2. USAID STRENGTHENING THE CARE CONTINUUM PROJECT (The Care Continuum)
Experiences of use of oral HIV self-testing kits among MSM and FSWs in Ghana: Observations of self-testing
10th May, 2018

3. Authors: Affiliation:
Henry Nagai1, Waimar Tun2, Edward Adiibokah2, Henry Tagoe2, Yussif Ahmed Abdul Rahman1, Placide Tapsoba2, Kyeremeh Atuahene3, Stephen Ayisi Addo4
1JSI Research & Training Institute, Inc.
2Population Council
3 Ghana AIDS Commission
4Ghana Health Service /National AIDS/STIs Control Programme
Authors: Affiliation:

4. WHO recommends HIVST as an additional approach to HIV testing (2016)
No HIVST operational guidelines in Ghana although mentioned in NSP
No HIVST research has yet been conducted in Ghana
Policy makers hesitant to endorse HIVST without sufficient evidence that it is safe, accurate, and leads to acceptable levels of “linkage” for post-test services
Research needed to understand implementation issues (e.g., distribution, ensuring human rights, linkages to care and treatment) to determine whether HIVST can be an alternative HTC service delivery model in Ghana
Evidence gaps

5. Study Goal & Specific Aim
Provide evidence of feasibility and acceptability of HIVST strategy to improve uptake of HIV testing among MSM and FSWs in Ghana
Specific aim of this study:
Examine KP’s ability to follow oral HIVST instructions and interpret HIVST results
Do they follow instructions?
Do they interpret the result correctly?
What problems do they encounter?
You can mention here that this was only one component of a larger body of work to examine feasibility and acceptability.

6. Overview: oral HIV self-testing
Oral HIVST involves the client obtaining an oral specimen, performing the test, and interpreting the test result him/herself in private

7. Overview: oral HIV self-testing
Orasure Oraquick is the only WHO pre-qualified oral HIV self-testing kit on the market
Considered a screening test and does not provide a definitive diagnosis; thus, it requires confirmatory testing or post-test follow-up.
Can have high specificity (99.9%) and sensitivity (99.3%)
WHO Prequalification aims to ensure that diagnostics, medicines, vaccines and immunization-related equipment and devices for high burden diseases meet global standards of quality, safety and efficacy, in order to optimize use of health resources and improve health outcomes.
The prequalification process consists of a transparent, scientifically sound assessment, which includes dossier review, consistency testing or performance evaluation and site visits to manufacturers. This information, in conjunction with other procurement criteria, is used by UN and other procurement agencies to make purchasing decisions regarding diagnostics, medicines and/or vaccines.

8. Methods
Conducted observations of 40 KPs (20 FSWs and 20 MSM) performing HIV testing on themselves
Study locations
Greater Accra

9. Study flow Exit Interview Eligibility Screening Post-test counselling
Recruitment of participants by peer educators of CSOs of Care Continuum
Participant exits the study
Exit Interview
Eligibility Screening
In-depth interview is conducted by research assistant
Eligibility screening and inform consent to participate in the study
Post-test counselling
Pre-information
All participants given post-test counselling by Nurse Counselor
HIV self-testing
Participants are given pre-information by KP-friendly Nurse Counselor
HIVST is conducted by participant in a testing room fitted with camera (non-recording) for observation by research assistants in another room

10. HIV testing status

11. Background characteristics of participants
Highest level of education of participants by category

12. Background characteristics of participants
Summary table of characteristics of participant
Indicator
MSM
FSW
Total
Age (years)
Mean
23.05
23.44
23.28
Minimum 18 19
Maximum 28 35
Marital status
Never married
20 (100%)
18 (90%)
38 (95%)
Divorced/Widowed/Separated
2 (10%)
2 (5%)
Source:

13. Background characteristics of participants

14. Observations: Key findings
MSM
(N=20)
FSW
Reviewed instructions before testing
18/20
17/20
Mean time reviewing instructions
2 minutes
Test result (observer’s verification) Negative
Positive
Unable to complete test*
Indeterminate
11/20
8/20
1/20
3/20
Correctly read test result (among those who completed test)
17/19
17/18
Note that indeed the positivity rate in the MSM group is high but be careful interpreting this since we did purposive sampling. It is not meant to be a representative sample.
* Due to error in testing procedure by participant

15. Background characteristics of participants
MSM
(N=20)
FSW
Placed test stick into solution before swabbing mouth 2 1
Emptied test solution from vial into test stand
Poured solution onto test stick
Spilled solution while opening bottle 5
Touched pad with fingers before swabbing 3
Did not put vial in stand 4 6
Did not place stand on flat surface
TOTAL errors 12 21
These were the errors that participants made during the self-testing procedure. …
Note that of these errors, the last two errors are actually ok although not advisable. But at least they do not result in an erroneous test result.
However, the first five errors (in the red box) can lead to an invalid test result or not being able to complete the test. But at least not too many of the participants made these errors. FSWs made a lot more errors than the MSM.
* Note: An individual can make multiple errors

16. Feedback about using the kit
Test was easy to use
Liked that it was a pain-free experience (compared to finger prick or needle)
Despite being able to read, participants preferred the pictorial instructions
What helped me was the pictures. If I didn’t understand anything I watched the picture to be sure of what I had to do.
- FSW
This self-test is really good and it should be done everywhere because it is better than bringing out blood to test but this is just simple and easily done and you will know your status
- MSM
Despite these errors, participants during interviews indicated the test was easy to use and that they liked the pain-free experience (as opposed to finger prick or a needle). Despite being able to read, participants preferred the pictorial instructions. The only negative feedback was that they did not like waiting 20 minutes for result.

17. Feedback about using the kit
Only negative comment: A few did not like the 20 minute waiting time for the result; most ok with waiting
Only a few expressed being nervous doing the test
“Since I was doing it myself let say if I am doing it in the house I think the time is not too much. I can leave it there and go and later I will come back and check.” - FSW
“It was like before I started, I was a little bit nervous. I was disturbed but after using it, it was ok. It is good for you to know such things yourself …”
- FSW
The only negative feedback about the test was that they did not like waiting 20 minutes for result.

18. Conclusion
Overall errors that impact test result few but must be considered (particularly for the FSW population)
These errors should reduce with time as HIVST becomes more common (like pregnancy tests or blood sugar for example)
The test was highly acceptable by both MSM and FSWs

19. Next steps Discussions around distribution strategies
Collaborate with GAC and NACP around national guidelines

20. Acknowledgments CSOs Population Council JSI MOH/GHS/NACP
WAPCAS
WIYO
Prolink
MIHOSO
WAAF
HFFG
Maritime
Population Council
JSI
MOH/GHS/NACP
Ghana AIDS Commission
USAID
Study participants

21. Thank you