A study in Malawi is offering glimpses into why couples opt for HIV self-testing – including issues of trust and honesty – and what it may mean for their relationships. Moses Kumwenda from the Malawi-Liverpool Wellcome Trust Clinical Research Programme presented findings at the recent 2nd International Conference for the Social Sciences and Humanities in HIV in Paris.
Self-testing for HIV, using the OraQuick oral HIV antibody test, has been found highly acceptable in Malawi and other countries. This option, in which people carry out the test themselves without a third party present, may overcome barriers such as the need to attend a health facility for testing, or fears of breaches of confidentiality. In Malawi, it has also been shown to increase the uptake of HIV treatment.
Launched in 2012, the Hit TB Hard study in Malawi investigates whether intensified tuberculosis (TB) case finding can curb new TB cases. As part of this five-year cluster randomised trial, HIV self-testing is offered in half of the trial’s 28 clusters in order to facilitate targeted HIV/TB prevention.
To evaluate the impact of self-testing on care-seeking and couples’ relationships, researchers kept in touch with 66 people, including seven serodiscordant couples, for a year after they had had an HIV self-test.
The researchers found that participants opted for self-testing for a number of reasons, including risk behaviour, mistrust within the couple, and a desire to either confirm an earlier HIV test result or check the effectiveness of local 'faith healing'. Some individuals used self-testing as an opportunity to disclose a previously known HIV status:
“We were not using condoms because I had not told my wife that I am positive. We were living normally as a family because she did not know and I was so afraid to tell her.”
Couples struggled immediately after results to deal with feelings of blame and disbelief, with men in particular being less willing to accept results. This led some couples to re-test, as advised by both researchers and the OraQuick self-testing kits, but also prompted others to incorrectly assume that HIV discordance within longstanding relationships indicated resistance to infection among partners who had remained HIV negative.
“I told him that we should use condoms,” reported one woman who had tested negative for HIV while her husband was HIV positive. “He told me, ‘why is it that all this time you have not been infected? We should live the way we have been living.’”
Men, who accounted for 44% of all those opting for self-testing as part of the trial, generally had a harder time accepting the need to practice safer sex than women. The study found that, while self-testing increased the ability of HIV-negative partners within discordant couples to negotiate condom use in the short term, men largely wanted to continue practicing unsafe sex.
“We found that within discordant couples – regardless of which partner was HIV-positive – males still preferred unprotected sex while women were more concerned about preventing HIV transmission,” Kumwenda said. “Some women reported trying to protect their marriages and the respect that they enjoyed in the community by accepting whatever their husband was telling them to do.”
One HIV-negative woman said:
“When you say no to unprotected sex, he would ask you ‘where should I go to have sex?’ I married you to be my wife.”
Social norms regarding definitions of a “good wife”, including the need to sexually satisfy their partners and to bear children, were cited as some of the reasons that women continued to be coerced into unsafe sex – as were local beliefs that unprotected sex during pregnancy was important to infant development.
While couples also reported experiencing fears regarding the future of their relationships after self-testing, most couples were still together a year after learning of their HIV statuses. Separation and physical violence were only reported in one couple with a pre-existing history of domestic violence.
Preliminary results suggest that, while HIV self-testing may not introduce violence into relationships, it may exacerbate it in relationships in which it already exists. This may indicate a need for relationship counselling within HIV testing.
“There needs to be specialised counselling,” Kumwenda said. “As testing is designed now, there is only pre- and post-test counselling but there is nothing to assist couples who already have issues.”
Dr Nicola Desmond, also with the Malawi-Liverpool Wellcome Trust programme, said that a larger study into the relationship between gender-based violence and self-testing involving 300 participants is ongoing.
Making the move to self-testing
The study comes as the World Health Organization works to develop guidelines on HIV self-testing following the first-ever WHO meeting on the subject in April 2013.
South Africa, Kenya and Malawi are currently considering adopting HIV self-testing to reach pockets that current testing campaigns continue to miss, according to Nicola Desmond.
“In Malawi, I think there’s the realisation that HIV testing uptake is ‘pocketed’ in the sense that there are certain groups being missed either for initial or repeat testing,” she said. “In Malawi, we have HIV testing campaigns once a year with door-to-door and mobile testing services but there are a lot of people who are being missed.”
“We know that self-testing addresses (concerns) of convenience and confidentiality and that these are some of the key things that make testing attractive,” she added.
Kumwenda M et al. Complex Sexual Behaviour Among Discordant Couples After Home HIV Self-testing. 2nd International Conference for the Social Science and Humanities in HIV, Paris, session CS51, 2013. (View the abstract and download presentation slides on the conference website.)
Desmond N. The Social And Ethical Dimensions Of Introducing HIV Self-testing Technologies. 2nd International Conference for the Social Science and Humanities in HIV, Paris, session CS51, 2013. (View the abstract and download presentation slides on the conference website.)