Exploring social harms during distribution of HIV self-testing kits using mixed-methods approaches in Malawi

Kumwenda, M. K., C. C. Johnson, et al.

INTRODUCTION: HIV self-testing (HIVST) provides couples and individuals with a discreet, convenient and empowering testing option. As with all HIV testing, potential harms must be anticipated and mitigated to optimize individual and public health benefits. Here, we describe social harms (SHs) reported during HIVST implementation in Malawi, and propose a framework for grading and responding to harms, according to their severity.

METHODS: We report findings from six HIVST implementation studies in Malawi (2011 to 2017) that included substudies investigating SH reports. Qualitative methods included focus group discussions, in-depth interviews and critical incident interviews. Earlier studies used intensive quantitative methods (post-test questionnaires for intimate partner violence, household surveys, investigation of all deaths in HIVST communities). Later studies used post-marketing reporting with/without community engagement. Pharmacovigilance methodology (whereby potentially life-threatening/changing events are defined as "serious") was used to grade SH severity, assuming more complete passive reporting for serious events.

RESULTS: During distribution of 175,683 HIVST kits, predominantly under passive SH reporting, 25 serious SHs were reported from 19 (0.011%) self-testers, including 15 partners in eight couples with newly identified HIV discordancy, and one perinatally infected adolescent. There were no deaths or suicides. Marriage break-up was the most commonly reported serious SH (sixteen individuals; eight couples), particularly among serodiscordant couples. Among new concordant HIV-positive couples, blame and frustration was common but rarely (one episode) led to serious SHs. Among concordant HIV-negative couples, increased trust and stronger relationships were reported. Coercion to test or disclose was generally considered "well-intentioned" within established couples. Women felt empowered and were assertive when offering HIVST test kits to their partners. Some women who persuaded their partner to test, however, did report SHs, including verbal or physical abuse and economic hardship.

CONCLUSIONS: After more than six years of large-scale HIVST implementation and in-depth investigation of SHs in Malawi, we identified approximately one serious reported SH per 10,000 HIVST kits distributed, predominantly break-up of married serodiscordant couples. Both "active" and "passive" reporting systems identified serious SH events, although with more complete capture by "active" systems. As HIVST is scaled-up, efforts to support and further optimize community-led SH monitoring should be prioritized alongside HIVST distribution.

May 12, 2019
Year of publication
HIV self-testing (HIVST), social harms

Similar Resources

DREAMS is an ambitious $385 million partnership to reduce HIV infections among adolescent girls and young women in 10 sub-Saharan African countries. The goal of DREAMS is to help girls develop into Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe women.

INTRODUCTION: HIV testing male partners of pregnant and postpartum women can lead to improved health outcomes for women, partners and infants.

Remarkable progress is being made on HIV treatment. Ahead of World AIDS Day, UNAIDS has launched a new report showing that access to treatment has risen significantly. In 2000, just 685 000 people living with HIV had access to antiretroviral therapy.

East and Southern Africa carries the global burden of HIV/ AIDS and the impact of HIV/AIDS on children, adolescents and their families is tremendous.

This report presents progress made after two years of implementation of the ESA Commitment (2013-2015). Significant progress has already been made thanks to concerted action by governments, civil society, and development partners at national and regional level.

USAID and PEPFAR's approach to pursuing HIV epidemic control is transforming lives and supporting the development of healthy, self-reliant Malawian people.

The HIV response is hampered by many obstacles to progression along the HIV care cascade, with men, in particular, experiencing different forms of disruption. One group of men, whose stories remain untold, are those who have succumbed to HIV-related illness. In this paper, we explore how next-of-…

Tsogolo la Thanzi (TLT) was designed to study how young adults navigate sexual relationships and childbearing during a generalized HIV epidemic.

Reaching universal HIV-status awareness is crucial to ensure all HIV-infected patients access antiretroviral treatment (ART) and achieve virological suppression.

As a strategy to avoid discrimination, violence and economic marginalisation, sexual and gender non-conforming people often turn to migration as a route to achieve independence and build social capital.