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Closing the gap with HIV self-testing

We have made great strides in bringing HIV testing services to communities and getting more people to test regularly. But we are still not reaching enough people with testing, particularly men, adolescents and key populations. Could HIV self-testing be the answer to closing the gap?

Despite the gains made in HIV testing, particularly in Africa where there has been huge scale-up, 40% of people living with HIV worldwide don’t know their status. According to Cheryl Johnson, Technical Officer at the World Health Organization, in Eastern and Southern Africa, uptake of testing has hit a plateau and is not having the hoped-for impact on new infections. With 70% of those who are tested being women, it seems that men, key populations and their partners, and adolescents are missing out, largely because these groups are reluctant to test in a clinical setting. “It is not possible to achieve the 90-90-90 goals with this testing gap,” said Johnson in a presentation to the Southern African HIV Clinicians Society.

Enter HIV self-testing or HIVST. Approved for sale over the counter by the South African Pharmacy Council in late 2017, HIVST is also included in the Department of Health’s HIV Testing Services Policy:

“HIVST provides people an opportunity to test discretely and conveniently and may increase uptake of HIV testing among people not reached by other HIV services.”

DEFINITION: HIVST is a test where the individual collects, performs and interprets the test themselves. Self-tests can be either oral or finger-prick.

While HIVST offers us a new opportunity to access hard-to-reach groups with testing, it is not without its detractors. Many in the HIV field – particularly clinicians – have expressed concerns around issues of stigma, disclosure, intimate partner violence and psychological trauma, quality assurance, accuracy and acceptability. There are also those that worry about integration into the healthcare system – how will a person who has tested themselves know what to do or where to go if they get a positive result?

Thankfully, a number of demonstration studies – including the HIV Self-Testing Africa (STAR) initiative – are evaluating HIV self-testing in the African market. So far the findings are positive, showing that HIVST can double the uptake of testing and also increase the frequency of testing. According to Johnson, no social harm has been identified in these studies: no suicides, self-harm or IPV reported as a result of HIVST. Overall, acceptability and willingness to test has been very high.

However, there are a number of guidelines that should be applied to the roll-out of HIVST, including:

  • Self-testing does not replace traditional HTS and it should be used as a self-screening tool
  • Users should be made aware that a positive test must be followed by a confirmatory test at a clinic or facility.
  • Instructions must be appropriate for an untrained person to use and should include pictoral instructions and be translated into local languages.
  • Instruction inserts should include referrals to care and support
  • HIVST is not recommended for people taking anti-retroviral drugs, as this may cause a false negative result.
  • Test quality must be managed. There are a number of tests flooding the market and available online but some are not actually self-tests; they are regular test kits marketed as self-tests.

According to the WHO:

“HIVST has been shown to be an empowering, discreet and highly acceptable option for many users, including key populations, men, young people, health workers, pregnant women and their male partners, couples and general population groups.”

If managed appropriately, and if the cost of the tests can be brought down, HIVST could be a powerful tool in our arsenal against HIV and AIDS.

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