Insights into Private Sector HIV Self-Testing in Kenya
Kristen M. Little, Christine Odour, Heather Awsumb, Hildah Essendi
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I have no conflicts of interest to declare
Conflicts of Interest
page 2
1.
Introduce HIV self-testing to private sector in Kenya
•
Private pharmacies & clinics
•
Provided self-testing service delivery training to all outlets
•
Nairobi and Mombasa
•
Blood-based & oral-fluid test kits
2.
Understand elements needed for a sustainable private sector self-test
market
3.
Ability to reach targeted end-user groups with HIVST in the private
sector
•
Adolescents
•
Young adult men and women
HIVST Demonstration Project
page 3
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We conducted a mystery shopper study at pharmacies and
private health facilities participating in an HIVST
demonstration project
Mystery Shopper Study Background
page 4
Outlets carrying HIVST kits as part of the demonstration
project were randomly selected for the study
Facility owners provided verbal consent
–
Were not informed about the date or time of visits
Mystery shoppers ages 18-30 recruited for study
–
Provided a two day training and pilot testing of survey instrument
Visited facilities and attempted to purchase a quality-
assured HIVST kit
Methods
page 5
Used one of 14 pre-defined mystery shopper scenarios
–
Shopper’s age (range: 16-24 years)
–
Reason for testing
–
Type of kit to be purchased
–
Questions to ask the provider.
Immediately after the visit, shoppers were interviewed about their
experiences using a structured guide administered by a trained data
collector
–
Quantitative and some qualitative data collected
Analyzed using Stata 15.0
Methods
page 6
Results
Visits evenly split
between facilities in
Nairobi (n=27) and
Mombasa (n=28)
Most visits (n=41)
were to pharmacies,
though some visits
(n=14) to private
health facilities
Majority of visits made to pharmacies
page 8
Test kits most commonly
stored in storage or back
rooms in both pharmacies
(41%) and health facilities
(57%)
Less than a quarter of the
pharmacies had test kits
displayed on the shelves
(24%)
7 facilities (13%) did not
have any quality-assured
HIVST kits in stock at the
time of the visit
Self-test kits frequently stored out of sight
page 9
8% (n=3) of
HIVST kits given
to mystery
shoppers in
pharmacies were
not QA’d kits
–
Repackaged
professional use
tests
–
Non PQ’d kits
manufactured in
China & South
Africa
Non-quality assured HIVST also distributed
page 10
While roughly
1/3 of providers
explained the
testing process
without
prompting, this
was not standard
Few clients
received no
explanation at all
Most providers are explaining the testing process,
but many need client prompting
page 11
Females more
likely than males
to receive all types
of self-test
information
Most information
about test use,
interpretation, and
post-test actions
Most information is about test use & interpretation
page 12
Most test kits (~80%) were
sold for suggested price of
500Ksh
Actual price paid ranged from
0Ksh to 900Ksh
Four pharmacies sold test kits
for prices above 500Ksh,
despite a 500Ksh price sticker
on the box
Price of test kits was not always consistent
page 13
“…[the provider] convinced me that it’s cheaper and faster to use
the [non-quality assured HIVST] costing 150Ksh [because] it’s
easy to interpret the result”
”Provider prefers INSTI over OraQuick, stating that OraQuick is
preferred for people with diabetes or those with a blood clotting
problem.”
“The provider preferred that I purchase the INSTI testing kit since
it’s blood-based.”
Providers Mediate End-User’s Test Kit Choice
page 14
Conclusions
page 15
Mystery shopper survey provided a unique source of information about the quality
of HIVST services in the private sector
Identified important quality issues in service provision difficult to collect through
routine monitoring systems
–
Inconsistent price
–
Non-quality-assured products
–
Location of test kits
–
Stock-outs
–
Provider mediation of test kit choice
Will be conducted quarterly as a form of monitoring in the second phase of the
project
Providers may need more ongoing support to answer client questions confidently
and accurately
Conclusions
page 16
Colleagues at PSI and PS Kenya
Children’s Investment Fund Foundation
Mystery shoppers
Providers participating in the pilot project
Acknowledgements
Extra Slides
page 19
Most test support
information provided was
about test performance,
result interpretation, and
IFU
Providers rarely
mentioned the website,
helpline, or other sources
of information
Limited information was provided about other
sources of test support
page 20
49% of mystery
shoppers in
pharmacies and 57%
of those in health
facilities either did
not have their
questions answered,
or the questions were
not answered
satisfactorily
End-user questions were usually answered,
but not always satisfactorily
page 21
Providers asked to
collect data on age,
sex, and HIV testing
history and to
provide direct
assistance to
adolescents
These activities
conducted more
frequently at health
facilities
Monitoring data collection was uneven
page 22
Most clients
received some form
of assistance in
both pharmacies
and health facilities
Roughly half had to
explicitly request
that assistance
Indirect assistance with test performance was
typically provided to consumers
page 23
Facilities provided
with demand
creation materials
to display
Presence of
materials more
common in health
facilities (79%)
compared to
pharmacies (56%)
Presence of HIVST signage varied significantly
page 24
Offers of professional use testing common at
health facilities
page 25
A mystery shopper study was conducted to assess the private sector's effectiveness in providing high-quality HIV self-testing services to adolescents and young people in Kenya. The study focused on pharmacies and private health facilities participating in an HIV self-testing demonstration project. Mystery shoppers aged 18-30 visited various outlets to assess the availability and quality of HIV self-testing kits and services. The study aimed to identify key elements needed for a sustainable private sector HIV self-test market and improve access to targeted end-user groups such as adolescents.
