Effect of Prices, Distribution Strategies, and Marketing on Demand for HIV Self-testing in Zimbabwe: A Randomized Clinical Trial

Abstract

Importance: HIV self-testing is a promising approach for increasing awareness of HIV status in sub-Saharan Africa, particularly in Zimbabwe, where HIV prevalence is 13%. Evidence is lacking, however, on the optimal pricing policies and delivery strategies for maximizing the effect of HIV self-testing.

Objective: To assess demand for HIV self-testing among adults and priority-population subgroups under alternative pricing and distribution strategies.

Design, setting, and participants: This randomized clinical trial recruited study participants between February 15, 2018, and April 25, 2018, in urban and rural communities in Zimbabwe. A factorial design was used to randomize participants to a combination of self-test price, distribution site, and promotional message. Individuals and their household members had to be at least 16 years old to be eligible for participation. This intention-to-treat population comprised 3996 participants.

Interventions: Participants were given a voucher that could be redeemed for an HIV self-test within 1 month at varying prices (US $0-$3) and distribution sites (clinics or pharmacies in urban areas, and retail stores or community health workers in rural areas). Vouchers included randomly assigned promotional messages that emphasized the benefits of HIV testing.

Main outcomes and measures: Proportion of participants who obtained self-tests in each trial arm, measured by distributor records.

Results: Among the 4000 individuals enrolled, 3996 participants were included. In total, the mean (SD) age was 35 (14.7) years, and most participants (2841 [71.1%]) were female. Self-testing demand was highly price sensitive; 260 participants (32.5%) who were offered free self-tests redeemed their vouchers, compared with 55 participants (6.9%) who were offered self-tests for US $0.50 (odds ratio [OR], 0.14; 95% CI, 0.10-0.19), a reduction in demand of more than 25 percentage points. Demand was below 3% in the $1, $2, and $3 groups, which was statistically significantly lower than the demand in the free distribution group: in pooled analyses, demand was considerably lower among participants in higher-than-$0 price groups compared with the free distribution group (2.8% vs 32.5%; OR, 0.05; 95% CI, 0.04-0.07). In urban areas, demand was statistically significantly higher with pharmacy-based distribution compared with clinic-based distribution (6.8% vs 2.9%; adjusted OR, 2.78; 95% CI, 1.74-4.45). Price sensitivity was statistically significantly higher among rural residents, men, and those who had never received testing before. Promotional messages did not influence demand.

Conclusions and relevance: This study found that demand for HIV self-testing in Zimbabwe was highly price sensitive, suggesting that free distribution may be essential for promoting testing among high-priority population groups; additionally, pharmacy-based distribution was preferable to clinic-based distribution in urban areas.

Trial registration: ClinicalTrials.gov identifier: NCT03559959.

Conflict of interest statement

Conflict of Interest Disclosures: Mr Takaruza reported receiving grants from the Bill & Melinda Gates Foundation through Population Services International during the conduct of the study. Dr Cowan reported receiving grants from UNITAID, the National Institutes of Health, the Bill & Melinda Gates Foundation, Viiv Healthcare, USAID, and Medical Research Council outside the submitted work. Dr Sibanda reported receiving grants from the Bill & Melinda Gates Foundation through Population Services International during the conduct of the study. Dr Thirumurthy reported receiving grants from the Bill & Melinda Gates Foundation and the National Institutes of Health during the conduct of the study. No other disclosures were reported.

Figures

Figure.. CONSORT Flow Diagram

An equal number of individuals from each price group were randomized to each distribution strategy and subsequently to each promotional message type. aPrivacy message: “Be the first to know your status and take the right action.” bEarly treatment message: “Positive or negative, life is full of hope. If you test HIV-positive, you can immediately access treatment and continue to lead a healthy life.”