Supervised HIV self-testing to inform implementation and scale up of self-testing in Zimbabwe

Background: HIV self-testing (HIVST) can potentially increase uptake of testing in a low-cost, confidential and non-stigmatizing manner. Rigorous evaluation of instructional materials for accurate selftesting has rarely been conducted. In preparation for implementation and scale-up of HIVST in Zimbabwe, we have adapted and iteratively refined instructional materials to support self-testing. Here we present results from our evaluation of these materials through supervised self-testing.

Methods: Participants were recruited at an HIV testing clinic using convenience sampling. They were given the instructional materials and left alone to complete their self-test and record the result. Confirmatory rapid testing after HIVST, and pre- and post-test questionnaires to evaluate their experience were conducted. The testing process was video recorded and videos analyzed using checklists. Data were evaluated weekly and IEC materials iteratively refined accordingly to optimize accuracy.

Results: We conducted 172 supervised self-tests among participants in urban Harare, with mean age of 30 (range 1870), 53% female and 20% first-time testers. Overall 93% read their result accurately, in some cases despite failing to follow instructions as determined by video. Six percent were unable to determine their result. One percent got inaccurate results, including one HIV individual on antiretroviral therapy (ART) who followed instructions correctly as determined by video. While most (88%) reported the test was not hard to use, 23% said some instructions were unclear, resulting in modifications to the materials. Common sources of confusion were in interpreting results, the purpose of the test kit desiccant and unclear images/language. Low literacy was associated with unsure/invalid results, prompting revision of the materials for a rural, less literate setting. There, among 29 participants, 3% were unable to determine their results and 31% got an inaccurate result. Materials have been further revised making them almost entirely pictorial, and supervised self-testing is ongoing.

Conclusions: Though there is little published research on optimizing HIVST materials, we found that thorough evaluation of materials through supervised self-testing has been critical to optimizing accuracy. Numerous revisions were required, and evaluation in different settings yielded differing results. Rigorous development and testing of HIVST supportive materials appropriate to country and setting is recommended prior to implementation of HIVST programs.