Date Published: August 29, 2018
Publisher: Taylor & Francis
Author(s): Michael Strauss, Gavin George, Emma Lansdell, Joanne E. Mantell, Kaymarlin Govender, Matthew Romo, Jacob Odhiambo, Eva Mwai, Eston N. Nyaga, Elizabeth A. Kelvin.
Providing HIV testing services to truck drivers in Africa is crucial but has proven challenging. The introduction of HIV self-testing promises to provide expanded service delivery options for clients, potentially increasing demand for services and expanding coverage – especially important for high-risk and difficult-to-reach populations. This study examines the preferences regarding HIV testing service delivery models, among long distance truck drivers to identify testing services that would appeal to this population. Using a discrete choice experiment, this study examines the drivers of choice regarding HIV counselling and testing among 305 truck drivers recruited from two roadside wellness clinics along major trucking routes in Kenya. Participants made trade-offs between characteristics of HIV testing service delivery models by making hypothetical choices in a series of paired HIV testing scenarios. Conditional logit models were used to identify the HIV testing characteristics driving the selection of preferred scenarios, as well as determine whether preferences interact with individual characteristics – especially HIV testing history. Participants preferred free, provider-administered HIV testing at a roadside clinic, using a finger-prick test, with in-person counselling, undertaken in the shortest possible time. The strongest driver of choice was the cost of the test. Those who had never tested previously preferred oral testing and telephonic counselling, while those who were not regular testers favoured clinic based – over self-testing. The results of this study indicate that for the majority of participants – most of whom had tested before – the existing services offered at roadside clinics were the preferred service delivery model. The introduction of oral self-testing increases the options available to truck drivers and may even improve testing uptake for some, especially among those who have never tested before. However, these findings suggest the impact on HIV testing uptake of introducing oral self-testing may be limited in this population.
Targeting interventions to meet the needs of high-risk groups is crucial to mitigating the impact of HIV and AIDS (Schwartländer et al., 2011). Mobile populations have been identified to be at high risk of HIV infection due to their propensity to engage in concurrent relationships and transactional sex (International Labor Organization, 2005; Lafort et al., 2010). Long distance truck drivers in sub-Saharan Africa are particularly prone to acquiring HIV, with previous studies documenting prevalence rates as high as 26% in the region (Azuonwu, Erhabor, & Frank-Peterside, 2011; Botão et al., 2016; Bwayo, Omari, et al., 1991; Delany-Moretlwe et al., 2014; Rakwar et al., 1999; Ramjee & Gouws, 2002; Regondi, George, & Pillay, 2013). Increased risk among truck drivers has been attributed to the engagement in sex with female sex workers (FSWs) stationed along truck stops on major transport routes (International Labor Organization, 2005). Multiple concurrent sexual relationships with other regular and non-regular partners are also common (Lurie et al., 2003; Progressio, 2013), often paired with low levels of condom use (Bwayo, Mutere, et al., 1991), further increasing HIV risk. Additionally, studies have shown that truck drivers have inadequate access to health services (Delany-Moretlwe et al., 2014; International Labor Organization, 2005; IRIN, 2013; Ojo et al., 2011) – a concern not only for their own health but also increasing risk of HIV transmission to their sexual partners.
The service delivery model for HTC used at NSA roadside clinics is well aligned with the stated preferences of this study sample. While the introduction of oral self-testing provides additional testing options for clients, it is unlikely to significantly alter HIV testing habits, especially amongst those that have tested before. Oral testing is more likely to align with the preferences of those who have never tested, but more so because it does not require a finger-prick than because it is a self-test, suggesting that introducing provider-administered oral testing in a clinical setting may result in similar outcomes. The stated preferences of the participants recruited at our NSA study sites suggest that the introduction of oral self-testing may have a limited immediate impact on their demand for HIV testing. Expanding this work to understand the preferences of truck drivers more broadly, especially those that do not currently access NSA clinics is vital for understanding the full effect that introducing oral self-testing is likely to have on demand for testing in order to help achieve the goals of the UNAIDS Fast Track targets (UNAIDS, 2015).