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

2. 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.

3. 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 18-49 years 10 IDIs of men and 10 IDIs of women 18-49 years 10 IDIs of MSM and 10 IDIs of FSW 18-49 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

4. Findings General Population

5. Mombasa %(n=392) Siaya %(n=390) Total sample %(N=782) Ever tested for HIV 81.4 94.187.7 (686) Tested for HIV in past 12 months 65.3 76.771.0 (555) Knows place to do HIV test 96.6 97.897.2 (692) Venue of last HIV test Public clinics/hospitals 54.963.259.3 (407) Private clinics 26.715.320.6 (141) HTC centers 20.411.715.7 (108) Mobile clinics 19.135.227.7 (190) HIV Testing Behaviour (1)

6. 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 16.820.018.1 (144) “I am confident in coping with test results”: Agreed or strongly agreed 85.594.690.0 (782) “I am confident that I can reveal HIV status to partner”: Agreed or strongly agreed 82.492.187.2 (682) HIV Testing Behaviour (2)

7. Mombasa %(n=392) Siaya %(n=390) Total sample %(N=782) Ever seen/heard of HIV test kit 4.9 5.65.2 (41) Ever used HIV test kit 0.0 4.82.5 (1) Would use if made available 94.6 97.496.0 (750) Incentives for using HIV Oral self-test kit Easy to use 64.257.160.6 (455) Convenient to use 25.929.227.6 (207) Confidentiality/privacy 52.846.349.5 (372) Do not have to visit a HF 25.937.431.7 (238) HIV Oral Self-testing: Perceptions (1)

8. Mombasa %(n=392) Siaya %(n=390) Total sample %(N=782) Would seek confirmatory test 41.8 79.860.7 Would recommend test to partner 90.3 94.892.5 How can HIV Oral Self-test be promoted in Kenya Mass media 83.765.974.8 Brochures 6.19.27.7 Health workers 31.937.434.7 Community Health Outreach workers 40.122.631.3 Others 4.136.720.3 HIV Oral Self-testing: Perceptions (2)

9. 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 80.1 78.279.2 Find cheaper HTC services 13.2 14.914.2 Not go for a test 6.4 6.96.7 If the price was the same as HTC, what would you choose? Oral self testing 96.288.292.2 Traditional HTC 3.110.36.7 Mobile HTC 0.71.51.1 HIV Oral Self-testing: Perceptions (3)

10. 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).

11. Preferred retail/distribution outlets (by city) Mombasa %(n=392) Siaya %(n=390) Total sample %(N=782) Public clinics57.178.467.9 Private clinics29.415.022.1 Private pharmacies/chemists 81.442.661.2 Shops/super markets24.525.024.8 Note: If we add private clinics and privates pharmacies together, the private sector is the preferred channel: 83%

12. Mombasa %(n=392) Siaya %(n=390) Total sample %(N=782) Confidentiality 41.07.924.3 (182) Friendly7.02.64.8 (36) Services always available0.33.72.0 (15) Easy to access49.976.863.5 (476) Others1.99.05.5 (41) Preference to get kit from mentioned outlet

13. 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

14. Messages General Population want to hear or see Mombasa %(n=392) Siaya %(n=390) Total sample %(N=782) Retail price46.923.635.3 Retail outlet15.68.211.9 Instructions how to use56.169.762.9 Benefits25.328.226.7 Advantages24.022.623.3 Safety features14.522.318.4 Referral services9.24.66.9

15. From where/who GP want to see/hear about HIV Oral self-test kits Mombasa %(n=392) Siaya %(n=390) Total sample %(N=782) Doctor38.531.835.2 Nurse/Counselor26.532.629.5 Television53.622.338.0 Radio51.041.846.4 Community health/outreach worker45.440.843.1 Pharmacist11.56.79.1

16. Findings Key Populations (FSW and MSM)

17. MSM %(N=100) FSWs %(N=100) Gender Male100 Female100 Age 18-24 years5339 25-34 years4761 Education Primary or less*6944 Secondary2449 Tertiary77 Demographics (1)

18. 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 70.252.0 Convenient to use 12.331.6 Confidentiality/privacy 68.470.4 Do not have to visit a HF 28.122.4 Saves time 21.19.2 HIV Oral Self-testing: Perceptions (1)

19. MSM %(N=100) FSWs %(N=100) Would seek confirmatory test 40 75 Would recommend test to partner 56 100 How can HIV Oral Self-test be promoted in Kenya Mass media 43.058.0 Brochures 5.014.0 Health workers 55.630.0 Community Health Outreach workers 55.037.0 Others (Community sensitization, road shows, seminars, churches/mosques) 23.031.0 HIV Oral Self-testing: Perceptions (2)

20. 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 84.5 74.0 Find cheaper HTC services 3.4 9.0 Not going to test3.0 If the price was the same as HTC, what would you choose? Oral self testing 96.595.0 Traditional HTC 3.55.0 HIV Oral Self-testing: Perceptions (3)

21. Preferred retail/distribution outlets (by city) MSM %(N=100) FSWs %(N=100) Public clinics47.453.1 Private clinics8.87.1 Private pharmacies/chemists49.174.5 Shops/super markets15.813.3 NGOS19.3 Other (Drop-in-centers, clubs, bars & lodgings) 10.514.3 Note: If we add private clinics and privates pharmacies, we get private sector as the preferred channel for both MSM and FSW

22. MSM %(N=100) FSWs %(N=100) Confidentiality 22.823.5 Friendly12.317.3 Easy to access59.644.9 Why prefers to get kit from mentioned outlet

23. 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

24. MSM %(N=57) FSWs %(N=94) Age 18.24 years 54.7 97.4 25-35 years 61.5 92.7 36-49 years 50.5 83.3 Education Primary or less*30.895.5 Secondary70.793.9 Tertiary50.085.7 Willingness to pay by age and education

25. Messages Key Populations want to hear or see MSM %(N=100) FSW %(N=100) Retail price7.05.0 Retail outlet2.03.0 Instructions how to use34.066.0 Benefits21.029.0 Advantages14.033.0 Safety features34.014.0 Referral services14.03.0

26. From where/who KP want to see/hear about HIV Oral self-test kits MSM %(N=100) FSW %(N=100) Doctor26.060.0 Nurse/Counselor22.033.0 Television17.022.0 Radio34.018.0 Community health/outreach Worker17.037.0 Pharmacist8.011.0 Street play14.03.0 Brochure/Magazine10.04.0 Post-Test Club16.0-

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

28.  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

29.  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)

30.  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)