Drug shops are an effective strategy to reach adolescent girls and young women with HIV self-testing and contraception: A randomized trial in Tanzania

Background: Adolescent girls and young women (AGYW, ages 15-24) comprise 25% of new adult HIV infections in sub-Saharan Africa and disproportionately bear 44% of all reported unintended births. Located in nearly every community, drug shops are extensions of the health system which offer unparalleled reach of health services to underserved populations. Thus, we designed and evaluated a girl-friendly intervention to deliver HIV self-testing (HIVST) and contraception to AGYW at privately-owned drug shops in Tanzania.

Methods: We conducted a 4-month randomized trial at 20 drug shops in Shinyanga, Tanzania, to determine if the Malkia Klabu (“Queen Club”) intervention increased AGYW patronage, provision of HIVST and contraception, and health facility referrals to AGYW. Drug shops were randomized 1:1 to the intervention or comparison arm. Both intervention and comparison shops were provided with OraQuick HIVST kits to give AGYW customers for free. Intervention shops implemented Malkia Klabu, a loyalty program designed for AGYW using behavioral economics and human-centered design. We measured AGYW patronage through time-location surveys at randomly selected 3-hour blocks at baseline (n=109) and endline (n=246). In intent-to-treat analyses, we used Poisson regression to estimate rate ratios via a difference-in-differences approach. We measured HIVST and contraception distribution and referrals with monitoring data. The trial was pre-registered ( NCT04045912).

Results: Drug shops implementing Malkia Klabu had higher AGYW patronage at endline than comparison shops (mean AGYW per survey 2.86 vs. 0.91; rate ratio: 3.16; 95% confidence interval: 1.94, 5.16). Over the study period, intervention shops distributed 140% more HIVST kits to AGYW (1,275 vs. 532), provided more contraception (5,237 vs. 148 products), and made more referrals for HIV services (71 vs. 2) and family planning (379 vs. 43) to AGYW than comparison arm shops. No adverse events were reported.

Conclusion: The Malkia Klabu intervention dramatically increased AGYW patronage and HIVST and contraception distribution, despite HIVST being freely available at all participating shops. A future effectiveness and sustainability study is warranted to evaluate Malkia Klabu’s impact on HIV diagnoses and unintended pregnancy among AGYW, assess its potential for scale up, and confirm underlying theories for behavior change.