School of Public Health

Patrick Owiti

Assessment of Repeat HIV Testing and Utilization of HIV Self-Testing to Increase Repeat Testing Amongst Pregnant and Postpartum Women in Kisumu County, Kenya

Repeat HIV testing of pregnant and postpartum women is key to prevention of mother-to-child transmission (PMTCT) of HIV, treatment for pregnant and postpartum women who are living with HIV, identification of untested positive partners and timely care for HIV infected children. Incident maternal HIV infection during pregnancy or in the postpartum period may lead to infant HIV acquisition; early diagnosis of such incident HIV infection provides opportunity for additional interventions. This thesis describes the results of two studies on the frequency and improvement of repeat HIV testing amongst pregnant and postpartum women. First, we conducted a cross-sectional study among 300 HIV seronegative women who were attending during the third trimester, at delivery, or at six weeks or six months postpartum. The objective of the study was to determine the frequency of repeat HIV testing. Overall, at 57.3% (95% CI: 51.5, 63.0) of visits, repeat HIV testing was done. The frequency of testing was higher within the antenatal period (54/72, 75.0%) compared to during delivery (43/64, 67.2%), and during the six-week (56/121, 46.3%) and six-month postpartum visits (19/43, 44.2%); in multivariate analysis, the postpartum period was associated with reduced likelihood of repeat HIV testing. In the second study, we assessed utilization of HIV self-testing to improve repeat testing amongst pregnant and postpartum women in programmatic settings in Kisumu, Kenya. Facility based HIV testing is conventionally offered through provider-initiated testing and counselling (PITC) but with the introduction of HIV self-testing (HIVST), that alternative approach could provide a user-friendly, time-saving alternative. We conducted a pilot evaluation of HIVST amongst 400 HIV seronegative women attending the third trimester, or at six weeks or six months postpartum within three health facilities. We offered them the opportunity to choose between clinic-based oral HIVST and standard finger prick based PITC for repeat HIV testing. We estimated the frequency of the choice between HIVST and PITC, and described the participants’ reasons for and experiences with the choices, as well as preferences for future testing. We found that just over half 53.8% (95% CI: 48.7, 58.7) chose oral HIVST. Unmarried women were more likely to use HIVST (PR: 1.26, 95% CI: 1.01 - 1.57). The most frequent reason for choice of oral HIVST was fear of needle prick (101/215, 47%). More HIVST than PITC users (95.3% vs 48.1%, p<0.001) would use the same testing approach in future and most HIVST users (94.9% vs 41.6%, p<0.001) would recommend their test of choice to other women. Our results show that repeat HIV testing amongst pregnant and postpartum women fell short of the guideline goals. These results highlight the need to evaluate barriers to HIV testing within PMTCT settings and opportunities for improving testing for maximal benefit for pregnant and postpartum women, their partners and their children. The use of clinic based oral HIVST in Kenyan antenatal and postpartum settings appears to be feasible and acceptable for repeat HIV testing and could improve repeat testing rates. Future work should explore the practical mechanisms for implementing such a strategy and evaluating its cost effectiveness.