Facility HIV Self-Testing in Outpatient Departments: An Assessment of Characteristics and Concerns of Outpatients Who Opt Out of Testing in Malawi

Abstract

Background: Facility HIV self-testing (HIVST) in outpatient departments can dramatically increase testing among adult outpatients. However, it is still unclear why populations opt out of facility HIVST and reasons for opt outing. Using data from a parent facility HIVST trial, we sought to understand individual characteristics associated with opting out of facility HIVST and reported reasons for not testing.Methods: Exit surveys were conducted with outpatients aged $15 years at 5 facilities in Central and Southern Malawi randomized to the facility HIVST arm of the parent trial. Outpatients were eligible for our substudy if they were offered HIVST and eligible for HIV testing (ie, never previously tested HIV positive and tested $12 months ago or never tested). Summary statistics and multivariate regression models were used. Results:Seven hundred seventy-one outpatients were included in the substudy. Two hundred sixty-three (34%) opted out of HIVST. Urban residency (adjusted risk ratios [aRR] 3.48; 95% CI: 1.56 to 7.76) and self-reported poor health (aRR 1.86; 95% CI: 1.27 to 2.72) were associated with an increased risk of opting out. Male participants had a 69% higher risk of opting out (aRR 1.69; 95% CI: 1.14 to 2.51), with risk being 38% lower among working male participants. Primary reasons for not testing were feeling unprepared to test (49$4%) and perceived low risk of HIV infection (30$4%)only 2.6% believed that HIVST instructions were unclear, and 1.7% were concerned about privacy. Conclusion:Working, risky sexual behavior, rural residence, and good self-rated health were positively associated with opting out of HIVST among outpatients. Strategies to address internalized barriers, such as preparedness to test and perceived need to test, should be incorporated into facility HIVST interventions.

Manuscript Title: Facility-based HIV self-testing as an additional testing option in health facilities: A systematic review and meta-analysis

“…Additionally, the systematic review found that FB-HIVST affords users the customary benefits associated with self-testing, such as convenience, autonomy, and ease of use, while also providing the added advantage of integrating post-test facility-based services. Notably, a more recent qualitative study has also found that FB-HIVST may help overcome traditional facility-based barriers to HIV testing [23].…”

“…It is noteworthy, that not all HIV self-tests are oral, and existing literature highlights the acceptance of blood-based self-tests [24][25][26]. Optimizing FB-HIVST implementation requires strategies for private and convenient service delivery, such as provision of private self-testing spaces [23]. The significance of demonstrations and sensitization in enhancing user experience should also leveraged, acknowledging that various HIVST methods remain essential to cater to diverse preferences and needs.…”