What is the Potential for HIV Self-Testing in Africa ?

By Karin Hatzold, MD, MPH, Deputy Director of HIV/TB, PSI; Project Director of UNITAID/PSI STAR Project

This blog post is the first in a series of four on the HIV Self-Test AfRica (STAR) project. The STAR team visit Malawi with PSI Global Ambassador Debra Messing to learn more about how HIV Self-Testing can contribute to achieving the UN’s 90-90-90 targets.

While global scale up of HIV testing services has been significant over the past ten years, an estimated 46% of people living with HIV globally and 49% of people living with HIV in Africa are unaware of their status and are therefore not accessing anti-retroviral therapy and continue to transmit HIV unknowingly.

Current HIV testing services approaches do not reach those still remaining undiagnosed, especially men, adolescents — particularly girls — key populations and other populations at high risk of HIV infection. This is most often because either services are not accessible to them or because people are concerned about lack of privacy and fear of stigma and discrimination. Many people living with HIV only present at health care facilities late, when they are already ill, reducing their chance of successful treatment. Currently 1 in 5 people living with HIV globally are starting anti-retroviral therapy at an advanced stage of their illness.

HIV Self-Testing (HIVST) is a new promising approach that could radically change the current situation and narrow the testing gap by addressing barriers to testing uptake. It can empower people to learn about their status on their own, when and where it is convenient to them and provide those who self- test positive with the necessary information and support to facilitate getting into care and treatment. HIV self-testing offered at the community- and household-level can help to identity people early in the course of HIV infection, before they develop signs and symptoms of HIV infection and AIDS and also ensure early treatment initiation. This is vital because early treatment with antiretrovirals (ARVs) is more effective to control HIV, prevents the progression to AIDS and keeps a person from passing the disease along to a partner.

Together, PSI, the World Health Organization (WHO), London School of Hygiene and Tropical Medicine, Liverpool School of Tropical Medicine and University College London and local research partners are evaluating distribution models to scale up HIVST in four African countries in a four-year project funded by UNITAID.

The  STAR project is the largest evaluation of HIVST ever done. It aims to distribute a total of 2.7 Million test kits. STAR is already generating public health evidence to inform WHO normative guidance, support development of national-level policies on HIVST, explore demand and acceptability and guide future scale up globally.

Several models of test-kit distribution are being evaluated throughout the project. The main distribution channel is through community volunteers who distribute HIV self-test kits by knocking on doors of people’s homes. These community workers are also going to other popular places of social gathering, convenient to rural and peri-urban populations with limited access to testing facilities.

To increase testing coverage and frequency of testing among sex workers, who are at highest risk of HIV infection, PSI is distributing test kits through sex worker peer-educators at convenient places for test kit pick-up.

Voluntary Medical Male Circumcision (VMMC) uptake is a key prevention intervention to stemming the HIV epidemic. Testing for HIV beforehand is recommended, yet fear of testing and receiving a positive test result is perceived as a major barrier to uptake of VMMC among men.  HIVST prior to accessing VMMC services could provide an acceptable option for men who fear finding out about their status at the VMMC clinic. Also, it could potentially reduce time spent at the clinic. STAR is investigating whether using HIVST for those interested in VMMC has the potential to increase uptake and efficiency of this critical HIV prevention intervention.

Other channels of test kit distribution that are evaluated include private sector pharmacies and public and private sector health care facilities.

Project Implementation started in August 2015 and preliminary results from pilot community based distribution in Zimbabwe have shown that the rural community was highly receptive to the kits when they were offered at the household level by community volunteers. Furthermore, the project reached high numbers of first time testers and found a high positivity rate, suggesting that the community-based approach to self-testing may be an effective model to improve HIV case finding. The majority of participants returned their used self-test kits and those who were HIV positive were successfully linked to care and treatment services. HIV test kit distribution has also started in Malawi and Zambia. PSI and partners will share results from research and pilot implementation at the international AIDS conference in Durban in July.