Experience of social harms among female sex workers following HIV self-test distribution in Malawi: results of a cohort study.

BACKGROUND: In Malawi, female sex workers (FSW) have high HIV incidence and regular testing is suggested. HIV self-testing (HIVST) is a safe and acceptable alternative to standard testing services. This study assessed; whether social harms were more likely to be reported after HIVST distribution to FSW by peer distributors than after facility-based HIV testing and whether FSW regretted HIVST use or experienced associated relationship problems. METHODS: Peer HIVST distributors, who were FSW, were recruited in Blantyre district, Malawi between February and July 2017. Among HIVST recipients a prospective cohort was recruited. Interviews were conducted at baseline and at end-line, 3 months later. Participants completed daily sexual activity diaries. End-line data were analysed using logistic regression to assess whether regret or relationship problems were associated with HIVST use. Sexual activity data were analysed using Generalised Estimating Equations to assess whether HIVST use was temporally associated with an increase in social harms. RESULTS: Of 265 FSW recruited and offered HIVST, 131 completed both interviews. Of these, 31/131(23.7%) reported initial regret after HIVST use, this reduced to 23/131(17.6%) at the 3-month follow-up. Relationship problems were reported by 12/131(9.2%). Regret about HIVST use was less commonly reported in those aged 26-35 years compared to those aged 16-25 years (OR immediate regret-0.40 95% CI 0.16-1.01) (OR current regret-0.22 95% CI 0.07 - 0.71) and was not associated with the HIVST result. There was limited evidence that reports of verbal abuse perpetrated by clients in the week following HIVST use were greater than when there was no testing in the preceding week. There was no evidence for increases in any other social harms. There was some evidence of coercion to test, most commonly initiated by the peer distributor. CONCLUSIONS: Little evidence was found that the peer distribution model was associated with increased levels of social harms, however programmes aimed at reaching FSW need to carefully consider possible unintended consequences of their service delivery approaches, including the potential for peer distributors to coerce individuals to test or disclose their test results and alternative distribution models may need to be considered.

Measuring sexual behaviour in Malawi: a triangulation of three data collection instruments.

BACKGROUND: There is a need for valid approaches to measure sexual interactions to assess the impact of behavioural interventions and to predict the impact of behaviour changes. Different methods of asking about sexual behaviour often yield conflicting answers and men often report higher levels of heterosexual activity than women. To better understand self-reported sexual behaviour data and how best to collect it, we analyzed data collected as part of a larger project (ST IMPACTS) on the social and behavioural impact of introducing community-level HIV self-testing (HIVST) with counseling (semi-supervised with pre- and generic post-test counseling provided on delivery or collection of test kits) in an urban Malawian setting. METHODS: Information on sexual behaviour was collected from HIV self-testers over a three-month period. Three different methods were used: retrospective face-to-face interviews (FTFI); audio computer assisted self-interviews (ACASI) and a prospective coital diary. Both retrospective instruments were used before and after the three-month study period. Frequency and cross-tabulation, as well as scatterplots, were used for exploratory analyses. Chi-square tests were used to test for differences in proportions. Spearman's correlation coefficient was used to explore associations between both continuous and ordinal variables and Wilcoxon's paired sample and Mann-Whitney test was used to test for differences in such variables or between variables. RESULTS: There was reasonable agreement between the two retrospective methods although both yielded inconsistent answers e.g. with lower reported numbers of life-time sexual partners at the end than at the beginning of the study period. The diary method elicited higher reported levels of sex with multiple partners than both retrospective instruments which may be due to inadequate recall. Over the study period 37.4% of men and 19.7% of women reported multiple sexual partners using the diary. There was no clear relationship between reported sexual behaviour and HIV status (prevalence 9.6%). CONCLUSIONS: Diaries may therefore have higher validity for sensitive behaviour reporting and thus be the preferred method in similar African contexts in measuring sexual behaviours.