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    Original Investigation
    Infectious Diseases
    August 28, 2019

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

    Author Affiliations
    • 1Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill
    • 2CeSHHAR Zimbabwe, Avondale, Harare, Zimbabwe
    • 3Population Services International, Washington, DC
    • 4Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, United Kingdom
    • 5Division of Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
    • 6Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
    JAMA Netw Open. 2019;2(8):e199818. doi:10.1001/jamanetworkopen.2019.9818
    Key Points español 中文 (chinese)

    Question  How is the demand for HIV self-testing influenced by pricing and distribution strategies?

    Findings  In a randomized clinical trial of 4000 adults in Zimbabwe, demand for HIV self-testing declined substantially from 32.5% among those offered self-administered tests for free to 6.9% among those offered the tests for US $0.50 and below 3% at prices of US $1 or greater. Price sensitivity was higher among rural residents, men, and those who had never had an HIV test; in urban areas, demand was higher with pharmacy- than clinic-based distribution.

    Meaning  This study suggests that demand for HIV self-testing is highly price sensitive in low-income settings; free distribution of self-tests may help promote their use in high-priority population segments.

    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

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