Effect of prices, distribution strategies, and marketing factors on demand for HIV self-tests in Zimbabwe: A randomized clinical trial

Importance: HIV self-testing (HIVST) is a promising approach for increasing awareness of HIV status in sub-Saharan Africa, but evidence is lacking on optimal pricing policies and delivery strategies for maximizing the impact of HIVST.

Objective: Assess demand for HIV self-tests among adults and priority population subgroups under alternative pricing and distribution strategies.

Design: Randomized trial between February 15, 2018 and May 25, 2018. A factorial design was used to randomly assign participants to a combination of self-test price, distribution site, and promotion message.

Setting: Urban and rural communities in Zimbabwe

Participants: Individuals aged ≥16 years

Intervention: Participants were given a voucher enabling them to redeem an HIV self-test within 1 month at varying prices (US$0-US$3) and distribution sites (clinics or pharmacies in urban areas, retail stores or community health workers in rural areas). Vouchers included randomly assigned promotion messages that emphasized benefits of HIV testing.

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

Results: Among 4,787 individuals assessed for eligibility, 4,000 were enrolled. Participants’ average age was 35 years, 71% were female, and 66% were married. Self-test demand was highly price-sensitive; 260 participants (32.5%) offered free self-tests redeemed vouchers compared with 55 (6.9%) participants offered self-tests for US$ 0.5 (odds ratio, OR, 0.14, 95% CI 0.10-0.19), a reduction in demand of >25%. Demand was below 3% in the $1, $2, and $3 groups, significantly lower than the free distribution group. In pooled analyses, demand was considerably lower among participants in groups with price >$0 compared to the free distribution group (2.8% vs. 32.5%, OR 0.05, 95% CI 0.04-0.07). In urban areas, demand was significantly higher with pharmacy-based distribution versus clinic-based distribution (6.8% vs. 2.9%, adjusted odds ratio, 2.78, 95% CI 1.74–4.45). Price sensitivity was significantly higher among rural residents, men, and those who had never tested before. Promotion messages did not influence demand.

Conclusions and Relevance: Demand for HIV self-tests in Zimbabwe is highly price-sensitive. Free distribution may be essential for promoting testing among high priority population groups. Pharmacy-based distribution is preferable to clinic-based distribution in urban areas.

Trial Registration: NCT03559959