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Presentation Transcript
Private Sector HIV Self-Testing in Kenya: Insights from a Mystery Shopper Study Kristen M. Little, Christine Odour, Heather Awsumb, Hildah Essendi 22 July 2019
Conflicts of Interest I have no conflicts of interest to declare page 2
HIVST Demonstration Project 1. Introduce HIV self-testing to private sector in Kenya Private pharmacies & clinics Provided self-testing service delivery training to all outlets Nairobi and Mombasa Blood-based & oral-fluid test kits 2. Understand elements needed for a sustainable private sector self-test market 3. Ability to reach targeted end-user groups with HIVST in the private sector Adolescents Young adult men and women page 3
Mystery Shopper Study Background Research Objective: To understand the private sector s ability to reach adolescents and young people with high quality HIV self-testing (HIVST) services We conducted a mystery shopper study at pharmacies and private health facilities participating in an HIVST demonstration project page 4
Methods Outlets carrying HIVST kits as part of the demonstration project were randomly selected for the study Facility owners provided verbal consent Were not informed about the date or time of visits Mystery shoppers ages 18-30 recruited for study Provided a two day training and pilot testing of survey instrument Visited facilities and attempted to purchase a quality- assured HIVST kit page 5
Methods Used one of 14 pre-defined mystery shopper scenarios Shopper s age (range: 16-24 years) Reason for testing Type of kit to be purchased Questions to ask the provider. Immediately after the visit, shoppers were interviewed about their experiences using a structured guide administered by a trained data collector Quantitative and some qualitative data collected Analyzed using Stata 15.0 page 6
Majority of visits made to pharmacies Mystery Client Visits by County & Facility Type, Sept 2018 Visits evenly split between facilities in Nairobi (n=27) and Mombasa (n=28) 60 Pharmacy Health Facility 50 40 Most visits (n=41) were to pharmacies, though some visits (n=14) to private health facilities 30 20 75% 86% 10 63% 0 Nairobi Mombasa Total page 8
Self-test kits frequently stored out of sight Where were the self-tests kept in the outlet? Test kits most commonly stored in storage or back rooms in both pharmacies (41%) and health facilities (57%) Less than a quarter of the pharmacies had test kits displayed on the shelves (24%) 7 facilities (13%) did not have any quality-assured HIVST kits in stock at the time of the visit 7% Other 0% 7% In the lab 0% Health Facility Pharmacy 0% On top of the counter 0% 21% None in facility 10% 7% On the shelf 24% 0% Under the counter* 24% 57% Store room/backroom 41% 0% 10% 20% 30% 40% 50% 60% page 9
Non-quality assured HIVST also distributed Which HIV Self-Test Were You Given/Tested With? 8% (n=3) of HIVST kits given to mystery shoppers in pharmacies were not QA d kits Repackaged professional use tests Non PQ d kits manufactured in China & South Africa 70% Health Facility (N=11) 60% Pharmacy (N=37) 50% 40% 30% 20% 10% 64% 62% 36% 30% 0% 8% 0% OraQuick INSTI Other page 10
Most providers are explaining the testing process, but many need client prompting While roughly 1/3 of providers explained the testing process without prompting, this was not standard Few clients received no explanation at all Did the Provider Explain the Testing Process to You? 70% 60% Pharmacy Health Facility 50% 40% 30% 20% 10% 17% 44% 64% 39% 36% 0% 0% No Yes, Client-Initiated Yes, Provider-Initiated page 11
Most information is about test use & interpretation Were you provided an explanation of: Females more likely than males to receive all types of self-test information 0% Other 10% 10% Additional sources of information Female Male 5% 60% Where to seek support for a positive result 43% 35% Things to do to maintain status if negative result 33% 65% Seeking confirmatory testing for a positive result 52% Most information about test use, interpretation, and post-test actions 50% What to do with an invalid result? 43% 90% How to interpret the results 76% 95% Step-by-step guidance on conducting the test 76% 45% Counseling before doing the test 33% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% page 12
