Exploring friendship-based chain referral for adolescent HIV testing

number of participants recruited in each wave
New HIV infections among adolescents continue to be a large public health burden in sub-Saharan Africa. In Kenya, an estimated 18,000 adolescents are infected with HIV each year. Girls are disproportionately affected. Most adolescents know where they can be tested, but the majority remain unaware of their HIV status.

Several studies have shown that encouragement from friends was an important motivation for young people to seek HIV testing and counseling, while the main deterrent was fear of stigma and discrimination from friends and family. New research from Family AIDS Care Education and Services (FACES) tested the use of a friendship-based chain referral approach, which has been successful in other settings, to recruit adolescents for HIV testing in Kisumu County, Kenya.

The study focused on reaching high-risk female adolescents. Researchers recruited girls age 15-19 who were willing to discuss HIV counseling and testing with at least 2 age group peers within a month. They gave the members of the seed group referral coupons to share with friends, which allowed the research team to track the referrals.

The study provided 1,049 adolescents with HIV information and tested 969—1/3 of whom were tested for HIV for the first time. Four tested positive for the first time, while an additional 15 were already known to be positive. Despite targeting sexually active adolescent girls as recruitment seeds, the peer chain referrals brought in an increasing number of male participants. The peer chain referral did not appear to increase the number of adolescents tested per month in comparison to before the intervention in the 3 health facilities where it was implemented.

During recruitment of seeds, sexually active girls, known for high risk of HIV acquisition, were targeted in hopes that they would refer other girls at risk. This was based on studies from the developed world that indicated that adolescents tend to have friends with similar risk profiles and tend to influence their friends to engage in similar behavior. However, adolescents in Kenya may have friends with similar risk profiles, but these were not the people who came in for testing through the referral network. Almost equal numbers of male and female participants came in through peer referral, despite efforts to prioritize adolescent girls. Very few participants ultimately referred friends, and those that did come were not as high risk as the seed members. Their decision-making may be influenced by concerns about anticipated stigma, accounting for different patterns of peer referral in the US compared to Kenya. It’s unclear whether referral cards weren’t used to get HIV testing, or if the participants never gave them to their friends in the first place.

Despite the limitations of this approach, the study reached a large number of first-time testers. The exposure to information, testing and counseling makes them more likely to appreciate the importance of frequent testing and retest in the future, allowing earlier diagnosis and linkage to care. There were not many new positive diagnoses, but all participants received risk screening and risk reduction counseling, which could prevent future HIV acquisition. Interesting patterns emerged regarding referral of peers that could be used to better understand HIV testing in western Kenya and to design future adolescent interventions.