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Introducing HIV self-testing to rural communities in Malawi: cognitive interviewing may alert implementers to the need for additional support beyond that provided by manufacturer

Indravudh et al.

Publication year


Type of approach

Type of assistance
Directly assisted


Study population
General population and young people: Adults over 16 years

Study design

Sample size

UNAIDS HIV prevalence (2017)
9.1 [8.4 - 9.9]

Oral fluid-based HIV self-test kits were procured with pictorial instructions-for-use and text in English and Chichewa (Malawian language). Ease-of-use was assessed by 20 cognitive interviews of literate adults (16 years) attending rural HIV testing services in Blantyre, Malawi. Participants were provided with packaged kits containing instructions-for-use but no other assistance. A standardised questionnaire and observation record was administered during self-testing. Feasibility was then evaluated in two villages where 281 participants were randomly-selected from households and community peer groups (age 16 years or older, not taking antiretrovirals). Baseline and exit questionnaires were administered to the feasibility group. HIVST followed a brief demonstration of contents and kit usage. HIVST results were compared to a reference standard (3 rapid kits in parallel, by a trained professional).

Summary of findings
20 cognitive interviews were conducted, in which many challenges arose including participants having difficulty opening the self-test packaging, misinterpretation of translated phrases (two pouches, test stand) and imagery. Abstract symbolisation (e.g. knife/fork for eating and traffic signal were not was not well-recognised by participants. Although 18/20 participants completed the HIV self-test, these difficulties greatly affected timeliness and confidence in validity. In contrast, all 281 feasibility participants (80.0% literate) completed an HIV self-test following a standardised demonstration. Self-read results agreed with reference for 11/12 HIV-positive participants (sensitivity 91.70%, 95%CI 61.5%-99.8%) and 268/269 HIV-negative participants (specificity 99.60%, 95%CI 97.9%-100%).


Acceptability details
81.0% of randomly selected adults and all peer group members opted to self-test. Perceived ease and satisfaction were high, with 100% recommending HIVST to friends/family.

Willingness to pay

Willingness to pay details




HIV positivity
4.3% (12/281)

Accuracy details

Social harm

Linkage to prevention, care and treatment

Study status

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