Price of test kits was not always consistent How much did you pay for the HIVST? Most test kits (~80%) were sold for suggested price of 500Ksh Actual price paid ranged from 0Ksh to 900Ksh Four pharmacies sold test kits for prices above 500Ksh, despite a 500Ksh price sticker on the box Pharmacy Health Facility 90% 80% 70% 60% 50% 40% 30% 16% 20% 5% 10% 78% 82% 18% 0% 0% Less than 500Ksh 500Ksh More than 500Ksh page 13
Providers Mediate End-Users Test Kit Choice [the provider] convinced me that it s cheaper and faster to use the [non-quality assured HIVST] costing 150Ksh [because] it s easy to interpret the result Provider prefers INSTI over OraQuick, stating that OraQuick is preferred for people with diabetes or those with a blood clotting problem. The provider preferred that I purchase the INSTI testing kit since it s blood-based. page 14
Conclusions page 15
Conclusions Mystery shopper survey provided a unique source of information about the quality of HIVST services in the private sector Identified important quality issues in service provision difficult to collect through routine monitoring systems Inconsistent price Non-quality-assured products Location of test kits Stock-outs Provider mediation of test kit choice Will be conducted quarterly as a form of monitoring in the second phase of the project Providers may need more ongoing support to answer client questions confidently and accurately page 16
Acknowledgements Colleagues at PSI and PS Kenya Children s Investment Fund Foundation Mystery shoppers Providers participating in the pilot project
Questions? Comments?
Extra Slides page 19
Limited information was provided about other sources of test support Did the provider refer to: Most test support information provided was about test performance, result interpretation, and IFU Other HIVST chatbot Female Male Gave HIST helpline # Referred to HIVST twitter handle Referred to HIVST facebook page Referred to beselfsure website Providers rarely mentioned the website, helpline, or other sources of information The instruction manual was enclosed How to interpret the results How the test is done 0% 20% 40% 60% 80% 100% page 20
End-user questions were usually answered, but not always satisfactorily Did the provider answer any questions you had regarding use of the kit? 49% of mystery shoppers in pharmacies and 57% of those in health facilities either did not have their questions answered, or the questions were not answered satisfactorily 60% Pharmacy Health Facility 50% 40% 30% 20% 10% 32% 21% 51% 43% 17% 36% 0% No Yes, satisfactorily Yes, unsatisfactorily page 21
Monitoring data collection was uneven Did the Provider: Providers asked to collect data on age, sex, and HIV testing history and to provide direct assistance to adolescents These activities conducted more frequently at health facilities 90% Pharmacy Health Facility 80% 70% 60% 50% 40% 30% 17% 20% 10% 64% 32% 64% 29% 43% 73% 86% 0% Ask your age** Ask if you'd ever tested for HIV before* Offer any pre-counseling Give you information about how to correctly use the kit? page 22
Indirect assistance with test performance was typically provided to consumers Did the Provider Assist you in Performing the Self-Test? Most clients received some form of assistance in both pharmacies and health facilities Roughly half had to explicitly request that assistance 60% Pharmacy Health Facility 50% 40% 30% 20% 10% 22% 43% 55% 35% 36% 0% 0% 9% 0% No Yes, Directly Yes, Indirectly (Client- Initiated) Yes, Indirectly (Provider-Initiated) page 23
Presence of HIVST signage varied significantly % of Facilities with HIVST Signage by County and Outlet Type Facilities provided with demand creation materials to display Presence of materials more common in health facilities (79%) compared to pharmacies (56%) 90% 80% 70% 60% 50% 40% 30% 20% 10% 41% 80% 67% 75% 56% 79% 0% Pharmacy Health Facility Pharmacy Health Facility Pharmacy Health Facility Nairobi* Mombasa Total page 24
Offers of professional use testing common at health facilities Did the provider offer to test you with something other than a self-test? 60% 50% 40% 30% 55% 20% 10% 16% 0% Pharmacy** Health Facility page 25
