We focus on a highly mobile population of fishermen in communities on Kenya’s Lake Victoria shoreline. Despite major progress towards HIV prevention and care goals, many lakeshore communities continue to carry a heavy burden of HIV disease. This study uses new technologies and insights from behavioral economics and social network research to test low-cost, scalable interventions to close gaps in the prevention and care cascade.

Study focus: Mobility and HIV

Our prior work illustrates how the intersection of mobility, gender, and sexual behavior contribute to extraordinarily high HIV  risks among Kenya fisherfolk. The mobility of fisherfolk between beaches and market places in an economy with steep resource constraints leads to a reliance on transactional sex for income, contributing to high HIV risks in lakeshore communities. The mobility of fishermen can challenge their ability to engage in HIV testing and visits to clinics to take up prevention or treatment medications. Fishermen find it difficult to access services at fixed-location clinics and typical clinic hours because fishing activities involve moving over sometimes far distances over the lake. In addition, HIV-related stigma, and gender norms that discourage men from taking up healthy behaviors, can inhibit their seeking care or prevention options.

The Owete study is addressing the urgent need for new approaches to increase men’s HIV testing access and connection to services for HIV prevention through PrEP and treatment through ART with HIV status-neutral approaches to counter stigma.

Secondary distribution of HIV self-tests

HIV self-testing (HIVST) is safe and can overcome barriers to clinic-based, counselor-administered testing by allowing   individuals to collect their own sample using a simple, rapid antibody test. Studies show that people in many settings prefer to use an HIV self-test rather than to test in a clinic. In a pilot study we conducted in Kisumu, Kenya, acceptability was high among men and over 85% found self-tests easy to use. HIVST offers convenience, privacy, and accuracy.

“Once you are taught you can just do it by yourself.”

“You can look at the results without stress.”

Recruit and train highly-connected, network-central men to distribute HIV self-tests and provide support to connect men in their close social networks to HIV prevention and treatment services.

Providing multiple self-tests to men and encouraging them to distribute tests to men in their social networks (i.e. ‘secondary distribution’) is a promising but untested strategy to increase men’s testing.

Based on pilot study findings, our study takes into account that men are highly influenced by their peers, fisherman trust other fisherman in their circle and are well-positioned to talk with other fisherman.

The Owete study is the first study to test the impact of secondary distribution of self-tests by leveraging men’s social networks.   If successful, this may be a low-cost way to dramatically increase HIV testing among men. 

“Peers were glad since they got the self-tests from a fellow man.”

Social network interventions

Social network-based approaches show promise for generating positive social influence and accelerating health behavior change in men.

The influence of social networks on health behaviors and outcomes is well   established; social networks can influence behavior through the circulation of ideas and social influence. Social network interventions are purposeful efforts to use networks to generate social influence, accelerate behavior change, and achieve positive health outcomes.

Our team has selected highly socially connected men within social networks to act as ‘promoters’, to help other men in their communities overcome long-standing barriers to HIV testing and connection to additional health services.

First, we conducted social network mapping in study communities in Siaya Country, Kenya to identify distinct close social networks of men. We then randomized these social networks to intervention and control groups.

Network-central, highly connected men in each network were recruited as promoters and well positioned to disseminate information and influence behaviors. The promoters received HIVST training. Promoters assigned to the intervention group distribute HIV self-tests, transport vouchers for referral services, and information on ART and PrEP to men in their network. Promoters assigned to the control group distribute vouchers for free self-tests at nearby health clinics.

HIV status-neutral approach to linkage to HIV care and PrEP services 

Integral to the design of our intervention is an HIV status neutral approach to promoting linkage to appropriate HIV prevention and treatment services following HIVST.  

Owing to the significant impact of stigma as a barrier to men’s engagement in testing and care engagement, the approach of the intervention was designed to not outwardly identify individuals by HIV status. Both HIV-positive and at-risk HIV-negative men are included in this social network-based intervention.  

Training and informational messages for HIV-positive and HIV-negative men are combined to reduce stigma and to emphasize that there are options for both groups, regardless of the result of the HIVST.