virus have come from?” Female counsellor, New Start centre

7. #AIDS2016 | @AIDS_conference Perceived negative impact to HCW jobs HIVST considered by HCW working at NGO to be a threat to HCW jobs – Thought to affect cadres whose job is primarily focused on counselling “...people will lose their jobs. I think there will be less workload…” Female nurse counsellor New Start Centre “…If the 20 counselors are seeing 10 clients (per day) instead of maybe the 30 they used to take, the employer will say aah what if we cut down the number of counselors…” Female nurse counsellor, New Start Centre

8. #AIDS2016 | @AIDS_conference Notion that HIVST is a low cost Intervention This was thought to provide further reason for job losses “…already there is talk that they will make use of community health workers, and these are cheaper, and we are more expensive, so they will away with us.” Counsellor, New Start Centre

9. #AIDS2016 | @AIDS_conference Views on linkage to care after HIVST Mixed views on whether clients would link to care after HIVST – View that individuals who self-test HIV positive would be keen to get confirmatory testing, treatment and support – Fear that HIV positive clients would not want to disclose result to anyone “...Remember there is no self treatment… this person will not have a treatment buddie, they will not have anything…” (to facilitate linkage) Male lab scientist, New Start Centre

10. #AIDS2016 | @AIDS_conference View that lay people may not test accurately Fear that lay people might fail to test themselves accurately “ Let me be specific there… The case of accuracy, if we want accuracy the test kit should not be taken to the community and used away from professional health care workers… people are not trained to do these tests” Nurse counsellor New Start Centre

11. #AIDS2016 | @AIDS_conference Views on potential for social harms Domestic violence, suicide, and forced testing were thought to be possible social harms “…people are going to fight each other; they will stab one another. Self-testing is both good and bad”. Female counsellor, Chitungwiza New Start Centre …what about suicides? Self-testing is indeed needed but it has to be stressed that counselling is important. Female counsellor, NAH New Start Centre Fear that devices showing HIV negative results could be ‘traded’ for deception

12. #AIDS2016 | @AIDS_conference Views from public sector HCWs HCWs thought ST might also bring some benefits: – HIVST thought to bring relief in workload – Implies that perceived threat is felt by HCW whose roles are limited to HIV testing & counselling – No worries about job losses HCW need to be educated about HIV ST and about how it will likely augment their jobs and enable to do them better rather than act as a threat to job security.

13. #AIDS2016 | @AIDS_conference Views on what a good HIVST programme would look like HCW should remain the cornerstone Custody of the kits – fear of uncontrolled informal markets HCWs felt that HCW should be given the role of distributing test kits “…The ideal in my own view is for us to be given these things, as we go out for outreach we then educate and distribute the kits..”. Female counsellor, New Start Centre Pre and post-test counselling – strongly emphasized Not without us!

14. #AIDS2016 | @AIDS_conference Views on what a good HIVST programme would look like Involvement of local leadership and health delivery structures in the mobilisation Distribution should be health facility based

15. #AIDS2016 | @AIDS_conference Discussion Training of HCW on HIVST is important HTS facts - what it is, oral fluid and HIV Effect of HIVST on HCW roles Added value of HIVST - how it augments MoH HTS strategy The belief that pre and post test counselling is important is a recurrent theme The nature and form of what counselling is required in the context of HIVST needs to established Their concern that HIVST will result in social harm. This needs to be proved/disproved – ongoing tracking/ surveillance for social harms will be important

16. #AIDS2016 | @AIDS_conference Acknowledgements The study participants The funders and partners