The Owete study deployed two recent innovations—HIV self-testing and social network analysis—to promote HIV prevention and treatment among fishermen living in communities along Kenya’s Lake Victoria shoreline. Fishermen in this region are highly mobile and face many challenges accessing medical care. In this study, men who are highly connected to other men in their community were recruited to distribute HIV self-testing kits to their peers with the aim of increasing HIV testing and linkage to HIV prevention and treatment.
HIV epidemic in sub-Saharan Africa
Ending the AIDS epidemic in sub-Saharan Africa (SSA) requires innovative approaches to engaging men in HIV testing: Nearly 50% of HIV-positive men in SSA are unaware of their HIV status and have lower uptake of HIV treatment (ART) and pre-exposure prophylaxis (PrEP) for prevention. This is particularly true of men working in the fishing communities along Lake Victoria's shores in SSA. These fishermen are highly mobile and have notably low rates of HIV testing and linkage to HIV prevention and treatment, despite the increasing availability of these services. As a result, HIV transmission risks remain high in these fishing communities.
Innovation and social networks
Two recent innovations: HIV self-testing (HIVST) and social network-based interventions hold promise for overcoming barriers to HIV testing and linkage to treatment for HIV-positive men and prevention for HIV-negative men.
This study sought to determine if an HIV status-neutral, social network-based approach could increase HIV testing, linkage to HIV prevention and treatment, and better health outcomes in men.
Better health outcomes in men would, in turn, reduce HIV risks in women in their communities.
Summary of Findings
The Owete study was the first randomized, controlled trial of a combined social network and HIV self-testing intervention to improve HIV testing and linkage to HIV prevention and treatment for mobile men in Africa. Our HIV status-neutral intervention effectively increased HIV self-testing and linkage to services among highly mobile Kenyan fishermen. The study showed that men's distribution of HIV self-tests to their male peers was successful at engaging a high proportion of a population of predominantly heterosexual men with HIV testing.
This highly-effective approach used social network mapping to identify high "in-degree" individuals— men named as contacts by many others— and their close social networks, then recruited and trained these men to distribute HIV self-tests to the other men in their close social networks. They were also asked to encourage their peers to link to health facilities for confirmatory testing and HIV treatment and prevention services after self-testing.
We found that HIV self-testing at 3 months was higher in intervention clusters (60% vs. 10%, p<0.001, intent-to-treat), as was HIV testing via any modality (65% vs. 32%, p<0.001). Linkage to health facilities was also higher in intervention clusters (70% vs. 17%, p<0.001).
Despite their high levels of geographic mobility, fishermen in these communities were socially highly connected and their social networks were strongly cohesive. While most men connected to other men on a single type or domain of relationship, a core group of 12-15% of men in the three communities were socially connected to other men on several relation types (e.g., both working together and also sharing health information, discussing financial matters, spending leisure time together, etc.) These were the men selected to be peer leaders (“Promoters”).
Our qualitative research found that Promoters were highly motivated and enthusiastic to use and distribute tests to other men in their close networks, and their peers liked receiving tests and support from known, trusted friends. These close relationships helped Promoters to feel comfortable distributing HIV self-tests and discussing sensitive, stigmatized behaviors and health issues with other men. It also helped men to accept and use HIV self-tests, link to clinics, and even disclose their results to Promoters.
The overall impact of this study is that it demonstrated an effective way to engage hard-to-reach populations of men in HIV testing and linkage to HIV treatment and prevention services. Highly mobile men have difficulty accessing these services, yet a social network approach where men can lead the intervention and take action to help one other proved to be highly effective. The approach is scalable, and can be adapted for other populations and other self-screening modalities and health conditions beyond HIV.
Owete intervention increases HIV self-testing and linkage! See our IAS 2023 presentation to learn more.
Funding and assistance
This study is funded by the National Institutes of Mental Health (NIMH), identification code NCT04772469. For information about testing, visit the ClinicalTrials.gov site.