Providing HIV self-testing kits to pregnant women to encourage HIV testing in their male partners is acceptable to men and women in Uganda, but women who are apprehensive about their partners’ reactions may need more support, according to findings from a qualitative study of participants in a randomised trial of the strategy published in the journal Global Health Action.
Self-testing for HIV permits people to test for HIV away from health facilities, in the privacy of their own homes or elsewhere, at a time of their own choosing. For these reasons, self-testing has the potential to improve testing rates in 'hard-to-reach' groups such as male partners of women attending antenatal clinics. There has been extremely low uptake when male partners have been given invitations to attend testing facilities, but testing rates have been improved by giving testing kits to women to pass on to their partners.
The qualitative study formed part of a pilot, cluster-randomised trial of an intervention to improve HIV testing rates in male partners of women attending antenatal services at three hospitals in central Uganda, using oral HIV self-testing kits. Women in the self-testing kit arm were given two to four self-testing kits, including one for themselves, one for their male partners and kits for any other adults in the household. They also received training in how to carry out the test and read the result. They took part in role-plays in how they could deliver the kits and persuade their partner to use them.
In-depth interviews were conducted with 17 women who had taken part in the study and 15 male partners who had agreed to use the self-testing kit. The interviews explored their perceptions of HIV self-testing as a testing strategy, the strategies used by women to deliver the testing kits to their partners and to persuade them to use the kits, and post-test experiences after using the kits.
Five interviewees were in concordant HIV-positive relationships, nine in HIV-discordant relationships and 18 in concordant HIV-negative relationships.
Perceptions of HIV self-testing
Women and men's perceptions differed. Whereas women were concerned about partners’ reactions to being offered the testing kit, men’s tended to be sceptical about whether the kits worked. One man said: “. . . I asked myself ‘is this really true’? Can really a person just get that ‘spoon’ [the kit] and pass it on the gum and then . . . [he spreads his hands] and test for HIV?” Other men expressed scepticism about saliva testing too, wondering if a blood test would prove more reliable.
Both men and women saw self-testing as a way of addressing men’s lack of time to go to health facilities. Most men were unconcerned about self-testing kits being brought home by women. Those who preferred that men should introduce the kits into the home said that they would prefer to establish their own HIV status before bringing the test kit home.
Strategies used by women to deliver the self-test kit
Approximately half of the women gave the self-testing kit to their partner either on the day they received it or on the following day. For all these women, placing the testing kit in a visible location such as the bedside was the means of starting a conversation about the purpose of the testing kit.
For the remainder, the level of communication between partners determined when they gave the testing kit to their partner. When women had concerns about the acceptability of self-testing, they might delay for some time to choose an opportune moment.
"I approached him when he was in his good moods because there are times when you can approach him amidst stress and he barks at you. For this one, I cracked some jokes, and I was able to gain the courage to test him. I realized that if I was to be scared I would then have made mistakes by not doing the test as we were instructed at the health facility." (HIV-positive female partner in an HIV-discordant relationship, age 20 years).
Strategies used by women to encourage use of the testing kit
Women in relationships with good communication did not report problems in convincing their partners to use the self-testing kit. Others who were unsure if their partner would agree to use the self-testing kit might lie about the purpose of the test or withhold some information about it. For example, one woman told her partner that the test was for syphilis, while another told her partner that the kit would “check and detect any disease in my body”. Two women did not fully explain the purpose of the test so that in one case the male partner learnt of his HIV-positive status only when asked to attend the clinic for a confirmatory test.
Two women chose to carry out the test on their male partners. One woman feared he would not do the test properly, while the other did not trust her partner to do the test at all:
"So, I did not trust him and the way I tested him, if you told it to anyone, they would not believe you. I timed when he was asleep and I swabbed with the kit down and when I was swabbing the upper gum, he woke up, and after waking up, after a little while I showed him the results. I didn’t trust him at first because these men are hard to trust . . .’" (HIV-negative female partner in a concordant HIV-negative relationship, age 23 years).
Women who encountered reluctance turned to healthcare workers for support in the process of persuasion or presented the testing kit as a device that had been sent by the healthcare worker and which must be returned to the health facility after use. This strategy created a relationship of accountability or provided leverage when the male partner was proving difficult to persuade.
Post-test experiences
Women did not report adverse experiences in the form of physical abuse after their partners tested, although several women reported that their partners were angry because they said they were unaware that they were self-testing for HIV.
Most women reported being happy that they had accepted the kits and that they had learnt their partner’s HIV status – including in cases where partners disclosed that they already knew they were HIV-positive. One woman who disclosed her own HIV-positive status reported that her partner had been very supportive since that time and gave her regular reminders about adherence to antiretrovirals.
Matovu J et al. ‘If I had not taken it [HIVST kit] home, my husband would not have come to the facility to test for HIV’: HIV self-testing perceptions, delivery strategies, and post-test experiences among pregnant women and their male partners in Central Uganda. Global Health Action, 11: 1503784, 2018. (Full text freely available).