HIV self-testing in Malawi. Photo courtesy of WHO
Today only half of people living with HIV are aware of their status. This testing gap, coupled with the importance of early treatment for HIV, is driving interest in of the role of self-testing for HIV.
Concerns about confidentiality and privacy are one of the key barriers to HIV testing services for adolescents (aged 10-19); however, recent studies on the use of HIV self-tests suggest that the availability of a simple and discreet way to know their status themselves may be one of the keys to dramatically increasing the number of adolescents who take a test and go on to access support and further HIV testing, prevention, treatment and care.
As a group, adolescents and young people are often extremely vulnerable to HIV infection, both socially and economically. AIDS is now the leading cause of death among adolescents in Africa and the second cause of death among adolescents worldwide.
Globally, in 2014 there were 220,000 new HIV infections among adolescents, with more than 60 percent among young girls and women - a figure which is even higher in sub-Saharan Africa. Yet, despite these facts, adolescents are less likely to be tested for HIV than adults.
Evidence is growing on the role HIV self-testing could play in helping countries reach the 90-90-90 UN targets, which call for a scale-up of HIV testing so that 90 percent of people with HIV are aware of their infection. In its newly-released Consolidated guidelines on HIV testing services, the World Health Organization encourages countries to conduct pilot programs on HIV self-testing so it can gather and synthesize evidence on the role self-tests can play in closing the HIV testing gap. The organization plans to release normative guidelines for HIV self-testing in 2016.
In the first large-scale HIV self-testing demonstration project in Africa, all adults (over 16 years) in the community of Blantyre in Malawi were offered a single HIV self-test. While uptake of the tests in the community was high in general, it was adolescents and young adults whose uptake was highest. Within 12 months of the introduction of HIV self-testing in the community, almost all adolescent (16-19 year old) girls were self-testing, as were more than 80 percent of adolescent males.
Such figures are unprecedented in a group that is often reluctant to or unable to be tested for HIV—frequently due to social, structural and health system barriers. “In our community, the youths are the ones who are now coming here in large numbers to take self-test kits. They say they want to prepare for their future,” said one community counsellor working in Blantyre.
Rachel Baggaley, coordinator of the Key Populations and Prevention Unit within the WHO HIV Department said the results were compelling. “This is beyond what is typically seen in terms of uptake of HIV testing services among adolescents in sub-Saharan Africa. HIV self-testing could potentially revolutionize HIV testing among young people,” she said.
Self-testing is a first test and does not itself provide an HIV diagnosis. Individuals whose self-tests are reactive, indicating that they may be infected with HIV, need to seek further testing at a health facility. If the test is confirmed, they can be linked to treatment and care.
Tests can be either a finger prick or an oral fluid rapid test kit, with the latter option helping drive use among adolescents. “You take the kit and move it around inside your mouth. Once you do that, you put it in a small bottle that contains medicine. Then the result comes out. This is a very easy approach - no needle, and no clinic,” explained one 18-year-old.
Several countries have now introduced self-testing into their national HIV testing policies, including Australia, France, Kenya, the United Kingdom and the United States of America. Many more countries have plans to do so, amongst them Brazil, Malawi, Thailand and Zimbabwe.
Early attempts to introduce self-testing were banned by several countries, often due to concerns about misuse, self-harm, and primarily the lack of/limited availability of treatment for people living with HIV. These concerns, as highlighted by WHO in the guidelines, are not unique to HIV self-testing but consistent with concerns raised about existing HIV testing services and have not been seen where HIV self-testing is being used. Major improvements in and access to HIV treatment during the past two decades have also alleviated some of these concerns; and many countries are now moving to test and offer of HIV treatment for all people with HIV.
HIV self-testing must be supported by programs, including community based programmes that raise awareness about the benefits of HIV self-testing, encourage and support those with a reactive test to link to treatment and care, and provide information and access to appropriate prevention. HIV self-testing has great potential to improve access to testing for those most underserved and to reach people earlier in their infection so that they can derive maximum benefit from early antiretroviral treatment.